agenda - cwm taf morgannwg university health boardcwmtafmorgannwg.wales/docs/health...

HEALTHCARE PROFESSIONALS FORUMMonday 2 October 2017

Rhondda Room, Ynysmeurig House, Navigation Park, Abercynon

2pm – 4pm

AGENDALead / Attachment

PART 1. PRELIMINARY MATTERS

1.1 Welcome and Introductions

1.2 Apologies for Absence

1.3 Declaration of Interests

1.4 Unconfirmed Minutes of the meeting of the HealthcareProfessionals Forum held on 14 March 2017

ChairAttachment

PART 2.

The new Chair of the Health Board Professor Marcus Longley has agreed to attend the meeting to meet members of the HealthCare Professionals Forum

PART 3. GOVERNANCE, PERFORMANCE AND ASSURANCE

3.1 Clinical Services Strategy Medical Director Presentation

PART 3. FOR INFORMATION

3.1 White Paper - Services fit for the future Attachments

3.2 Prosperity for All Attachments

3.3 National Joint Professional Advisory Committee (NJPAC) Terms Of Reference And Constitution

Attachment

PART 4. OTHER MATTERS

4.1 Any Other Urgent Business Chair

4.2 Dates of Next Meeting (s) all held at Ynysmeurig House, AbercynonTuesday 14 November 9-12pm; Tuesday 13 March 2018 1-4pm

1. Agenda HPF 2 Oct 2017

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Minutes of the meeting of the Health Professionals Forum held on 14 March 2017

Page 1 of 5 Healthcare Professionals Forum Meeting

2 October 2017

MINUTES OF THE MEETING OF THE CWM TAF HEALTHCARE PROFESSIONALS FORUM

HELD ON TUESDAY 14 MARCH 2017 IN YNYSMEURIG HOUSE, NAVIGATION PARK, ABERCYNON

PRESENT

Mrs Collette Kiernan (Chair) Therapies RepresentativeMr Jonathan Arthur Scientific RepresentativeMs Carolyn John Hospital Nursing & Midwifery RepresentativeDr Sajitha Koratala Medical Representative for Mental Health Mr Tim Palmer Optometry RepresentationMs Suzanne Scott Thomas Clinical Director Medicines ManagementDr Penny Owen Specialist and Tertiary Care medical

representativeMr Paul Crank Community Nursing and Midwifery

RepresentativeMrs Katrina Clarke Dental representativeMr Steve Davies Community Pharmacy Wales

IN ATTENDANCE

Mr Chris White Chief Operating Officer / Director of Therapies and Health Sciences

Ms Gwenan Roberts Head of Corporate Services (Secretariat)Mr Gareth Hardacre Assistant Director of WorkforceMrs Karen Winder Head of Clinical IT Systems

HPF/17/08 WELCOME AND INTRODUCTIONSMrs Collette Kiernan welcomed all to the meeting. All present introduced themselves.

HPF/17/09 APOLOGIES FOR ABSENCE

Apologies for absence were received from: Mrs Lynda Williams, Director of Nursing Midwifery and Patient Services; Mr Kamal Asaad, Medical Director;and Dr Kelechi Nnoaham, Director of Public Health.

HPF/17/10 DECLARATIONS OF INTEREST

There were no declarations of interest received.

HPF/17/11 MINUTES OF PREVIOUS MEETING

Members AGREED the notes of the meeting which took place on 14 February 2017.

1.4 Unconfirmed Minutes HPF 14 March 2017

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HPF/17/12 WORKFORCE ISSUES

Mr Gareth Hardacre was in attendance at the meeting and a discussion was held around the recent nurse recruitment campaign. Members noted that external research was used to target key staff in the 25-40 age group and the insight work identified activities and lifestyle choices to target advertising. Most in the target age range used social media and Channel 4. Members felt that the ‘talking heads’ staff from Cwm Taf was a really effective way of helping people to understand the culture of Cwm Taf.

Members noted that significant enquiries had been received with increased applications across Cwm Taf which was very positive news. The microsite dedicated for recruitment had been rolled into the new website and people interested in coming to work for Cwm Taf would be able to easily register their interest. The success of the work had also raised awareness with the Welsh Government and they had also asked that Cwm Taf host their campaign of ‘train live work’. This would commence with medical staffrecruitment and be rolled out to therapists with plans for the remaining staff. Members were invited to nominate members of their teams who could be an ambassador for Cwm Taf to assist in the recruitment processes.

Members were interested to note that all health boards in Wales were struggling to recruit nursing staff and although attempts had been made to recruit from across Europe; success was very limited. In terms of the recruitment of Filipino nurses, 54 had been offered an opportunity to work in Cwm Taf if they could satisfy the Nursing and Midwifery Council (NMC) requirements. It was felt that although numbers were increasing within the universities this was some way off being an influence on the current crisis in staffing levels.

Members noted the work around the skills escalator and methods to innovate across the health board area. Other avenues being considered also included ensuring that exit interviews take place in order to do as much as possible to retain the current workforce. Members provided ideas about different ways of working and diversification of ward teams to include staff which traditionally did not form part of the ward environment such as medicines management technicians to administer medication and other models. Members noted that the medicines management team were aiming to pilot new ways of working aiming to provide more integrated services.

Suzanne Scott Thomas explained that ongoing work with Community Pharmacy Wales to ‘grow our own staff’ was continuing including pre registration integrated posts which could attract more portfolio working. This was of interest to the members and an update would be provided at a future meeting.





2 October 2017

Gareth Hardacre explained that apprenticeships was also an area where more opportunities would be available in terms of career frameworks, physicians associates etc; Cwm Taf was analysing all options in order to create a great workforce for the future.

Discussion took place around nursing associates and band 4 level training, although strict criteria would need to be in place with the NMC examining the relevance of the educational element. Members noted that radiographers had assistant practitioners and this was also available in the therapy directorate.From the discussion it was clear that there was a lot of progress in some areas and all felt that the future workforce would look very different fromtoday.

Members RESOLVED to:∑ Receive an update regarding progress in staff recruitment in medicines

management at a future meeting

HPF/17/13 UPDATED TERMS OF REFERENCE

Members discussed the updated Terms of Reference, it was agreed to include reference to influencing patient care outcomes and wellbeing.

Members RESOLVED to:∑ ENDORSE the Terms of Reference and seek approval from the Health

Board.

HPF/17/14 DIGITAL HEALTH STRATEGY

Mrs Karen Winder presented the recently developed Digital Health Strategy and the programme of work for IT.

Members noted that more results would be available electronically and ultimately patients could also have access to their own results to better help to manage their conditions. Staff were becoming increasingly mobile and the aim was to capture information once for onward use.

The aim of the strategy was to work smarter, use ideas and innovation proven to be practicable and helpful elsewhere and develop bespoke Cwm Taf options when required. The basics for infrastructure and requirements were explained and lots of cross working and common themes were identified.

Using business processes and technology to deliver was considered vital and the strategic outline plan was building on the identified priorities across Cwm Taf. Members noted that funding was available from the Welsh Government although a business case would be required for each distinct area of work, this was being prioritised. Members noted that there was no forum to discuss IT developments although many areas would benefit from digital dictation for





2 October 2017

example.

Members RESOLVED to:∑ NOTE the update and receive a further update on the process of

implementation at a future meeting.

HPF/17/15 INTEGRATED MEDIUM TERM PLAN (IMTP)

A discussion was held regarding the process of developing the IMTP. Some felt that that small departments within larger directorates had experiencedsome difficulty in getting key messages into the overall document, accepting that the final version would need to be of a manageable size. The changes within the management structure could also lead to some areas not being included in the organisational plan.

Discussion took place regarding the staff training places available, particularly around clinical and cardiac physiology which would have an impact on the repatriation of interventional cardiology, without the appropriate workforce. Another area of concern raised was in relation to succession planning and the in year focus still of the IMTP. It was felt that this had a major impact on the development of services to meet future needs; for example, the development of the nurse specialist role would require planning starting for 5 years before fruition. In terms of the directorates being able to work together, it was felt that the timescales were too short although it was the right way to develop the plan further.

Other Members were not able to distinguish their own contributions within the final document, although made on time and it was felt that although the requirements were time based and considerable work had taken place this was not visible in the final version.

Members suggested that it would be helpful to have the planning lead at the next meeting to further discuss the process to ensure parity for the smaller ‘ologies’. The inability to recruit key staff to specific areas was impacting on the organisations ability to meet its obligations and targets.

Chris White suggested that he would provide additional support for specific areas if he was aware and it was agreed that the conversations would continue outside of the meeting. Members noted that training places were analysed annually and Stephen Griffiths as the national lead was aware of some of the smaller professionals needs. Gareth Hardacre agreed to circulate the commissioning numbers as this may assist in highlighting areas of concern and disconnection. In addition, it was felt that this information would also be useful for the recruitment campaigns and future plans.





2 October 2017

Members RESOLVED to:∑ RECEIVE the commissioning numbers for professions (Gareth

Hardacre)∑ INVITE the senior planner with responsibility for the IMTP to a future

meeting in advance of the next round of development.

HPF/17/16DATE OF NEXT MEETING

Tuesday 11 July between 1pm and 4pm in the Rhondda and Cynon Rooms, Ynysmeurig House.

Chair …………………………………….

Date ………………………………………………



Development of Cwm TafUHB’s Clinical Services

Strategy

Healthcare Professional Forum 2nd October 2017

Mr Kamal Asaad, Medical Director

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Developing a Clinical Services Strategy – Progress to Date

• Clinical Services Strategy required by Welsh Government as part of the IMTP submission

• However, the critical importance of this is recognised and owned by the UHB

• Series of clinical workshops held over the last 18 months to start to develop the thinking

• Excellent progress made in a number of areas where the strategy is now clear:• e.g. Acute Medicine Model, Paediatric Assessment

Model, Mental Health Redesign• Work commenced in other areas, but strategy not yet as

clear e.g. Frailty Model, Gynaecology, Day Surgery• Draft/ emerging clinical services strategy included in the

2017-20 IMTP2

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Developing a Clinical Services Strategy – Recent Progress

• Two further clinical workshops held in April 2017• Reviewed examples of clinical services strategies from

Scotland in particular, which are closely aligned with Cwm Taf thinking

• Strategy to be developed on the basis of services to be delivered as locally as possible

• Strategy to be drafted by the Autumn and completed by January 2018 for inclusion in the next IMTP

• Reviewed current timeline for service changes over the next few years. This is being expanded to include primary care and mental health

• Primary & Community Care workshop held to focus in this area in May 2017

• Builds upon the findings of the Well-Being and Population Needs Assessments3

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Healthcare Model

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Increased focus on proactive assessment with sign-posting to a range of statutory and non-statutory services to help people stay healthy and support independent living where necessary.

Joint working between all contractor professions (not just GPs) and community-based health and social care services focusing on prevention, early intervention, reablement and rehabilitation.

Hospitals and hospital clinicians working together across organisational and professional boundaries to deliver joined-up services but potentially in a smaller number of places. Some tertiary services devolved to DGHs in networked arrangements.

Highly specialised care delivered in a very small number of places as part of a networked approach to integrated patient care

Primary care, community & hospital clinicians working together at locality level in line with prudent healthcare principles to deliver more equitable and specialised out-of-hospital care.

Tertiary Services

DGH Services

Integrated Primary,

Community & Secondary Care in Cluster Hubs

Integrated Primary Care andCommunity Services within Cluster Footprints

Integrated Primary Care andCommunity Services within Cluster FootprintsWell-being, Self Care and Supported Self Care

Cwm Taf Clinical Services Strategy

Integrated Primary Care & Community Services

within Cluster Footprints

Well-being, Self Care and Supported Self

Care

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Timeline and Work Programme

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Apr. May Jun. Jul. Aug. Sept. Oct. Nov, Dec. Jan

Clin

ical w

orkshop

Primary C

are

Worksh

op

Articulate case for change

Draft high level key messages

Other surgical services

Review of T&O services

Vision for integrated primary and community care services incl. Community hospitals, frailty, extra care

Review of Gynaecology and PON move

Front door pathways including acute medicine at PCH and A&E workforce models

Draft and redraft strategy

Diagnostic Hub / Regional Diagnostics Plan

Clin

ical w

orkshop

Board

develo

pm

ent

First full

draft S

PG

Board

Exec B

oard

Board

Develop

men

t

Final to

Board

Board

develo

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ent

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Board

Dev

Sessio

n

Exec B

oard

Apr May June July Aug Sept Oct Nov Dec Jan

Clin

ical W

orksh

ops x2

Primary C

are W

orksh

op

Clin

ical W

orksh

ops

1stFu

ll Draft to

SPG

Dra

ft to E

xec Board

Final D

raft to

UH

B B

oard

Phase 1 Engagement:

• CHC• WiPF & HMSCs• Professional Groups (e.g. MLF, HoNs, LMC, PACT)• Stakeholder Reference Group •Public Fora• Site briefings

Phase 3 Engagement:

• CHC• WiPF & HSMCs• Professional Groups (MLF, HoNs, LMC)• Stakeholder Reference Group• Public Fora• Site briefings•Partner briefings •Social Media

Phase 2 Engagement:

• Big Bite• Global Village• Social Media• Targeted internal focus groups?

Convey & Test Key Messages , Gather Views

Gather Views (on a larger scale)

Consolidate Views and Test Emerging Recommendations

Board

Dev

Sessio

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Board

Dev

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Key Messages• The Strategy will describe the longer-term (10 year) vision for

health services in Cwm Taf;• This will be influenced and informed by discussions with our staff,

patients, carers, local communities and our partners;• However, we are not starting from scratch. We intend to build on

innovations and work that has already begun:– E.g. the redesign of mental health services; the Diagnostics

Hub; GP cluster networks; and Dewi Sant Health Park;• The Health Board to continue to review:

– what the pattern of health services will look like across primary, community and secondary care in the future

– what the workforce requirements & opportunities will be– what the next step opportunities are for collaboration or

integration with partners in social services and the voluntary sector

– quality and safety of services in line with agreed clinical standards

– that the future model is sustainable and affordable;7

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Key Messages

• The Strategy will be developed on the basis of services being delivered as locally as possible. In doing so we will determine what services could be provided:

– At GP practice level;– At Cluster Hub/ Health Park level;– At both District General Hospitals (i.e. the Royal

Glamorgan and Prince Charles Hospitals),– Or centralised at one DGH (e.g. breast services).

• Innovation, quality and access to services will be the overarching principles which underpin the development of the Strategy.

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What have we alreadydelivered?

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Deliverables 2014-17 Further Work Required• Prudent healthcare approach• Primary & Community Care Delivery Plan• Redesign of Out of Hours• Explorer Pathfinder with WAST• Sustained A&E and development of the

Acute Medicine Model• Centralisation of Acute Stroke Services• Diagnostic Hub Model• Sustained Paeds, Obs & Neonates• Innovation (e.g. Valleys Steps)• Older People’s Mental Health Phases 1&2• Intermediate Care Fund & Implementation of

the Social Services & Well-Being Act• @Home Services• Graduate Growth & PACT Programmes• Clinical Engagement• Financial balance

• Unscheduled Care• Referral to Treatment Times• Cancer targets• Gynaecology Service Model• Trauma & Orthopaedics• Day Surgery• Outpatients• Delayed Transfers of Care• Mental Health Measure• CAMHS• Older People’s Mental Health Phase 3• Primary Care Sustainability• Recruitment & retention in certain

areas• Integration (both across primary,

community and secondary care, andwith social services and the voluntarysector)

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Emerging High Level Clinical Services Strategy

• Creation of opportunities to reduce health inequalities within Cwm Taf, preventing ill health, improving longer-term well-being and increasing the resilience of local communities– Working collectively with all public service leaders and

organisations.– Work embedded in all areas of the organisation, from primary

through to secondary care.– Challenge for staff, patients and people across Cwm Taf to

enjoy four or five healthy behaviours.

Key considerations for Cwm Taf UHB:• The role of anticipatory care in delivering / embedding prevention• New models of health and social care as facilitators of a universal

approach to prevention• Place-based initiatives and a focus on Adverse Childhood

Experiences, frailty, obesity, inequalities and loss of wellbeing10

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• Timely access to high quality primary care providing a comprehensive service that deals with the whole person recognising their home circumstance– Building on universal access to primary care.– Focused on prevention, anticipatory care planning with early

intervention.– Care where possible within a primary care setting.– Focus for continuity of care and co-ordination of care for

patients with multiple conditions.– Services delivered in smaller number of larger practices by

wider primary care team

Key considerations for Cwm Taf UHB: • What will the range of services look like at practice level and at

cluster level?• What services currently provided at DGH level or cluster level

could be provided at practice level?11

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• A comprehensive range of community services, integrated across health and social care and working with the third sector to provide increased support at home:– Single point of access, accessible 24/7 from acute and

community settings.– Services focused on preventing deterioration and supporting

independence.– Multi-disciplinary care plans in place to respond in a timely

way to crisis.– Working as part of a team with primary care providers within

each of the clusters.

Key considerations for Cwm Taf UHB :• Work will build on the principles of the mental health services

redesign and the Stay Well @Home model• What is the role of the community hospitals?• What is the role of the Health Parks?• Where would the single point of access be? Role of 111?12

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• Coordinated care at crisis / transition points, and for those people most at risk:- Access to specialist advice by phone, in community settings or

through rapid access to outpatients.- Jointly agreed care plans with input from GPs, community

teams, specialist nurses and consultants, with shared responsibility for implementation.

- Rapid escalation of support, on a 24 / 7 basis, with the aim of keeping people at home or as close to home as possible.

Key considerations for Cwm Taf UHB:• Need to ensure that this is also closely linked and integrated with

social care. • How are social care and acute care crises managed? 13

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Draft High Level Clinical Services Strategy

• Hospital assessment for unscheduled care which focuses on early comprehensive assessment driving care in the right setting:– Senior clinical decision makers at the front door.– Specialist care available 24/7 where required.– Rapid transfer to appropriate place of care, following

assessment.– In-patient stay for the acute period of care only– Early supported discharge to home or step down care.– Early involvement of primary and community care team in

planning for discharge.

Key considerations for Cwm Taf UHB:• What will the A&E service look like on each of the DGH sites?• Further work required to define which services will be available on

both DGH sites and those which will need to be centralised on one DGH site14

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• Planned care which is locally accessible on an outpatient / ambulatory care basis where possible:– Wider range of specialist clinics in the community, working as

part of a team with primary care and community services.– Diagnostic services organised around patient needs, with

investigations front-loaded to speed up pathways.– Interventions provided as day case where possible.– Limited hospital-based follow up care, with emphasis on virtual

clinics and patient led follow up.– Rapid access as an alternative to emergency admission or to

facilitate discharge.

Key considerations for Cwm Taf UHB:• Build on the concept of the Diagnostic Hub• Major emphasis on reduction in follow up care, with reductions in

avoidable appointments, increase in virtual clinics, telephone follow ups, nurse led care and patient directed follow up

• Move to day surgery as the norm15

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• Low volume and high complexity care provided in defined units equipped to meet the care needs:- Driven by clear evidence of the relationship between volume

and outcome.

Key considerations for Cwm Taf UHB:• Are there more services current provided in tertiary centres that

could safely be repatriated back to Cwm Taf?• How bold do we want to be on our commissioning intentions?

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• Key principles and enablers will need to run through the clinical services strategy:– Quality of care will need to be one of the key considerations in

transforming services– Desire to deliver prudent healthcare and increase the ‘value’ of

the services provided will also be a key theme– Importance of ICT as a major enabler– Impact of University status in terms of innovation, education

and evidence based care– Recruitment and retention along with workforce redesign will

be required as a key enabler for change and transformation– Sustainability of services will also be a key driver

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Key Questions for the Healthcare Professionals Forum

• What are the Healthcare Professionals Forum views on the components of the emerging clinical strategy?

• What are the key issues we should be considering for the service areas we’re focussing on initially? (T&O, Gynaecology, Paediatrics, Front door pathways, Diagnostics Hub etc)

• How do you want to engage in this process?

• How do we engage with the wider clinical workforce?

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WHITE PAPER CONSULTATION: SERVICES FIT FOR THE FUTURE, QUALITY AND GOVERNANCE IN HEALTH AND CARE IN WALES

Page 1 of 5 University Health Board Development Meeting

2 August 2017

2 August 2017

Health Board Report


Executive Lead: Chief Executive

Author: Director of Corporate Services & Governance/Board Secretary

Contact Details for further information: [email protected]

Purpose of the Health Board Report

The purpose of the report is to aid discussion on the Cwm Taf approach to responding to the White Paper Consultation on Services Fit for the Future Quality and Governance in Health and Care in Wales.

Governance

Link to Health Board Strategic Objective(s)

The Board’s overarching role is to ensure its Strategyoutlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:

∑ To improve quality, safety and patient experience

∑ To protect and improve population health∑ To ensure that the services provided are

accessible and sustainable into the future∑ To provide strong governance and assurance∑ To ensure good value based care and treatment

for our patients in line with the resources made available to the Health Board.

This report focuses mainly on providing strong governance and assurance.

Supporting evidence

The Consultation is attached as Appendix 1 as well as an easy to read version (Appendix 2) and the Impact assessment (Appendix 3)

Engagement – Who has been involved in this work?

Welsh Government consultation; a briefing has been drafted by the NHS Confederation and attached as Appendix 4.

4.1 Cover paper for WG White Paper Consultation - Service Fit for the Future UHB Development session 2 Aug 2017




2 August 2017

Health Board Development Session To:

APPROVE ENDORSE DISCUSS √ NOTE

Recommendation The Health Board is asked to:∑ DISCUSS the report and start to draft

responses to the consultation which need to be submitted before 29 September.

Summarise the Impact of the Health Board Report

Equality and diversity

Impact Assessment for the consultationundertaken by the Welsh Government attached at Appendix 3

Legal implications This is a White Paper Consultation before the law is developed

Population Health The aim of the consultation is to improve the population health for the people of Wales

Quality, Safety & Patient Experience

Ultimately, the aim of the consultation is to develop law to support the delivery of health and social care services

Resources None specific in terms of this report.

Risks and Assurance As the legislation would have a significant impact potentially on the health board it would be important to develop a response which would be the organisation’s opportunity to be open and transparent in terms of the response will be public

Health & Care Standards

The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:Staying Healthy; Safe Care; Effective Care; Dignified Care; Timely Care; Individual Care; Staff & Resourceshttp://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015_E1.pdfThe work reported in this summary ultimately will support all of the standards

Workforce No specific workforce requirements related to the report.

Freedom of information status

Open



http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015_E1.pdf





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1. SITUATION / PURPOSE OF REPORT

The purpose of the report is to aid discussion on the Cwm Taf approach to responding to the White Paper Consultation on Services Fit for the Future Quality and Governance in Health and Care in Wales (Appendix 1); to be able to respond to the Welsh Government by 29 September 2017.

2. BACKGROUND / INTRODUCTION

The White Paper seeks views on proposals covering a number of health and social care issues which may require future legislation. The aim of any new legislation would be to enable organisations and empower citizens. Proposals include the strengthening of local health boards so they function as integrated, accountable, population-based organisations; new duties of candour and quality; areas where health and social care can act more collaboratively; and more effective inspection, regulation and capture of citizens’ voices.

The NHS Confederation have developed a briefing on the White Paper (attached at Appendix 4).

A written statement by Vaughan Gething, Cabinet Secretary for Health, Wellbeing and Sport stated the following:

Today the Minister for Social Services and Public Health and I are publishing Services Fit for the Future, a White Paper which sets out proposals to take forward health and care services for generations to come, to put people at the centre of service delivery and enable organisations to work together and across boundaries.

In recent years we have set out a clear mandate for public services to work with each other and with the public to meet the needs of the individuals and populations they serve. Legislation already passed by the Assembly, including the Social Services and Well-being (Wales) Act 2014, the Well-being of Future Generations (Wales) Act 2015, and the Regulation and Inspection of Social Care (Wales) Act 2015 supports this aim. The White Paper looks at opportunities to build on existing responsibilities, to unlock potential and future-proof services.

In 2015, the previous Government consulted on Our Health, Our Health Service, a Green Paper which promoted a high level discussion and posed open questions to help inform any future actions, including potential legislation, on a range of issues. The consultation generated a wave of interest and appetite to ensure greater partnership working across health boards; more effective engagement with the public and representation of citizens’ voices, and further integration and openness, transparency and clarity in the remit of inspection.





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The responses received from the Green Paper consultation, as well as a number of the recommendations made in the OECD Review of Health Care Quality in the UK and other reviews, have shaped the White Paper proposals.

The White Paper includes:

Measures to promote stronger governance and leadership to ensure our services are led, planned and developed in the way they need to be in the years to come – this includes proposals about the composition of NHS boards, as well as statutory protection for the Board Secretary role;

Duties to promote cultural change across health and social care so that service planning and delivery are more aligned – this includes a Duty of Quality for the Population of Wales which will focus on quality at a local level as well as supporting regional and national collaborative working; and a new Duty of Candour to place citizens at the heart of decisions and information sharing;

Common processes to underpin person-centred health and care, which will promote further integration and be of benefit to citizens – this includes proposals for high level common standards across health and social care; and the joint investigations of complaints which span health and social care, irrespective of setting;

A strengthening of the voice of citizens in the way services are planned – this includes proposals to replace the current model of Community Health Councils with new independent arrangement across health and social care to represent the interest of the public;

A future-proofed inspection and regulation service, potentially sitting with the citizen voice arrangements as part of a newly formed independent body; and

A clearer process for service change.

It is our hope that the direction of travel set out in the White Paper will act as a platform for the findings of the Parliamentary Review, which are eagerly awaited by us all.

The consultation will run from 28 June until 29 September and the Minister and I very much hope people will take this opportunity to influence potential future legislation on the quality and governance of our health and care services in Wales.

https://consultations.gov.wales/consultations/services-fit-future



https://consultations.gov.wales/consultations/services-fit-future



2 August 2017

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

The proposals set out in the White Paper are:

Effective Governance: Including Board Membership and Composition and Board Secretaries;

Duties to Promote Cultural Chance: Including duty of Quality of the Population of Wales and Duty of Candour. The introduction a Duty of Quality for the Population of Wales which will focus on health boards working together to meet the needs of the population in the planning and delivery of quality healthcare services;

Person-centred health and care: Including setting and meeting common standards and joining investigation of health and social care complaints; and

Effective citizen’s voice, co-production and clear inspection: including representing the citizen in health and social care, co-production and services with citizens and inspection and regulation.

∑ Strengthening of the voice of citizens – this includes proposals to replace the current model of Community Health Councils with a new independent arrangements which would represent the interests of citizens across health and social care;

∑ A clearer process for service change - introducing an independent mechanism to provide clinical advice on substantial service change decisions, with advice from the proposed new citizen voice body, which will encourage continuous engagement and increase the pace of strategic change; and

∑ Improving inspection and regulation – including improving the legal framework for the inspection and regulation of health services and questions about whether a new independent body for patient voice and regulation and inspection should be established.

4. RECOMMENDATION

The Health Board is asked to:

∑ DISCUSS the report and start to draft responses to the consultation which need to be submitted before 29 September.

Freedom of information status

Open



Number: WG32220

Services fit for the future

Quality and Governance in health and care in

Wales

Date of issue: 28 June 2017 Action required: Responses by 23:59 on 29 September 2017

Mae’r ddogfen yma hefyd ar gael yn Gymraeg. This document is also available in Welsh.

© Crown Copyright

Welsh Government

White Paper Consultation Document

4.1.1 Appendix 1 WG White Paper Consultation Services Fit for the Future Quality and Governance in Health and Care in Wales


2

Overview This White Paper seeks views on proposals covering a number of health and social care issues which may require future legislation. The aim of any new legislation would be to enable organisations and empower citizens. Proposals include the strengthening of local health boards so they function as integrated, accountable, population-based organisations; new duties of candour and quality; areas where health and social care can act more collaboratively; and more effective inspection, regulation and capture of citizens’ voices. Your responses will be considered in developing any new legislation.

How to respond The closing date for responses is 29 September 2017. You can respond by

using the online form or

downloading a copy of the response form and returning it either by e-mail to:

[email protected] Or by post to Healthcare Quality Division Health and Social Services Group Welsh Government Cathays Park Cardiff CF10 3NQ

Further information and related documents

Large print, Braille and alternative language versions of this document are available on request.

Data protection

How the views and information you give us will be used Any response you send us will be seen in full by Welsh Government staff dealing with the issues which this consultation is about. It may also be seen by other Welsh Government staff to help them plan future consultations. The Welsh Government intends to publish a summary of the responses to this document. We may also



mailto:[email protected]

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publish responses in full. Normally, the name and address (or part of the address) of the person or organisation who sent the response are published with the response. This helps to show that the consultation was carried out properly. If you do not want your name or address published, please tell us this in writing when you send your response. We will then blank them out. Names or addresses we blank out might still get published later, though we do not think this would happen very often. The Freedom of Information Act 2000 and the Environmental Information Regulations 2004 allow the public to ask to see information held by many public bodies, including the Welsh Government. This includes information which has not been published. However, the law also allows us to withhold information in some circumstances. If anyone asks to see information we have withheld, we will have to decide whether to release it or not. If someone has asked for their name and address not to be published, that is an important fact we would take into account. However, there might sometimes be important reasons why we would have to reveal someone’s name and address, even though they have asked for them not to be published. We would get in touch with the person and ask their views before we finally decided to reveal the information.



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Contents page Foreword by Cabinet Secretary for Health, Well-being and Sport and Minister for Social Services and Public Health

5 – 6

Introduction

7 – 8

The Reasoning Behind Our Proposals

9 – 11

Chapter 1: Effective Governance

1.1. Board Membership and Composition 1.2. Board Secretary

11 – 17

Chapter 2: Duties to Promote Cultural Change 2.1. Duty of Quality for the Population of Wales 2.2. Duty of Candour

18 – 22

Chapter 3: Person-Centred Health and Care

3.1 . Setting and Meeting Common Standards 3.2. Joint Investigation of Health and Social Care

Complaints

23 – 27

Chapter 4: Effective Citizen Voice, Co-production and Clear Inspection

4.1. Representing the Citizen in Health and Social

Care 4.2. Co-producing Plans and Services with Citizens 4.3. Inspection and Regulation

28 – 38

Summary of Questions

39 – 42



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Foreword by Vaughan Gething, Cabinet Secretary for Health, Well-being and Sport and Rebecca Evans, Minister for Social Services and Public Health

As citizens of Wales we are fortunate to enjoy some of the best health and social care services, provided by committed staff at all levels. However, over the years, meeting everyone’s needs has become an increasing challenge and the system is now under great pressure. People are living longer than ever, which is good news. We all hope for good health as we approach our later years but sadly this is not always the reality. Many people in Wales continue to face numerous health problems, causing them to rely heavily on health and social care services. A number of factors contribute to the current position, including economic disadvantage, the effects of our industrial past, smoking, drinking, lack of physical exercise and poor eating habits. If we are to be sure of having good quality services available to us for a long time into the future, then all of us - citizens, health and social care organisations, educators, housing providers, national and local government and others - need to come together to prevent illness and reduce overall demand on services. The Welsh health and care system does not rely on market forces, competition and the sort of fractured picture we see in some other parts of the UK. Our local health boards are not just there to provide services - they have a unique responsibility for the health and well-being of their populations which can only be fulfilled through co-ordinated planning and working with citizens and partners. Understanding the needs of the people living in their areas and meeting those needs requires talented leaders capable of communicating the vision and working both within and across organisational boundaries to deliver high quality services. It also requires continuous improvement, including the engagement of local people on an ongoing basis. The report published last year by the highly respected Organisation for Economic Co-operation and Development (OECD) assessed our health service as a system which is committed to quality improvement, with the building blocks largely in place to provide excellent, sustainable services to the people of Wales. However the OECD also challenged us to do more to embed prudent healthcare, to strengthen the voice of the citizen, build more accountability and challenge into the system and unlock the undoubted potential of our local health boards. This White Paper sets out how we may use legislation, either primary or secondary, to respond to some of these challenges. It builds on work already started by the



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Social Services and Well-being (Wales) Act 2014 and the Regulation and Inspection of Social Care (Wales) Act 2016. It also acts as a potential platform for any recommendations arising from the Parliamentary Review of Health and Social Care, which is currently underway and which we await with interest. We look forward to receiving your views on our proposals.



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Introduction

1. This White Paper sets out the Welsh Government’s proposals in various areas of quality and governance in health and care services which may require future legislation. First and foremost, it focuses on the principles of enabling and empowering organisations, staff and citizens. In particular, we want to unlock the potential of local health boards to demonstrate that they govern and behave strategically and that quality is at the heart of all they do. This is very much in support of the principles of Prudent Healthcare and its place in securing health and well-being for future generations. We are therefore proposing a number of specific enablers which are set out in the following Chapters.

2. It is now clearer than ever before that we need to future–proof health and social care services for the generations to come. The Well-being of Future Generations (Wales) Act 20151 sets the goals, ways of working we all need to adopt, and places duties on public sector organisations, both individually and working together on Public Services Boards, so the Wales we want becomes a reality in the future. This means health and social care services working together, with staff, partners and the public to prevent ill health and to provide the care people need, when they need it. Organisations cannot continue to work in isolation of each other and must now look beyond their own boundaries when making decisions about what services and actions will deliver the best outcomes for citizens. This requires mature partnership working on a national, regional and local level.

3. We must ensure the right levers are in the system to promote continuous improvement, drive high standards and provide the sort of care that meets people’s needs and helps them to live the lives they want to lead. People have to be given a real and meaningful say in what happens to them individually and, more widely, in decisions about services. The concept of co-production is seen by many as the way to achieve sustainability in health and social care in the years ahead but this can only be achieved through an open and transparent approach.

4. Co-production is about breaking down the barriers between professionals and the people who use their services. It is about people making joint decisions about their own care. It is also about service planners and providers seeing their users as people with useful skills and experience to bring to the decision-making and care-giving process. Systems across health and social care now need to make a real shift toward this way of working because this is how standards and quality will be driven up.

5. Between July and November 2015, the Welsh Government published a consultation document called Our Health, Our Health Service.2 This document was a Green Paper. A Green Paper gathers views on issues which

1 Well-being of Future Generations (Wales) Act 2015

2 Our Health, Our Health Service Green Paper, Welsh Government, July 2015



http://www.legislation.gov.uk/anaw/2015/2/contents/enacted

https://consultations.gov.wales/consultations/green-paper-our-health-our-health-service

8

might appear in future Government policy. The purpose of Our Health, Our Health Service was to seek views on what else we might do to improve the quality of services provided by the NHS in Wales, as well the governance and accountability of the organisations and the people who manage them. It asked how we might encourage closer working with other public services, what the barriers are to more joined up working and ultimately whether the Welsh Government should use legislative powers to help achieve continuous improvement and stronger accountability

6. The responses to the Green Paper consultation showed there was an appetite for further work and potential legislation across a number of areas related to quality and governance. These include greater partnership working across local health boards; more effective engagement with the public and representation of citizens’ voices; common processes, such as standards and complaints systems to underpin services; openness and transparency and clarity in the remit of inspection.

7. This White Paper develops these areas in more detail and sets out the Welsh Government’s proposals for areas which could be addressed in future legislation. We fully intend to dovetail these proposals with the outcome of the Parliamentary Review of Health and Social Care in Wales. We are keen to ensure that any legislation acts as an enabler for real change, and is not just something which papers over the cracks. This has been the overarching principle guiding the development of these proposals. We look forward to receiving your views.



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The reasoning behind our proposals

8. Before proposing any legislative change we need to be clear about the issues we are trying to address, what we are building on, and the intended effect of the changes. We also need to be clear on the principles which are guiding us and we have already described how above all we want to enable and empower organisations and citizens to work together.

9. It is almost 20 years since the publication of Quality Care and Clinical

Excellence,3 which set out a framework for NHS organisations in Wales to continually improve the quality of care. Since that time, there have been a number of policies, pieces of legislation, campaigns and initiatives designed to gradually build a culture of quality improvement within the NHS in Wales.

10. The OECD Review of Health Care Quality in the UK4, published in 2016, made a number of positive observations about systems for quality improvement in Wales. They noted that the Welsh health service is committed to quality improvement, with the building blocks largely in place to promote high quality care and excellent, person-centred health services. This is very good news and testament to all the work which has been done. There are indeed many examples across health and social care in Wales of people working in partnership and with citizens to deliver person-centred care; however, there is still a lack of a truly systematic approach. It is also the case that systems for ensuring quality have developed separately both within health as well as across health and social care in Wales.

11. The OECD made a number of recommendations on how we might tackle some of these issues in Wales and we have taken these into account in developing this White Paper.

12. In terms of the effectiveness of our organisations, the OECD commented that some years after their establishment, local health boards are showing less innovation, and fewer radical approaches to system change and quality improvement that might have been expected. The OECD recommended that the Welsh Government play a more supportive and prescriptive role in order to maximise the potential of local health boards. We are pursuing our direct support of local health boards in a number of ways which do not require legislation, for example, through the current planning process (IMTPs) and actions taken through the escalation and intervention arrangements. Through these measures we are now holding organisations to account much more directly. Our specific proposals in this White Paper therefore look for ways to enable local health boards to demonstrate their effectiveness and their ability to work strategically and in partnership with others. We also propose some specific duties of quality and candour, to help reinforce our commitment to quality and a culture of openness and transparency.

3 Quality Care and Clinical Excellence, Welsh Office, 1998

4 Review of Health Care Quality in the UK, Organisation for Economic Co-operation and

Development, 2016



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13. The OECD also looked at the system for inspection and regulation and noted the international trend for moving to system-wide methods for accreditation and inspection, in particular inspections which better reflect patient pathways. This would mean an approach to inspection and regulation which spanned the whole experience of the individual, across organisational boundaries traditionally represented by primary care, hospital care and social care, and measured in accordance with common standards. Our specific proposals in this White Paper therefore look at how we might better align our inspection and regulation systems to allow for more joint working in accordance with common standards.

14. In terms of promoting the citizen’s voice in the system, the OECD noted the role of Community Health Councils (CHCs) in representing Wales and acknowledged their potential. However they questioned the value added by some of the CHCs’ functions and indicated a need to focus on reflecting the patient voice, closer working with other scrutiny bodies in Wales and ensuring that the concerns of citizens are heard and followed through. Other reports have raised concerns about the visibility of CHCs and the duplication of their functions with other bodies. The Welsh Government has also for some time had concerns about the sustainability of the membership model for CHCs. Recruiting members through public appointments, local authorities and the third sector is not delivering a sufficient level of diversity and experience to fully reflect the citizen voice. We have considered all of this and set out some specific proposals in this White Paper on how we might better focus on ensuring the voice of citizens is properly reflected across health and social care, both strategically and locally. We also set out a clearer process for service change and how citizens’ views will be woven into plans and decision-making.

15. Taking into account the above, there are now a number of enablers which might need to be set out in primary legislation which will take us further on our journey towards integrated services. These are:

Enabler How these are addressed in the White Paper

Measures to promote effective governance

Board membership and composition and also flexibility for Welsh Ministers’ to make particular appointments (e.g. under special measures) Protection for the role/function of Board Secretaries to ensure independence

Duties for health and social care which promote cultural change

Wide Duty of Quality to encompass the needs of population of Wales to facilitate collaborative, regional and all Wales planning and solutions to service change and delivery including



11

extending the powers of LHBs and Trusts to work in partnership. Duty of Candour to encourage individual and organisational openness and transparency.

Common processes to underpin person-centred health and care

Common standards across NHS, independent health sector and social care (where appropriate) which organisations are required to comply with Joint investigations of health and social care complaints.

Focus on promoting citizen voice and clarity in inspection and service change

A new arrangement for citizen voice replacing the existing Community Health Council (CHC) model to focus on how organisations are held to account for the way they engage the public. A clear process for service change decision-making. Addressing the legislative gaps underpinning Healthcare Inspectorate Wales. Proposals for a new independent body to bring together inspection, regulation and citizen voice in health and social care.



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Chapter 1: Effective Governance

16. The Green Paper said that local health boards need to have the right powers, governance and accountabilities to enable leaders to take the right decisions with and for the people. Boards also need to be of the right size and have the right people on them to act strategically and in partnership with citizens and other organisations.

17. This Chapter sets out our proposals to help bring about this mix of culture, strong leadership and partnership approach which will be essential if local health boards are, in line with the recommendations of the OECD, to unlock their promise as population-based organisations.

1.1. Board Membership and Composition Where are we now and where do we need to be?

18. Since the creation of local health boards in 2009, we have seen numerous changes and challenges across health and social care. Therefore it is the right time to review the governance of the local health boards to support continuous improvement and future proofing. This will help to deliver a more effective service with focus on strong leadership, key priorities, strategic decision making and a consistent culture.

19. At the heart of a person-centred health service should be a robust governance framework which continually improves the quality of services and experience to ensure that the best possible care is delivered for patients.

20. NHS Wales Board governance has come under increased scrutiny following the Betsi Cadwaladr Targeted Intervention Report (2015)5, and the OECD Review of Healthcare Quality (2016)6. These reports questioned whether Boards have the correct representation and skills to oversee quality and service improvement.

21. The current legislation framework is underpinned by the National Health Service (Wales) Act 20067 which makes provisions for the constitution and membership of local health boards and NHS trusts, with regulation making powers that include appointments, tenure and procedure.

22. The current composition of health boards is provided for by the Local Health Boards (Constitution, Membership and Procedures) (Wales) Regulations 20098. This model currently has:

5 Betsi Cadwaladr Targeted Intervention Report, Anne Lloyd CBE, March 2015

6 See footnote 4

7 National Health Service (Wales) Act 2006

8 The Local Health Boards (Constitution, Membership and Procedures) (Wales) Regulations 2009



http://www.wales.nhs.uk/sitesplus/documents/861/Ann%20Lloyd%20Report.pdf

http://www.legislation.gov.uk/ukpga/2006/42/pdfs/ukpga_20060042_en.pdf

http://www.legislation.gov.uk/wsi/2009/779/pdfs/wsi_20090779_mi.pdf

13

Nine non-officer members (four positions are specified by the regulations) with a Chair and Vice Chair appointed by the Minister, following a public appointment process;

Nine executive officer members (all positions are specified by the regulations);

Three associate members. Standing Orders state these associate members should be: the chair of the local health board’s Healthcare Professionals Forum, the chair of the local health board’s Stakeholder Reference Group and a director of social services from a local authority within the local health board’s area. The health board is also, subject to Ministerial approval, able to appoint a fourth associate member.

23. The NHS trusts each have their own Establishment Orders (including

subsequent Amendment Orders) which determine the composition of the Boards. The key difference with the NHS trusts’ Boards are that they are smaller in size and do not have an appointed Vice Chair.

24. Due to the size and complexity of NHS organisations, it is not possible to have everybody who needs to serve the Board as a fully fledged Board member. However it is crucial that the Board is supported by experienced and skilled membership and support which understands and reflects current priorities but can adapt to changing needs.

What are we proposing to do?

25. Taking into consideration the findings of recent reviews, the feedback from the Green Paper and research within the field of governance, we believe there are a number of key principles that Boards should adopt.

26. We believe key core principles should be consistent and applied across all NHS organisations under the same suite of legislation. We recognise that not all of these principles are necessarily achieved by primary legislation and alternative interventions could assist in meeting these objectives including secondary legislation and improved guidance and training.

Core Key Principles for all NHS organisations

The Board has a culture of openness and transparency and operates within a highly trusting, challenging and engaging environment;

It will show clear leadership in quality improvement which will be embedded in everything it does, including board member training;

It works in partnership with the public and partners to plan and deliver person-centred care;

There should be a majority of independent members over executive officers on the Board to provide independence and challenge;



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The independent members should be referred to as “public member” as they are there to bring the perspective of the population to board discussions;

The Board infrastructure is underpinned by a strong governance framework which enables the Board to work effectively and meet its statutory duties including achieving financial balance;

It should be supported by a well functioning and supporting committee structure that ensures it involves and receives views and input from a wide range of stakeholders including the professions and patients;

Every chair is supported with a vice chair;

There should be provision for Welsh Ministers to appoint additional Board Members based on time limited appointments during times of poor performance and escalation as set out in the NHS Wales Escalation and Intervention arrangements. This would allow the Board to call upon the necessary skills and experience to provide specialist advice and closer scrutiny to drive change and improvements within the organisation at a time when it is needed;

The Board to involve and are supported by the senior management below the Executive Directors to ensure wider professional and staff engagement

Associate membership of Boards should address citizen representation. Local Health Boards

27. Local health boards should be the right size and mix of executive, non-

executive and associate members in order to be dynamic, ideally no more than 20 full members. As mentioned above, currently the roles of all the executive members of the Board are set out in regulations. This has proved restrictive and some local health boards have sought to merge roles and/or include the roles in the Chief Operating Officer post. This can result in a loss of focus in some important areas, such as primary care and mental health, not meeting the requirements of existing law. In order to address this issue we have considered whether there should be a “core” membership together with some flexibility for Boards to decide what further roles are required to meet their population needs.

28. One option could be to set out a core membership in regulations, allowing a small amount of flexibility for other roles. This would ensure key roles are covered, and provide an element of consistency between all local health boards However, we are conscious to achieve smaller, more agile Boards together with some element of flexibility, could mean some executive Board members not being regarded as “core” and this could be unpopular.

29. Another option could be to be altogether less prescriptive in regulations about Board membership and allow Boards to decide on almost all the executive



15

members themselves, apart from one or two and noting the spilt between clinical and non-clinical members. The advantage of this would be to allow Boards to decide on executive membership to meet local needs; however complete flexibility would mean that consistency across health boards would inevitably be sacrificed. We welcome views on both these options.

NHS Trusts

30. For NHS Trust Boards we believe executive members should continue to be determined through the regulations to include a Chief Executive Officer and Finance Director. The trust Boards should be able to appoint up to three additional executive officer posts to support it to deliver on its purpose.

Questions on Board Membership The Welsh Government believes that the Boards of both health boards and NHS trusts should share some core key principles which are outlined including delivering in partnership to deliver person centred care and a strong governance framework to enable the Board to work effectively and meet its responsibilities. All Boards should have Vice Chairs in order to support focussed and skilled leadership. The Welsh Government also believes that Ministers should have the authority to appoint additional Board members on time limited appointments if an NHS Health Board/Trust is under performing or under escalation procedures in accordance with the NHS Wales Escalation and Intervention arrangements. The Welsh Government believes that Board Executive Officer membership for local health boards should probably include some key positions which are consistent across local health boards but also allow some flexibility to appoint based on remit and priorities. Do you agree with these proposals? What further issues would you want us to take into account in firming up these proposals?



16

1.2. The role of the Board Secretary Where are we now and where do we need to be?

31. The Welsh Ministers issued directions in April 2011 (updated in March 2014), in the form of Model Standing Orders for adoption by local health boards and NHS trusts. They describe the Board Secretary as the guardian of good governance within the local health board and as an advisor to the Board.

32. The role of the Board Secretary is crucial to the ongoing development and maintenance of a strong governance framework within NHS organisations. As principal advisor to the Board and the organisation, they are a key source of advice and support on all aspects of good governance and the assurance framework. The Board Secretary is not a Board member, and the independence of the role is an important element of the assurance mechanism to ensure that the Board is properly equipped to fulfil its responsibilities and meet its statutory duties.

33. The role of Board Secretary has come under scrutiny following the Overview of Governance Arrangements at Betsi Cadwaladr University Health Board report 2014 undertaken jointly by the Wales Audit Office and Healthcare Inspectorate Wales. The report raised issues in relation to unsustainable wider responsibilities and the potential for considerable conflict of priorities.

34. The importance of the separation and accountability of the Board Secretary role is understood and consideration should be given to providing statutory protection for the role.

35. The role of Board Secretary across each NHS Wales organisation varies considerably in terms of their responsibility, scope of portfolio, reporting lines and available resources. One of the key issues is whether there should be a legislative requirement for the key principles of the Board Secretary role which strengthen good governance to be adopted consistently across all local health boards and NHS trusts.


36. Taking into consideration the findings of recent reviews, the feedback from the Green Paper consultation and models used within other public sectors, we believe there are a number of key principles to adopt for the role of Board Secretary.

Key Principles

There is statutory protection to have a Board Secretary and for the role;

There is protection to cover raising concerns and independently challenging the decisions of the Chief Executive and the Board more widely.



17

An independent process is put in place to dismiss a Board Secretary from post.

The Board Secretary should be able to highlight in a report when/if there is a key issue of concern to either the Board Chair or Chief Executive, depending on where the concern lies;

There should be a standard job description that is clear on the requirements and duties that should and also should not be undertaken by the Board Secretary, to avoid potential conflicts of priorities and interests.

NHS organisations should ensure an appropriate level of resource to support Board Secretaries to effectively carry out their role.

37. We recognise to deliver on these principles does not necessarily require

primary legislation and alternative interventions could assist in meeting these objectives such as secondary legislation (regulations), guidance and training.

Questions on Board Secretary In order to deliver on the key principles outlined the Welsh Government believes that the role of Board Secretary should be placed on a statutory basis and have statutory protection to allow the role to be independent with safeguards in place to challenge the Chief Executive of an NHS organisation or the Board more widely. Do you agree with these proposals? What further issues would you want us to take into account in firming up these proposals?

Chapter 2: Duties to Promote Cultural Change

38. The Green Paper said that in order to promote a culture of co-production, we must explore options for further enhancing openness, transparency and candour in health and social care. It also talked about the need for local health boards to look beyond their own statutory boundaries and population when making decisions in order to focus on the quality and safety of health and care services. To do this they may need to plan and make decisions collectively working with our NHS Trusts and other partners. The Social Services and Well-being (Wales) Act 2014 and the Well-being of Future Generations (Wales) Act 2015 are landmark pieces of legislation which impact on the statutory duties of NHS organisations to plan in partnership.



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39. This Chapter sets out our proposals for two new duties to be placed on local health boards and NHS Trusts which we believe will further support cross boundary working and bring more focus to their actions and decision-making.

2.1. Duty of Quality for the Population of Wales Where are we now and where do we need to be?

40. NHS bodies are already under a duty of quality which is set out in legislation dating back to 20039. This duty was put in place when our landscape looked very different - when it was largely made up of smaller NHS Trusts which were divorced structurally from primary care. It therefore predates our planned, integrated health system. This duty is focused on having arrangements in place to monitor and improve the quality of health care provided by or on behalf of an organisation. The current duty is particularly focussed on the quality of services provided to an individual rather than at a wider population level. This is not suited to local health boards which should no longer see themselves as mere providers of care but as organisations responsible for the health of their population. As such, local health boards must be prepared to apply quality across the planning and provision of services for their populations. Within NHS Wales we have adopted the model of the Triple Aim10 - a quality system based on securing better outcome, better user experience and better value, underpinned by the internationally accepted Institute of Medicine definition of quality11 which is to provide safe, effective, patient-centred, timely, efficient and equitable care.

41. The NHS (Wales) Act 2006 also sets out the responsibilities of local health boards in developing plans for improving the health of the local population. The Well-being of Future Generations (Wales) Act 2015 also sets out responsibilities for Health Boards as statutory partners on Public Services Boards to work in partnership on local well-being assessments and plans.

42. All health systems are facing significant challenges to provide sustainable services. Changes in demographics, the evidence base, innovative treatments, the need to meet standards as well as the resource constraints contribute to this. There will be times when services need to be planned and provided across health board boundaries whether regionally or all Wales. Local health boards perceive the need to plan and deliver across boundaries conflicts with their current duties outlined above.

43. We also need to have a changing focus to promoting good health and wellbeing so developing services to promote wellness rather then the traditional focus on treating ill health. This means enabling individuals to take more control of their own health as well as being directly involved and engaged in co-designing and co-producing solutions. The introduction of the

9 Health and Social Care (Community Health and Standards) Act 2003

10 Institute for Healthcare Improvement (IHI)

11 Crossing the Quality Chasm Institute of Medicine, 2001



http://www.legislation.gov.uk/ukpga/2003/43/pdfs/ukpga_20030043_en.pdf

http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx

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prudent healthcare principles provides a universal framework to help make this shift. This encompasses the six domains which make up our definition of quality and particularly the need to tackle inequalities in service provision and outcomes.

44. We are mindful other legislation has also come onto the statute book which is not sufficiently aligned with the current duty of quality. The legislation that underpins the requirement to have an integrated medium term plan12, whilst requiring bodies to plan services to improve health or provision of health care services focuses very much on doing so within budgets available and makes no explicit reference to quality. It is also, as already noted above not explicit about giving consideration to planning beyond organisational boundaries. Under the Social Services and Well-being (Wales) Act 2014, local authorities are under a duty of cooperation with their relevant partners, persons or bodies to ensure well-being and safeguarding of those requiring care, and improve the quality of care and support needed.

45. Taking all this into account we therefore consider the existing duty of quality and the local population planning duty to be outdated, too provider focussed and too narrow in their scope.

46. When we consulted on the Green Paper there was considerable support for a duty of quality to span organisations, including social health and for it to align with the Well-Being of Future Generations Act and the Social Services and Well-being Act to enable a greater focus on quality.


47. We are looking to place a new enhanced and extended duty of quality on NHS bodies to enable and require them to demonstrate that where needed they collaborate on planning and agree regional or all-Wales solutions to secure quality services for the population of Wales. For local health boards this would ensure there is an explicit need to extend this to the development of their integrated plans and future service proposals. To better enable the planning and provision of person centred care we would also look to extend that duty and also broaden the powers of local health boards and trusts to co-operate and work in partnership with local authorities and/or other bodies including the third sector, aligning it with the duties already placed on local authorities.

48. We consider this will enable a system shift to promote services based on the person, rather than the organisation. There are also situations where more specialist services may be required but cannot be provided in every local health board area as demand and resources - human, physical and financial could not deliver this, let alone meet the clinical service standards required. We believe this new duty would facilitate planning and decision making within and by NHS bodies if they were under a wider duty of quality requiring them to

12

Section 175(2), NHS (Wales) Act 2006 – as amended by the NHS Finance (Wales) Act 2014



20

take in account a regional or all Wales population perspective. To further support this we propose to strengthen the existing planning duty to make sure of this.

Questions on Duty of Quality for the population of Wales The Welsh Government believes that the duty of quality should be updated and enhanced to better reflect our integrated system. This duty should be sufficiently wide in scope to facilitate the needs of the population of Wales to facilitate and enable collaborative, regional and all-Wales solutions to service design and delivery NHS bodies should also be placed under a reciprocal duty with local authorities to co-operate and work in partnership to improve the quality of services provided. Welsh Government also believes that strengthening the existing planning duty will make sure health boards work together on the needs of the population of Wales in the planning and delivery of quality healthcare services. Do you agree with these proposals? What further issues would you want us to take into account in firming up these proposals?

2.2. Duty of Candour Where are we now and where do we need to be?

49. The 2016 Welsh Labour Manifesto13 promised a consultation on a potential statutory duty of candour so as to further promote a culture of openness in our health and care system. We are not starting from scratch because the existing Putting Things Right arrangements for the investigation of concerns and complaints in the NHS already promotes openness and the underpinning regulations14 contain a duty to be open with patients when harm has been caused. In social care, there are also proposals out to consultation15 to place a duty, in regulations, on regulated providers in Wales to be open and transparent in all dealings with people, not just when concerns are being raised. The details of how regulated providers should comply with this requirement will be set out in guidance.

13

Together for Wales, Welsh Labour Manifesto, 2016 14

The NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 15

Consultation on Phase 2 implementation of the Regulation and Inspection of Social Care (Wales) Act 2016



http://www.legislation.gov.uk/wsi/2011/704/made

https://consultations.gov.wales/consultations/phase-2-implementation-regulation-and-inspection-social-care-wales-act-2016

https://consultations.gov.wales/consultations/phase-2-implementation-regulation-and-inspection-social-care-wales-act-2016

21

50. There have been several calls for a stronger legal duty of candour in the NHS in Wales. Mr Keith Evans’s review16 of Putting Things Right in 2014 supported these calls. The Green Paper consultation responses also revealed significant support for a statutory duty of candour.

51. The Welsh Ministers do not currently have the power to provide for an express statutory duty of candour for the health service. The existing NHS complaints regulations referred to above, are drawn from powers set out in the Health and Social Care (Community Health and Standards) Act 2003. These are limited to making regulations about the handling and consideration of complaints, including the action to be taken as a result of complaints. In order to trigger the duty to be open, therefore, a member of staff must first notify a concern under the procedure. It seems clear that the current duty on NHS organisations in Wales, as set out in the Putting Things Right regulations needs to go further.

52. The proposed regulations in social care in Wales (referred to above) are drawn from the Regulation and Inspection of Social Care (Wales) Act 2016. They are arguably wider since they encourage candour at all levels and do not necessarily rely on a concern being notified.


53. We want to ensure that all health and social care organisations and providers are under similar duties to be open and transparent, because then the public will know what they should be able to expect. More consistency will encourage the health and care system to behave culturally as one and will be in the interests of a person-centred system of health and social care.

54. We have looked at the situation in the rest of the UK. There is currently a legal duty of candour for the NHS in England, set out at Regulation 20 of duty of the Health and Social Care Act 2008 (Regulated Activities), Regulations 201417. This duty of candour was put in place in England following the Mid Staffordshire NHS Foundation Trust inquiry. It only applies to health service bodies (hospitals and special health authorities), so it does not cover GPs, dentists or pharmacists.

55. In Scotland, a duty of candour procedure is set out in Part 2 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 201618. This duty applies across all health and social care services, including independent health care, GPs, dentists and pharmacists. It means that if an unintended or unexpected incident occurs in the course of providing a health service, a care service or a social work service, then the person responsible is under a duty to be open and honest.

16

Using the Gift of Complaints, Keith Evans, 2014 17

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 18

Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016



http://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents

http://www.legislation.gov.uk/asp/2016/14/enacted

22

56. We would like to achieve a position where all health and social care bodies are under a statutory duty to be open and transparent, in all dealings with individuals as well as at a population level. In taking this forward, we would look to build on the work already done on duty of candour under the Regulation and Inspection of Social Care (Wales) Act 2016.

Questions on Duty of Candour The Welsh Government believes that the development of a statutory duty of candour across health and social services in Wales would consolidate existing duties and be in the interests of a person centred system. Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?


57. Every person in Wales who uses health and social care services or supports others to do so has the right to receive excellent care as well as advice and support to maintain their health and wellbeing. This right exists whether the care is received in their own home, in their community, in a primary care setting, a residential home, a nursing home, or a hospital. All health and social care service providers in Wales need to demonstrate that they are doing the right thing, in the right way, in the right place, at the right time and with the right staff. Their care should be ‘person centred’ and individualised.

3.1. Setting and Meeting Common Standards Where are we now and where do we need to be?

58. The current system consists of separate standards for NHS health care, independent health care and social care. The Health and Care Standards for Wales19 have been designed so that they can be implemented in all NHS health care services, settings and locations. They establish a basis for improving the quality and safety of healthcare services by providing a framework which can be used in identifying strengths and highlighting areas for improvement. This includes services and arrangements to promote health and well being and not merely those focused on treating ill health. They also provide the framework for wider governance and accountability within NHS bodies. Healthcare Inspectorate Wales (HIW) inspects NHS services against the Health and Care Standards, whilst it inspects and regulates the

19

Health and Care Standards, Welsh Government, April 2015



http://gov.wales/topics/health/publications/health/guidance/care-standards/?lang=en

23

independent sector against the National Minimum Standards for Independent Healthcare20.

59. Social Care possesses its own separate standards and regulations. A number of Acts and Regulations govern the standards of social care in various settings. The Care Standards Act 2000 makes provision for the registration and regulation of social care services. Care and Social Services Inspectorate Wales (CSSIW) is the regulator for social care and social services in Wales and inspects services from child minders and nurseries to residential and nursing homes for older people.

60. There have been numerous developments in social care in Wales in recent years. The Regulation and Inspection of Social Care (Wales) Act 2016 provides for requirements to be placed on providers of regulated services and responsible individuals in regulations and statutory guidance, currently being consulted on.21 The aim of these requirements is to assist individuals to achieve the outcomes they wish to achieve.

61. The existence of different standards can be confusing for service users and care providers alike and makes for complexity for commissioners of services if they are not commissioning services for individuals against a common framework, wherever they may be receiving a service. In the absence of common standards there is potential for care to be fragmented and poorly coordinated. In a system without common standards, care can appear to be complex and confusing to the recipient. Individuals receiving care can be left perplexed as to why different standards operate in different settings when they feel that they have the right to the same standard of care regardless of where they receive it.


62. The person receiving care needs to feel confident that the standard of care will remain the same regardless of where they receive their care. The care should be focused on meeting the person’s needs and helping the person to achieve the outcome they desire.

63. The standards that underpin care should therefore have common principles regardless of whether the focus is health care or social care. Care and the standards that underpin care needs to be perceived principally through the eyes of the person receiving care and not through the eyes of the organisations delivering the care. There should therefore be common standards.

64. We are proposing that a common set of high level standards are developed which applies to health and social care and regardless of the location where care is delivered.

20

National Minimum Standards for Independent Healthcare Services in Wales, Welsh Government, April 2011 21

See footnote 15



http://gov.wales/legislation/subordinate/nonsi/nhswales/2011/4927892/?lang=en

http://gov.wales/legislation/subordinate/nonsi/nhswales/2011/4927892/?lang=en

24

65. Common standards will provide a common set of requirements applying across all health and social care organisations to ensure that services commissioned and provided are both safe and of an acceptable quality. Common standards also provide a framework for continuous improvement in the overall quality of care people receive.

66. Person centred care aims to be people focused, to promote independence and autonomy and to provide choice and control. The principle of individual care is that people are treated as individuals, reflecting their own needs and responsibilities. All those who provide care have a responsibility to ensure that whatever care they are providing includes attention to basic human rights. Where people are unable to ensure these rights for themselves, when they are unable to express their needs and wishes as a result of a sensory impairment, a mental health problem, learning disability, communication difficulty or any other reason, access to independent advocacy services must be provided. This includes complying with the Welsh Language standards and considering how they can be delivered in the form of an active offer which is a key element of the More Than Just Words22 strategic framework. Every person has unique needs and wishes. Individual needs and wishes vary with factors such as age, gender culture, religion and personal circumstances, and individual needs change over time, respecting people as individuals is an integral part of all care.

Questions on Common Standards The Welsh Government believes there should be a common set of high level standards applied to health and social care and that the standards should apply regardless of the location of care. Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?

3.2. Joint Investigation of Health and Social Care Complaints Where are we now and where do we want to be?

67. More than ever before, services are being provided to individuals by organisations working together. For example, packages of care for individuals may be arranged by local health boards and local authorities working together, or provided by staff employed by different bodies, or by care homes. This way of working puts people at the heart of their own health and care and is something we want to build on. People receiving health and social care

22

More Than Just Words



http://www.wales.nhs.uk/sites3/page.cfm?orgid=415&pid=64158

25

may not, and should not need to, understand that different organisations are responsible for different parts of their care. To the individual, this should appear seamless.

68. If something goes wrong with a person’s care, organisations should work to discover what went wrong, and to put things right. When the concern spans health and social care, it should not be for the person receiving the care or their family to make multiple complaints or to be passed around between organisations. We want to make it easier for people to complain when their complaint covers care provided by different organisations. By working together to investigate complaints, health and social care organisations can learn lessons and improve the quality of their services. There are several examples in the Public Services Ombudsman for Wales’s casebooks of complaints which span both health and social care.

69. Complaints about health services in Wales are dealt with under the Putting Things Right23 process and complaints about social care follow the Social Services Complaints procedure.24 Complaints about private care homes are dealt with by the individual businesses. The Care and Social Services Inspectorate for Wales (CSSIW) has an overview of these concerns, although CSSIW cannot investigate them.

70. The statutory health service process came into effect in 2011. The process is:

You are encouraged to talk to the staff involved with your care or treatment as soon as possible, so they can try to resolve your complaint immediately.

If this does not help, you should contact the health board or trust’s concerns team.

The concerns team will look into your concern (complaint) and aim to respond within 30 working days.

If you are not happy with their response you can contact the Public Services Ombudsman for Wales.

71. The statutory social services process came into effect in 2014. The process

is:

You talk to the local authority about your complaint as soon as possible. They will try to resolve it within 10 working days.

If this does not help, you should contact the local authority’s complaints officer.

An independent investigator will work with the complaints officer to look into your complaint and aim to respond within 25 working days.

If you are not happy with their response you can contact the Public Services Ombudsman for Wales.

23

Putting Things Right - raising a concern about health services in Wales 24

A guide to handling complaints and representations by local authority social services



http://gov.wales/topics/health/socialcare/complaints/?lang=en

http://www.wales.nhs.uk/sites3/page.cfm?orgid=932&pid=50738

http://gov.wales/topics/health/socialcare/complaints/?lang=en

26

72. At present, people whose complaint covers health, social care, or a private care home have to make at least two complaints. This also means the staff in the organisations concerned may be looking at the same complaint for different reasons. We want organisations to work together when investigating these complaints. Mr Keith Evans noted this when he reviewed Putting Things Right in 2014. His report25, recommended that we need a complaints process which is people centred not service centred.


73. We want to make it a requirement for organisations to work together to investigate and resolve complaints which cover both health and social care. This will benefit the citizen but will also help those working in health and social care to understand how to investigate complaints together and learn lessons which can be used to improve their services.

74. We propose that health and social care organisations and independent providers of health and social care will need to come together to agree to follow a joint complaints process for these types of complaint. When people make a complaint about health and social care, organisations will need to explain to them that they will be following this joint process rather than the separate existing complaints processes. We acknowledge that there may be a number of operational challenges to overcome, for example, the consideration of the redress arrangements in relation to health service related concerns, but feel that seeking to have a joint process for certain complaints will be in the best interests of citizens.

75. In order to make these changes it may be necessary to change the regulations which underpin Putting Things Right26 and the Social Services Complaints procedure regulations27. Primary legislation may also be required to provide the Welsh Ministers with the powers to make revisions to the regulations.

Questions on Joint Complaints The Welsh Government believes that requiring different organisations to work together to investigate complaints will make it easier for people to complain when their complaint is about both health and social services. We also believe it will encourage organisations to learn lessons to improve their services. Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?

25

See footnote 16 26

NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 27

The Social Services Complaints Procedure (Wales) Regulations 2014





27

Chapter 4: Effective Citizen Voice, Co-production and Clear Inspection

76. The Green Paper described how the direction of travel is for health and social

care services to be provided in a more integrated fashion, aiming to provide a seamless, person centred experience, along a pathway which potentially encompasses primary, community, hospital and social care. The system of inspection and regulation and the representation of citizens’ views should support this direction of travel. Co-production means continuous involvement and engagement with the public on how decisions are reached and working with individuals to make decisions about their own health care.

77. This Chapter sets out our proposals for further strengthening the voice of citizens in health and social care, for how services should be co-created with citizens and how further clarity and future-proofing might be brought to the work of Healthcare Inspectorate Wales and Care and Social Services Inspectorate Wales.

4.1. Representing the Citizen in Health and Social Care Where are we now and where do we need to be?

78. With organisations now increasingly starting to collaborate to provide seamless services to individuals and communities, there needs to be a way of capturing people’s views about services across the whole system. This will mean that people are more involved in the way services develop and how they are delivered. There are a number of arrangements already in place from which we can build better, stronger ways to represent the voice of people in health and social care and work collaboratively to engage and involve the public. At a cross-boundary level, the statutory Regional Partnership Boards (RPBs) established under the Partnership Arrangements (Wales) Regulations 2015, bring together organisations to effectively assess and plan for the health and social care needs of local populations. The Public Services Boards, established under the Well-being for Future Generations (Wales) Act 2015 also bring together public services organisations on a local level to work together to develop local well-being assessments and plans. They need to all be informed about people’s views in undertaking their functions and potentially work together to engage with the public.

79. For health services, there are a number of mechanisms for engaging with patients and the public. Local health boards are under a duty to involve and consult service users in the way services are planned and delivered and they carry out this duty in numerous ways. GPs are required to have Patient Participation Groups. The statutory Community Health Councils (CHCs) represent the public’s interest in the way services are planned and provided. There are seven CHCs in Wales, which mirror the boundaries of, and are responsible for the same local populations as the local health boards. They are comprised of both paid staff and volunteer members. Members are appointed in part by the Welsh Government as well as selected from local



28

authorities and third sector organisations. There is also a Board of CHCs which oversees the work and performance of the seven CHCs. CHCs can be said to have four broad functions:

Scrutiny of the operation of the health service, including the entry and inspection of premises;

Engagement with the public on issues;

Referral by individual CHCs of matters to Welsh Ministers in connection with service changes;

Independent complaints advocacy services (a function of Welsh Ministers which has been conferred on CHCs through regulations).

80. Local authorities are also under a duty to promote user-led services and to involve people in the design and provision of services28. There are no specific statutory bodies for citizen engagement in social care, as in health with CHCs. Instead, effective citizen engagement is an expectation of the implementation of the Social Services and Well-being (Wales) Act 2014 and the Care and Support (Area Planning) (Wales) Regulations flowing from that Act require engagement with citizens. It is largely left to regions to decide the most effective method within their area and the Welsh Government has not been prescriptive as to how citizen engagement should look.

81. As part of this picture, a number of reports in recent years have questioned whether the CHC model for representing the public voice in the health service, which has been in place since 1974, is flexible enough to respond to a health and care services that works increasingly across organisational boundaries29,30,31. The Green Paper asked whether the current CHC model needed to change or if its activities needed to be refocused. We received a large number of responses to these questions, expressing a wide range of views. What is certain, and supported by the findings of the OECD, is that there is now a need to take some action.

82. The way CHCs are currently configured enables them to represent the public’s interest in the health service, something which is not reflective of an increasingly integrated approach to service delivery. As highlighted above, their attachment to a particular geographical area and population also causes challenges when cross-boundary working or service change is proposed. More broadly, while members are appointed according to their skills and ability to represent patients, the membership is not at all representative of local communities. The member appointments process has over recent years

28

Section 16, Social Services and Well-being (Wales) Act 2014 29

Moving Towards World Class? A Review of Community Health Councils in Wales, Professor Marcus Longley, June 2012. 30

Lessons Learned Independent Review into NHS Service Change Engagement and Consultation, Ann Lloyd CBE, January 2014 31

An Independent Review of the Work of Healthcare Inspectorate Wales, Ruth Marks MBE, November 2014



29

grown increasingly unsustainable and it is becoming difficult to attract sufficient people to the role, whether it is through the public appointments process, local authority or third sector nominations. Overall CHCs also lack visibility within communities.

83. There is also a perception, highlighted by the OECD review that some of the CHCs’ activities, such as inspections, duplicate the work of other bodies and detract from the true representation of citizens’ voices. However we are aware that the CHCs have been mindful of this and changing the focus away from inspection to one of engagement which includes visiting premises to gain feedback on the experience of care.


84. We want to further strengthen the voice of people in the way health and social care is planned and delivered by setting up a new arrangement which will have a national and local focus, but will be flexible, look at the whole system and work within the context of increased joint working and planning across public services through the regional partnership boards and public services boards

85. We would therefore propose the creation of a new, independent, arrangement to replace CHCs, based in some respects on the Scottish Health Council32 and working across health and social care. This new national citizen voice arrangement would represent the interests of the public in health and social care and would sit alongside Healthcare Inspectorate Wales and the Care and Social Services Inspectorate Wales and work closely with them. We want these bodies to be organised in such a fashion that they can take a unified approach when required, for example, through joint planning or advisory structures, but similarly can continue to operate independently of each other when necessary. Some further discussion on how this arrangement could work in practice is set out in the final chapter 4.3.

86. The new citizen voice body would have considerable operational autonomy and be free to decide its own work programme and recruit volunteers locally in line with a number of refreshed functions. We propose the current functions of CHCs could be replaced by a new set of functions which could include:

Working with local community organisations, user groups and others to promote the co-design and co-creation of services;

Support the building of local networks and effecting join up across health and social care groups;

Providing support for health and social care organisations (local health boards, NHS trusts, local authorities, Regional Partnership Boards, etc.) in improving the way they engage individually and jointly with their communities on health and social care service matters;

32

http://www.scottishhealthcouncil.org/home.aspx



http://www.scottishhealthcouncil.org/home.aspx

30

Monitoring and evaluating the way in which health and social care organisations involve local people, probably in accordance with agreed standards;

Providing advice to local health boards and/or the Cabinet Secretary in relation to the level of engagement undertaken on substantial changes (as outlined below).

87. We believe this refreshed citizen voice arrangement will provide better

assurance and the impetus for health and social care organisations to improve the way they engage with the public and work in partnership to gather views and involve citizens in planning and delivery of services. Positioning the new arrangement alongside the inspectorates, will increase profile and visibility, remove a number of duplicative activities and functions currently invested in CHCs (for example inspection of premises) and embed patient voice more systematically within the work of the inspectorates. We think this is the best way to strengthen the public voice in line with the recommendations of the OECD and will be more sustainable than the current system which relies on the recruitment and retention of members.

88. We would propose some of the resources and staffing currently allocated to CHCs could be repurposed to support the new arrangements but this would need further detailed consideration as part of the development of the proposals. The current independent advocacy service provided by CHCs in relation to NHS complaints has proved valuable and this could be continued under the new arrangements. We may want to consider how such a service could be extended to also cover complaints about social care services, in order to mirror the proposals about the joint investigation of complaints outlined in Chapter 3.2.

89. To abolish CHCs in their current form and establish a new body with responsibility for representing the interests of the public across health and social care, would require primary legislation.

Questions on Citizen Representation The Welsh Government believes that local health and social care organisations should be working with the public to co-design and co-create services and that the way they do this needs to be independently monitored. We propose replacing the current statutory CHCs and their functions with a new national arrangement to represent the citizen voice in health and social care, to advise and provide independent assurance. The new body will work alongside Healthcare Inspectorate Wales and Care and Social Services Inspectorate Wales and have autonomy to decide how it will operate at local level. Do you support this proposal?



31

Can you see any practical difficulties with these suggestions?

4.2. Co-producing Plans and Services with Citizens Where are we now and where do we need to be?

90. The NHS in Wales is finding it difficult to bring about the sort of change which will place services on a more sustainable long-term footing and deliver improvements in service quality and safety, whilst at the same time ensuring that the voice of the citizen is an integral part of decision-making. Services may need to be provided locally, regionally or nationally in order to provide the best possible outcomes for Welsh people. However, making decisions about how and where services should be provided is not easy within the current NHS Wales structure where local health boards have responsibility for the population within specific geographical boundaries.

91. It is particularly hard to agree change when services affect large numbers of people and it is often these changes which end up being referred to the Minister for a decision. This will sometimes be the right thing to do, but it should be the last resort. We feel that changes need to be made to the process to ensure everything possible has been done to allow decision-making to take place locally. This means supporting more of a shift towards the genuine involvement of people in drawing up plans, together with better and more independent scrutiny of any substantial service change and reconfiguration proposals.

92. We describe in Chapter 2.1 how we think a Duty of Quality for the Population of Wales will facilitate collaborative all-Wales and regional planning and service delivery.

93. Proposals for service change must of course be based on strong clinical evidence on what will provide the right health outcomes for people; but plans will have a greater chance of success if citizens are involved in co-designing and co-creating them. People must have an opportunity to weigh up the arguments and consider how a possible service change will affect them and others. Local health boards must be able to show they have listened to the views of citizens and taken their views into account in their proposals to deliver sustainable services for the future. This process requires a very open approach by local health boards which must find ways to balance the clinical evidence with the views and experiences of local people. They must also be able to demonstrate they have done so.

94. The National Health Service (Wales) Act 2006 already places a duty on local health boards to involve and consult local people or their representatives in the planning and delivery of services, including proposed service changes. Whilst this duty, and associated guidance, sets a broad framework for involving the public in decision-making, there is currently quite a wide interpretation of what this means. To date, NHS organisations in Wales have



32

taken different approaches to involving citizens in service planning, delivery and change.

95. Our goal is for inclusive continuous engagement that fully reflects public voice to become the norm, so we can “co-create” improved patient outcomes. We want to place more emphasis on the importance of regional and strategic working and the range of modern digital and social media options available to better target engagement and make it more inclusive and representative. As a first step we will be revising existing guidance to illustrate what effective engagement based on co-production principles looks like and to provide greater clarity on what is meant by substantial service change.

96. Community Health Councils (CHCs) currently have a role in scrutinising

change proposals to promote a better understanding and ensure they meet the health needs of local communities. Under present arrangements, CHCs, on behalf of the public, can refer a matter to the Cabinet Secretary for decision if they are not satisfied a proposal would be in the best interests of their local communities. In these circumstances they are expected to represent wider public views in proposing alternative change options and plans, a function which has not been consistently delivered.

97. Disagreement may arise between local health boards and/or CHCs, particularly on proposals which cross local health board and CHC boundaries that could deliver important benefits for the wider population. This is because there is usually an expectation from local communities and politicians that CHCs will act in the interests of their local population and prioritise these local interests ahead of wider, national interests. In such cases, implementing essential improvements to services can become cumbersome and involve lengthy delays to resolve disputes. In turn, higher quality, safer services and improved patient outcomes take longer to deliver.

98. As indicated in Chapter 4.1, we propose to replace CHCs with a different arrangement which enables citizens to have a stronger, continuous voice in contributing to the planning and development of their health and social care services.


99. When a change can be described as substantial, then we need a very clear process in terms of decision-making. Under the current arrangements, independent expert advisory panels have been convened on an ad hoc, non-statutory basis when a disputed substantial service change decision has been referred to the Minister by a CHC and there is a need for stronger clinical evidence. If the proposed changes are made to CHCs, there will no longer be a mechanism for referring disputed substantial service change proposals to the Cabinet Secretary. We have considered a number of options for introducing independent scrutiny into the process to provide advice on all health board service change proposals that meet agreed criteria for substantial change and reconfiguration.



33

100. We are aiming to establish an approach similar to that currently in place in Scotland, in which health boards in Wales will be required to identify all change proposals meeting the criteria. This will then trigger a process of further scrutiny relating to the clinical evidence and an assessment of whether adequate involvement of the public has been achieved in drawing up the proposals.

101. We propose to establish an independent mechanism to provide clinical advice and assurance on substantial change proposals; the new citizen voice body referred to in Chapter 4.1 will provide an independent assessment on the adequacy or otherwise of the involvement of citizens. Health boards will be expected to reach a decision through their existing governance arrangements, based on both these sources of evidence. In the event that they are unable to reach consensus, then as a last resort the Welsh

Ministers will be able to intervene and make a decision based on the independent evidence, both clinical and how well public opinion has been integrated into the proposals. The diagram at Figure 1 shows, at a high level, how this process could work in practice.



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Figure 1

Service change phase

Action and broad steps

C

O

N

T

I

N

U

O

U

S

E

N G

A

G E

M

E

N

T

Planning Step 1: Health Board/s develop and set out their service change proposals engaging with the population and staff

Assessment Step 2: Health board considers whether change could be

described as a substantial proposal. If yes it moves to step 3 and 4. If no, it moves straight to Step 5

Advice – citizen voice

Step 3*: Independent citizen voice body advises whether

public engagement process undertaken by the health board complies with guidance. This could result in more engagement.

Advice – clinical Step 4*: Independent clinical panel considers the relevant clinical evidence for the change proposal.

Decision Step 5: Health board(s) make decision through their

existing governance mechanisms, based on independent clinical panel recommendation, advice from the citizen voice body and any other relevant factors

Call in Step 6: If health board(s) cannot reach a decision on a substantial proposal, Minister may call in the proposal.

In making a decision the Minister will consider the advice received, including from the clinical panel and citizen advice body and any other relevant factors

*Steps 3 and 4 are undertaken simultaneously

102. Following our consultation on the Green Paper, there was support for

the principle that ultimate accountability for making such decisions should rest with the Welsh Ministers, however there will need to be careful consideration of the point at which Ministers will intervene and call in decisions.

Questions on Service Change The Welsh Government believes that introducing an independent mechanism to provide clinical advice on substantial service change decisions, with advice from the proposed new citizen voice body, will encourage continuous engagement and increase the pace of strategic change through enabling a more evidence-based, transparent process and a more directive and guiding role on the part of Welsh Government. Do you agree with this proposal?



35

What further issues would you want us to take into account in firming up this proposal?

4.3. Inspection and Regulation Where are we now and where do we need to be?

103. Healthcare Inspectorate Wales (HIW) is the inspectorate and regulator of healthcare in Wales. It is responsible for reviewing and inspecting NHS and independent healthcare organisations to provide assurance for patients, the public, the Welsh Government, and healthcare providers, that services are safe and of good quality. Although HIW is part of the Welsh Government and carries out functions on behalf of Welsh Ministers, its independence is secured through operational autonomy. This is also the case for the Care and Social Services Inspectorate Wales (CSSIW).

104. Over the last three years, there has been a continuing discussion about the role of HIW and an assessment of whether the scope of its work needs to be reformed and broadened33, 34, 35, 36. The wider opportunities for better joined up working with other bodies, such as CSSIW and CHCs have featured as a prominent part of these discussions. In relation to CHCs, their ability to enter and inspect premises has raised concerns about duplication with HIW’s role. These reviews culminated in the Green Paper consultation exercise which sought views on enhancing HIW’s independence, enabling collaboration with CSSIW, and further exploring opportunities for setting up a single inspectorate.

105. In parallel to the reviews of HIW and the Green Paper consultation, the introduction of the Social Services and Well-being Act 2014 and the Regulation and Inspection of Social Care Act 2016 (the 2016 Act) has led the way in placing service quality and improvement at the heart of social care in Wales.

106. The 2016 Act created a clear statutory framework for CSSIW and a clearer platform for assurance that services are meeting people’s needs. This has highlighted the constraints that the existing legislation underpinning HIW creates practically, which we would like to future-proofed in a similar vein to that which now underpins CSSIW. Legislative reform for HIW would address the fact that there are insufficient powers to regulate in some areas, and that different arrangements apply across NHS and independent healthcare settings. There is also some seemingly illogical use of HIW resources, for

33

The work of Healthcare Inspectorate Wales, Health and Social Care Committee, March 2014 34

See footnote 29 35

Wider issues emanating from the governance review of Betsi Cadwaladr University Health Board, Public Accounts Committee, February 2016 36

See footnote 4



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example the regulation of lasers in tattoo and beauty parlours. Services are also regulated and inspected on an establishment, rather than service basis, which is at odds with the way CSSIW regulate and inspect under the 2016 Act.

107. While legislation may be required, it is important to acknowledge the ongoing work that has been and continues to develop in terms of joint working and the sharing of intelligence, for example, a planned pilot joint review of healthcare provision in care homes. This work has informed our considerations as to what is currently preventing good practice and what mechanisms are necessary in order to improve and build on the opportunity for bodies to work together


108. We want to ensure the system of regulation and inspection across health and social services is aligned and future-proofed in order to provide the relevant assurances to support improvement within organisations from a person-centred perspective. In improving well-being, preventing ill-health and providing services in health and social care, there should be a consistent approach to inspection and to examining the quality and safety of services received. People should expect the inspectorates to work together where those health and care services overlap. In practical terms there appears to be no strong appetite at the moment for merging the two inspectorates or for making them legally independent. Both HIW and CSSIW are already operationally independent and can work together if they need to – but this may be too narrow a view.

109. It would clearly be desirable and beneficial to, at the very least, overhaul HIW’s underpinning legislation to ensure it has a clear, single, legislative framework to work to, as CSSIW now does following the Regulation and Inspection of Social Care (Wales) Act. Working to a similar framework would no doubt lead to more integration and common methodologies, and this in turn will benefit citizens.

110. However, we would also like to seek views on a wider proposal to create a new independent body, picking up on some of the recommendations made in the Ruth Marks review. We could, for example set up a Welsh Government Sponsored Body to encompass both inspectorates, as well as the national citizen’s voice body proposed in 4.1. Such a new body could see the pooling of significant existing resources to create a more independent entity which could provide further rigour and focus on quality in a more integrated system.

Questions on Inspection and Regulation and single body The Welsh Government believes that ensuring a clearer underpinning legislative framework for HIW will help to foster closer integration and joint working with CSSIW and at the very least this should be taken forward.



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What do you think of this proposal? Are there any specific issues you would want us to take into account in developing these proposals further? However we also believe there could be merit in considering a new body – for example, a Welsh Government Sponsored Body – to provide more independence in regulation and inspection and citizen voice. Would you support such an idea? What issues should we take into account if this idea were to be developed further?



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Summary of questions

Chapter 1: Effective Governance 1.1. Board Membership and Composition The Welsh Government believes that the Boards of both health boards and NHS trusts should share some core key principles which are outlined including delivering in partnership to deliver person centred care and a strong governance framework to enable the Board to work effectively and meet its responsibilities. All Boards should have Vice Chairs in order to support focussed and skilled leadership. The Welsh Government also believes that Ministers should have the authority to appoint additional Board members on time limited appointments if an NHS Health Board/Trust is under performing or under escalation procedures in accordance with the NHS Wales Escalation and Intervention arrangements. The Welsh Government believes that Board Executive Officer membership for local health boards should probably include some key positions which are consistent across local health boards but also allow some flexibility to appoint based on remit and priorities. Do you agree with these proposals? What further issues would you want us to take into account in firming up these proposals? 1.2. Board Secretary In order to deliver on the key principles outlined the Welsh Government believes that the role of Board Secretary should be placed on a statutory basis and have statutory protection to allow the role to be independent with safeguards in place to challenge the Chief Executive of an NHS organisation or the Board more widely. Do you agree with these proposals? What further issues would you want us to take into account in firming up these proposals?



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Chapter 2: Duties to Promote Cultural Change 2.1. Duty of Quality for the Population of Wales The Welsh Government believes that the duty of quality should be updated and enhanced to better reflect our integrated system. This duty should be sufficiently wide in scope to facilitate the needs of the population of Wales to facilitate and enable collaborative, regional and all-Wales solutions to service design and delivery NHS bodies should also be placed under a reciprocal duty with local authorities to co-operate and work in partnership to improve the quality of services provided. Welsh Government also believes that strengthening the existing planning duty will make sure health boards work together on the needs of the population of Wales in the planning and delivery of quality healthcare services. Do you agree with these proposals? What further issues would you want us to take into account in firming up these proposals? 2.2. Duty of Candour The Welsh Government believes that the development of a statutory duty of candour across health and social services in Wales would consolidate existing duties and be in the interests of a person centred system. Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?


3.1. Setting and Meeting Common Standards The Welsh Government believes there should be a common set of high level standards applied to health and social care and that the standards should apply regardless of the location of care. Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?



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3.2. Joint Investigation of Health and Social Care Complaints

The Welsh Government believes that requiring different organisations to work together to investigate complaints will make it easier for people to complain when their complaint is about both health and social services. We also believe it will encourage organisations to learn lessons to improve their services. Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?

Chapter 4: Effective Citizen Voice, Co-production and Clear Inspection 4.1. Representing the Citizen in Health and Social Care The Welsh Government believes that local health and social care organisations should be working with the public to co-design and co-create services and that the way they do this needs to be independently monitored. We propose replacing the current statutory CHCs and their functions with a new national arrangement to represent the citizen voice in health and social care, to advise and provide independent assurance. The new body will work alongside Healthcare Inspectorate Wales and Care and Social Services Inspectorate Wales and have autonomy to decide how it will operate at local level. Do you support this proposal? Can you see any practical difficulties with these suggestions? 4.2. Co-producing Plans and Services with Citizens The Welsh Government believes that introducing an independent mechanism to provide clinical advice on substantial service change decisions, with advice from the proposed new citizen voice body, will encourage continuous engagement and increase the pace of strategic change through enabling a more evidence-based, transparent process and a more directive and guiding role on the part of Welsh Government. Do you agree with this proposal? What further issues would you want us to take into account in firming up this proposal?



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4.3. Inspection and Regulation and single body The Welsh Government believes that ensuring a clearer underpinning legislative framework for HIW will help to foster closer integration and joint working with CSSIW and at the very least this should be taken forward. What do you think of this proposal? Are there any specific issues you would want us to take into account in developing these proposals further? However we also believe there could be merit in considering a new body – for example, a Welsh Government Sponsored Body – to provide more independence in regulation and inspection and citizen voice. Would you support such an idea? What issues should we take into account if this idea were to be developed further?



Services fit for the future – health and social care in Wales

Easy Read Version

This is an Easy Read document from the Welsh Government

White Paper

4.1.2 Appendix 2 WG Services fit for the future easy read


2


How to use this document

This is an Easy Read version. The words and their meaning are easy to read and understand.

You may need help and support to read this document. Ask someone you know to help you.

Where the document says ‘we’, this means the Welsh Government.

© Crown copyright 2017 WG32220 Digital ISBN 978-1-4734-9932-4

Mae’r ddogfen yma hefyd ar gael yn Gymraeg. This document is also available in Welsh.



3

Easy Read

To get more copies of this Easy Read version please contact the Healthcare Quality Division in Welsh Government and we will be happy to help you.

Phone: 03000 253090

E-mail: [email protected]



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Contents

What is in this booklet?

Chapter 1 – What this document is about 5

Chapter 2 – Why changes are needed 7

Chapter 3 – The things we are considering changing 9

Chapter 4 – How to tell us what you think 20

Chapter 5 – About you 22



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Easy Read

Chapter 1

What this document is about

This document is about health and social care in Wales.

Health and social care is provided by doctors, nurses, managers, care workers and lots of other people. They help people to stay healthy and independent. When people are ill, they care for them.

Health and social care is provided at the doctor’s surgery, in hospital, in clinics, at home and in care homes.

We want health and social care to do a good job. People should be happy with the care they get.

People should also have more say in the way health and social care works, and in their own care.



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We have already asked people about the things they would like to change. We did this in 2015 in a document called Our Health, Our Health Service.

We listened to what people said, and now we might make some changes to make things better.

White

Paper

White Paper

This document is called a White Paper. It looks at 2 things:

Quality: this means people having really good care in the way they want it.

Governance: this means making sure health and social care in Wales is run properly and by the right people.

To do this we may need to make some new laws.

We want you to tell us what you think about the changes we are thinking about making.

You don’t have to answer all the questions. You might just want to answer some. It’s up to you to decide.



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Easy Read

Chapter 2

Why changes are needed

A lot of people need health and social care services in Wales.

It is sad that so many people in Wales aren’t very well. We want people to be as healthy as they can be, and to live independently.

It is important for health and social care services to work together so they can provide good care now and in the future.

This is especially important because more people are living longer than used to happen.

If health and social care doesn’t start to work differently now, the services might not be able to cope in the future.



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We also want people to have more say in the way health and social care works, and in their own care.

We think making some new laws will help health and social care become better.



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Chapter 3

The things we might change

We might make some changes, and we talk about these below.

Good leaders

It is important for all of us that health and social care is run properly.

The group of people in charge of delivering health and social care services must also make sure they know what people want.

This does not always happen at the moment.

In Wales, organisations called Local Health Boards and Trusts are in charge of health services. We think they could work better.



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What are we going to do?

We might change the law to make it easier to get the best group of people to make the right decisions on how health services in Wales are run.

What do you think?

Telling the truth

We want health and social care workers and organisations in Wales to be honest and tell people if something goes wrong.

People need to know if something has gone wrong with their care because then they can become involved in helping to make things right.

This does not always happen at the moment and we want to make this better.



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We might make a new law to make sure workers and organisations will always tell the truth and speak to people.

If workers and organisations are not honest then the new law will mean they could get into trouble.

What do you think?

Good quality care

The people who work in health and social care should give really good quality care.

This means people like doctors, nurses and care workers.

It also means the people who run health and social care and who make plans for the future.



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Because Wales is a small country, we need to look at new ways to give people the services they need.

We think this could all work a lot better than it does at the moment.


We might make a new law to make everyone work together to plan and give good quality care.

This means organisations will have to decide and work together on what is best for all the people, not just the ones in their own areas.

What do you think?



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High standards across health and social care

We should all expect to receive good care.

The Welsh Government tells health and social care services in Wales what good care is. This is called “setting standards”.

At the moment there are different standards for family doctors, NHS hospitals, private hospitals and places like care homes or for the care in your own home.

We think the same standards should apply in all these places, so people receive the same quality of care wherever they need it.

This will be easier for everyone to understand.



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We might make a new law to ensure the same standards apply wherever you get your care.

What do you think?

Making a complaint

Complaints

Policy

If people are unhappy then it should be easy for them to say so, even if their complaint is about more than one service.

We don’t want people to have to make lots of complaints to different organisations within health and social care.

We want to make organisations work together to look into complaints. This won’t be needed for every complaint, but it will for some.

We think this will be better for people and easier for them to understand.



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Easy Read


We might make a new law to make health and social care organisations work together to look into a complaint.

This should make things easier for the person making the complaint.

What do you think?

Making sure people have a say

It is important for people to have a say in their own care and also in the way health and social care is carried out.

Local Health Boards and Local Authorities already have to ask people what they think about health and social care. We think they could do this better.

We also think that someone should check how Local Health Boards and Local Authorities are asking people what they think.



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At the moment, Community Health Councils – or CHCs for short – tell Local Health Boards what local people think of health services. People who work in the CHCs attend meetings and go around looking at places like hospitals and doctors’ surgeries.

CYNGOR IECHYD CYMUNED

COMMUNITY HEALTH COUNCIL

BWRDD CYMRU | WALES BOARD

CHCs do not look at social care.

We would like to replace CHCs with a different way of making sure people have a say about all health and social care services.

We would like to have one organisation to do this in Wales. Its job will be to check if health and social care is giving people a say. This is very similar to the way it works in Scotland.

This new organisation will also work very closely with the organisations which check health and social services and help them improve.

We think this will be a better way of making sure people are having a say because it puts more responsibility on Local Health Boards and Local Authorities to make sure this happens.



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We might make a new law to set up an organisation in Wales which makes sure people are having a say about health and social care.

What do you think?

Organising changes to health services

The way some health services are organised and where they are provided needs to change.

As well as people having a say in this, we also need to decide what to do if people can’t agree.

Some changes might need to be looked at by experts.

We think some difficult changes will need to be decided by the Welsh Government.

The Minister will look at all the information and decide what to do.



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The Minister will take advice from experts and from the new organisation which makes sure people have a say in health and social care.


We might make a new law to make it clear about what will happen if people can’t agree about a change to health services.

This will mean that Ministers will be able to decide but they will have to take advice first.

What do you think?

Checking how things are going

We need people to check that things are going well with health and social care.

The people who check health services in Wales are called Healthcare Inspectorate Wales – or HIW for short.

The people who check social care are called Care and Social Services Inspectorate for Wales – or CSSIW for short.



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We think HIW and CSSIW can do a lot more work together. We think this will be better for people and easier for them to understand.

We also think the law could be clearer about what HIW can check.


We might make a new law to set out what HIW can check. We will put all the new law in one place so it is easier for people to find and read it.

We might also make a new law to ensure HIW and CSSIW work together better.

Another idea is to have a new organisation to bring together HIW and CSSIW.

What do you think?

These are things we might want to do. We hope you think they sound like good ideas. If you think we have forgotten anything, please let us know!



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Chapter 4

How to tell us what you think

You can tell us what you think about the things we might want to do.

Please tell us by 29 September 2017.

You can write what you think on the next page.

You can send it:

By post: Matthew Tester Healthcare Quality Division Department of Health and Social Services Welsh Government Cathays Park Cardiff CF10 3NQ

By e-mail: [email protected]



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Easy Read

Write here about what you think. Add more pages if you want to.



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Chapter 5

About you

Your name

Your e-mail address or phone number

Your address



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Easy Read

Are you telling us what you think as part of a group?

If so, please write the name of the group here

We will write a report about what everyone tells us. This information will be on the internet.

If you do not want us to use your name or some of your address in our report, please tick here.

If you want us to keep what you say private, please tick here.



Quality and Governance in Health and Care in Wales

White Paper Impact Assessments

Title / Piece of work:

White Paper on Quality and Governance in Health and Care in Wales

Name of Official:

Sioned Rees, Senior Responsible Owner

Department:

Health and Social Services Group

Date:

28 June 2017

Welsh Language Clearance:

17.06.02.

4.1.3 Appendix 3 WG Services Fit for the Future Impact Assessment


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Contents Page

The White Paper on Quality and Governance in Health and Care in Wales

3

Background Context

o Programme for Government o Green Paper Consultation o Green Paper Summary Report

3

White Paper Development

o Summary of Proposals o Evidence Base

4

5

Stakeholder Engagement

o Green Paper consultation

7

Monitoring and Evaluation 8

The Impact Assessments

Our Approach to the Impact Assessments for this

White Paper

9

Equality and Diversity 9

Children’s Rights 10

Welsh Language 11

White Paper Enablers and Impact Assessments Schedule 1



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White Paper on Quality and Governance in Health and Care in Wales Background Context Programme for Government

1. The Programme for Government – Taking Wales Forward 2016-211 states – we

will protect and improve the Welsh NHS over the next five years and ensure it develops effectively to meet future needs.

Green Paper Consultation 2. On 6 July 2015, we published the Green Paper, ‘Our Health, Our Health Service’

on NHS Quality, Governance and Functions2 for consultation to promote a high level discussion and pose open questions to help inform any future actions.

3. The Green Paper was set out in two parts:

Part 1 dealt with the quality and service improvement agenda and set out the

actions taken so far, the challenges faced, and a number of questions on what else might need to be done to improve quality in health care in Wales. It explored potential mechanisms such as duties of quality and candour, and common standards frameworks, and also looked at strengthening engagement, the patient voice, and regulatory and inspection bodies. Part 2 covered a number of issues relating to the organisational and governance structures currently in place which need to be revisited since the last major health reforms of 2009, and which are key drivers in ensuring that organisations have the structures, skills and enablers to support quality. It looked at issues of finance, planning, board membership, workforce partnership working, and the potential expansion of NHS Wales Shared Services Partnership to a Wales-wide role.

Green Paper Summary Report

4. The summary of responses report3, published on 22 February 2016, highlighted

the key themes which emerged as the potential areas where there was most support for further work, whether that is through further guidance, policy development, or legislative proposals. These have now been developed further into a White Paper.

1 Welsh Government Taking Wales Forward 2016-2021, Welsh Government 2016

2 Green Paper, ‘Our Health, Our Health Service’ on NHS Quality, Governance and Functions, Welsh

Government, July 2015 3 Green Paper Summary Report, Welsh Government, February 2016



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White Paper development Summary of Proposals

5. As indicated above, the responses to the Green Paper consultation showed there was an appetite for further work and potential legislation across a number of areas related to quality and governance. The White Paper develops the policy areas in more detail, categorised under the following headings:

Effective Governance

6. Local health boards and NHS Trusts need to have the right powers, governance and accountabilities to enable leaders to take the right decisions with and for people. Boards also need to be of the right size and have the right people on them to act strategically and in partnership with citizens and other organisations.

7. The White Paper sets out how our proposals for change including through potential new legislation will help to bring about this mix of culture, strong leadership and governance which will be essential if local health boards are to unlock their promise as population-based organisations. It looks at:

The Composition of Boards, and

The Role of the Board Secretary.

Duties to Promote Cultural Change

8. In order to promote a culture of co-production, we must explore options for further enhancing openness, transparency and candour in health and social care. It also talked about the need for local health boards to look beyond their own statutory boundaries when planning and making decisions in order to focus on the quality and safety of health and care services.

9. The White Paper sets out our proposals for two new duties which we believe will bring more focus to actions and decision-making. These are:

A Duty of Quality for the Population of Wales, and

A Duty of Candour. Person-centred Health and Care

10. All health and social care service providers in Wales need to demonstrate that

they are doing the right thing, in the right way, in the right place, at the right

time and with the right staff. Their care should be ‘person centred’ and

individualised. The White Paper sets out proposals which will strengthen

person centred care, through:



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Setting and Meeting Common Standards, and

Joint Investigation of Health and Social Care Complaints.

Effective Citizen Voice, Co-production and Clear Inspection

11. The direction of travel is for health and social care services to be provided in a

more integrated fashion, aiming to provide a seamless, person centred experience, along a pathway which encompasses primary care, acute care and social care. The White Paper looks at plans for strengthening arrangements for:

Representing the Citizen in Health and Social Care

Co-producing Plans and Services with Citizens, and

Inspection and Regulation.

Evidence Base

12. Before proposing any legislative change we need to be clear about the issues we are trying to address, what we are building on, and the intended effect of the changes. The White Paper builds on recommendations made in reviews by the OECD, Ruth Marks, Sir Paul Williams and others as well as in important pieces of legislation including the Well-being for Future Generations (Wales) Act 2015 and the Social Services and Well-being (Wales) Act 2014. The proposals in the White Paper aim to enable and empower organisations and citizens to work together.

13. Below is the reference to some of the evidence sources used in the White Paper, however it is not an exhaustive list.

White Paper Area Evidence Base

Board Membership The Commission on Public Service Governance and Delivery (Williams Commission)4 questioned whether the current arrangements for health board membership provide the required level of challenge and, by extension, the spur to improve service quality. It recommended a review of the current number, representation and appointment process of independent members of health boards.

Board Secretary The National Assembly Public Accounts

4 Commission on Public Service Governance and Delivery (Williams Commission), Sir Paul Williams, January

2014



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Committee’s inquiry report into the governance arrangements at Betsi Cadwaladr University Health Board5, in 2013 and the earlier joint report into governance arrangements at Betsi Cadwaladr University Health Board by Healthcare Inspectorate Wales and the Wales Audit Office scrutinised the role of Board Secretary.

Quality The OECD Review of Health Care Quality in the UK6, published in 2016, made a number of observations about systems for quality improvement in Wales.

Duty of Candour A legal duty of candour formed part of the Mid Staffordshire NHS Foundation Trust public inquiry recommendations7. The duty recommended by the Francis report promoted enabling complaints to be made without fear; sharing the truth about performance with staff, patients, the public and regulators and informing patients of any harm done to them and offering appropriate remedies, regardless of whether a complaint has been made. This was also picked up in the Evans Review (see below).

Joint complaints The Evans review8 recommended that Putting Things Right guidance should be reviewed in order to reflect the closer-knit working between the NHS and social care in Wales and enhance the ability of organisations to deal effectively with cross-cutting complaints received.

Regulation and Inspection The Ruth Marks’ review of Healthcare Inspectorate Wales (HIW)9 made a number of recommendations about the effective operation of HIW and also advised further work on independence and a potential merger with Care and

5 National Assembly Public Accounts Committee’s inquiry report into the governance arrangements at Betsi

Cadwaladr University Health Board, NAfW Public Accounts Committee, February 2016 6 OECD Review of Health Care Quality in the UK, OECD, February 2016

7 Mid Staffordshire NHS Foundation Trust public inquiry recommendations, Robert Francis QC, February 2016

8 The Evans review, Using the Gift of Complaints, Keith Evans June 2014

9 Ruth Marks’ review of Healthcare Inspectorate Wales (HIW) Ruth Marks, November 2014



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Social Services Inspectorate Wales (CSSIW).

Citizen Voice The Ruth Marks review also raised the issue of potential duplication between some Community Health Council (CHC) functions with the inspectorates. The OECD report also recommended a focus on patient voice and asked questions about the value of CHCs’ current functions. The Ann Lloyd Review (see below) also touched on the role of CHCs in service change.

Service Change and Co-production Ann Lloyd reviewed the way in which health boards carried out their engagement and consultation role in major service reconfiguration.10 She identified a number of strengths in the approaches taken, highlighting for example, better engagement with clinicians but she also identified a number of areas for improvement. In particular, she pointed to the need for better continuous engagement with local communities and not just when specific change options are being presented.

Stakeholder Engagement

14. Extensive engagement took place during the Green Paper consultation and some specific policy engagement has been carried out in advance of the White Paper publication. Further engagement with partners and the public will take place during the consultation on the White Paper from 28 June to 29 September.

Green Paper Consultation

15. The consultation ran for an extended period from 6 July until 20 November

2015, to provide plenty of time to gather views. We utilised a number of communication streams to engage stakeholders, interested parties and the public including:

Technical briefing with the press

Emails to key stakeholders

10

Lessons learned independent review into NHS Service Change Engagement and Consultation Exercises by Health Boards in Wales. Ann Lloyd CBE, January 2014



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Welsh Government social media channels

Articles in key stakeholder groups’ magazines/bulletins

BSL video on the Welsh Government YouTube channel

Easy Read version of the Green Paper.

16. A total of 170 written responses were received11 ; 15 of these arrived after the

closing date but the comments were taken into account. We also held two stakeholder events during the consultation period, one in Carmarthen and one in Wrexham, to capture views. The responses and comments varied widely from detailed views about health board membership and leadership, to comments about achieving collaboration and partnership working and from thoughts about effective regulation and inspection to capturing the patient voice. Generally one of the wider messages was that the introduction of new legislation in a number of areas was not supported where existing provisions could be more effectively used with the strengthening of systems and mechanisms preferred to placing further statutory duties.

17. A report summarising the key themes arising from the consultation, including the written responses, the various meetings attended by officials and the two hosted events was produced. The report aimed to present a balanced summary of those responses received with no specific weight given to any organisation or individual. The summary of responses report was published on 22 February 2016.

Monitoring and Evaluation

18. The measure of success of the policy will be assessed through a monitoring framework which will be developed as part of the implementation plan once the outcome of the White Paper consultation is known. Should future legislation be taken forward by the end of this Assembly term, we will be giving further consideration as to how to measure the success of the various policy proposals. We will also set out in updated individual Impact Assessments.

19. We expect that monitoring the success of these proposals will be carried out via various existing mechanisms for overseeing quality improvement.

20. As part of the White Paper consultation and consideration of proposed future legislation we will engage with key stakeholders including the Children’s Commissioner for Wales, the Older People’s Commissioner for Wales, the Welsh Language Commissioner and the Future Generations Commissioner for Wales.

11 Our Health, Our Health Service Green Paper Consultation – Full list of respondents February 2016



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The Impact Assessments

Our Approach to the Impact Assessments for this White Paper

21. The White Paper sets out the Welsh Government’s proposals for action in a number of areas. Whilst there is a possibility that some or all of these areas could in time be developed into legislation, no firm decisions have yet been made. Therefore, for the purposes of the White Paper we consider that a relatively high level of impact assessment is proportionate at this stage. We have therefore brought the three mandatory impact assessments together within one overarching paper. If legislation is developed then more detailed impact assessments will be prepared.

22. Schedule 1 provides a more detailed breakdown against the enabler areas of the White Paper.

Equality and Diversity

23. The objective of this White Paper is to establish a robust governance framework and continued focus on quality improvement allowing for greater partnership working across local health boards and with partners; more effective engagement with the public and representation of citizens’ voices; the implementation of common processes, such as standards and complaints systems to underpin and integrate services; openness and transparency and clarity in the remit of inspection.

24. Because the core themes of this White Paper are to strengthen leadership and governance and drive improvements in quality, these should have a direct impact in reducing the chances of unlawful discrimination, harassment or victimisation.

25. Co-production should break down the barriers between professionals and the people who use their services. It is about people making joint decisions about their own care. It is also about service planners and providers seeing their users as people with useful skills and experience to bring to the decision-making process. Systems across health and social care now need to make a real shift toward this way of working because this is how standards and quality will be improved.

26. One of the objectives outlined as part of the White Paper is to promote key principles across NHS organisations in Wales to encourage a common approach across the whole system, whilst ensuring that individual needs are met. Individuals and their families can expect to have the same standard of care across regions and services rather than a fragmented disparate approach. All individuals of Wales should be subject to common principles, arrangements and opportunities in their well being and health and social care services.



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Children’s Rights

27. Wales was the first country to enshrine children’s rights in law. This means whenever we make a decision we must consider the impact on children and young people. We want children and young people in Wales to lead safe, happy and healthy lives and feel listened to and respected by those around them.

28. The Social Services and Well Being Act 2014 states that a person exercising functions under this Act in relation to a child must have due regard to Part 1 of the United Nations Convention on the Rights of the Child (UNCRC) adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989 (“the Convention”).

29. The UNCRC articles that are most relevant to the proposals put forward by this White Paper are the following:

Article 6

All children have the right of life. Governments should ensure that children survive and develop healthily.

Article 12

Children have the right to say what they think should happen, when adults are making decisions that affect them, and to have their opinions taken into account.

Article 23

Children who have any kind of disability should have special care and support so that they can lead full and independent lives.

Article 24

Children have the right to good quality health care and to clean water, nutritious food and a clean environment so that they will stay healthy. Rich countries should help poorer countries achieve this.

Article 33

Children have the right to learn and use the language of customs of their families, whether these are shared by the majority of people in the country or not.

30. Furthermore the 2016 UNCRC Report for the UK Government (including Welsh Government) Report highlighted concern that many children with disabilities do not see that their views are given due weight in making personal decisions in their life, including choice of support and future.

31. Recognising the needs of children and young people in the planning of services and taking their opinions into consideration as part of continuous and active engagement for a renewed citizen voice model will go some way to promote the UNCRC Articles and recommendation above.



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32. Through the key principles proposed all citizens should be at the centre of their own healthcare, through joined up integrated arrangements, informed decision making and improved quality services. The White Paper is proposing to legislate for a new statutory mechanism for continuous engagement with appropriate outcome measures. This will take into consideration engaging with a cross representation of the local population, which would include children and young people.

Welsh Language

33. The Welsh Language (Wales) Measure 2011 gives official status to the Welsh

language in Wales. This includes treating the language no less favourably than English, and the freedom for people to use the Welsh language with one another. The measure provides for new standards which are being placed on a range of organisations across the public and private sector. Public bodies in Wales, including Health Services, must promote and facilitate the use of the Welsh language, and support those who wish to work or conduct their business through the medium of Welsh through an active offer.

34. The Welsh Government’s present strategy for the Welsh language; Iaith fyw: iaith byw - Strategaeth y Gymraeg 2012–17: A language for living - Welsh language strategy 2012 to 2017 – is currently being replaced by a new strategy to support the Welsh Government’s objective of a million Welsh speakers by 2050. A draft of the new strategy has been consulted on and a summary of the consultation responses published. The final strategy will be published in 2017. It is likely to stress the importance of education and early years provision, use of Welsh in the workplace and in delivering public services, and promoting the use of Welsh more widely. There is likely to be a particular focus on using the language – in the community, when accessing public services, and within the workplace.

35. This White Paper and accompanying Impact Assessment will adhere to the ministerial commitment that consultations, legislation and guidance will have due regard to the Welsh language, and therefore are available in both English and Welsh.

36. Mwy na geiriau: fframwaith Llywodraeth Cymru ar gyfer gwasanaethau iaith

Gymraeg mewn iechyd, gwasanaethau cymdeithasol a gofal cymdeithasol: More than just words: the Welsh Government’s framework for Welsh language services in health, social services and social care sets out a strategic approach to ensuring patients receive services according to Welsh language need and choice. Many Welsh speakers feel more comfortable expressing themselves and communicating their needs in Welsh, as they think and live their lives in Welsh. . The delivery of the framework will be supported through the proposals in the White Paper that focuses on patient centred care and for a new statutory mechanism for continuous engagement that will provide additional support, expertise and guidance to engage with a



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cross representation of the local population, including those who communicate, engage and get involved in Welsh should they need or wish to.

37. Ensuring that NHS organisations fulfil their duty to engage through various mechanisms, such as patient panels or participation groups, will help people exercise their rights and make informed choices. NHS organisations would need to evidence that representation from all of the local population, including Welsh speakers, have been taken into consideration as part of the engagement mechanisms in the planning and delivery of services to meet the needs of the population.

38. Co-production should break down the barriers between professionals and the

people who use their services. It is about people making joint decisions about

their own care. It is also about service planners and providers seeing their

users as people with useful skills and experience to bring to the decision-

making process. If patients want to engage in this process through the

medium of Welsh they can be afforded this opportunity.



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Schedule 1

White Paper Enablers and Impact Assessments

Equality and Diversity Children’s Rights Welsh Language

Effective Governance

Impact One of the underlying principles of the White Paper is to ensure that the citizen’s voice is heard. This will be strengthened through Board appointments to reflect the diversity of the society in which we live and take account of the necessary balance of skills and backgrounds. The White Paper will provide mechanisms to allow representation to be strengthened where required, through the further amendment of Regulations. All appointments made by Welsh Ministers must comply with the requirements of the Equality Act 2010. The role of the Board Secretary which is to provide independence, challenge and ensure the Board meets its statutory duties will be further bolstered by the White Paper proposals for protective status.

As highlighted the Boards must reflect representation from their local population, which will include consideration of Children’s Rights.

As highlighted the Boards must reflect representation from their local population, which will include consideration of the Welsh Language. All appointments made by Welsh Ministers should comply with the requirements of the Welsh Language (Wales) Measure 2011, specifically the requirements of their Welsh Language Standards on recruiting and appointing.

Monitoring & Review

We will continue to monitor through the public appointment process, which takes into consideration the performance and attendance of existing Board members as well as the principles of the Governance Code on Public Appointments and compliance with relevant legislation. We will also monitor how equality/ children’s rights and Welsh language considerations/ impacts are considered

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within Board papers/ discussions and input from champions to ensure there is balanced and strengthened representation of issues to improve decision making

Duties to Promote Cultural Change – Duty of Quality for the Population of Wales

Impact A duty of quality for the population of Wales will ensure local health boards work with partners and citizens to promote well-being and to plan and provide services to meet the needs of the population. This will mean paying particular attention and focussing on the needs of different sectors of the community and of individuals including older people, those with sensory impairment, physical disabilities and mental health needs.

Recognising the needs of children and young people in the planning of services will be a key consideration and the new duty will underpin this expectation.

Ensuring that services are planned and delivered to meet the needs of Welsh speakers is part of the provision of a safe, quality health service, which this new duty will support. Meeting the needs of the population in the planning so services will also include involvement and consideration of the needs of Welsh speakers.

Monitoring & Review

We would expect to monitor this duty via a number of mechanisms, including the Integrated Medium Term Plans (IMTPs), Annual Quality and Governance Statements, engagement plans and other information published by local health boards, as well as through Quality and Safety meetings and more strategic groups such as the National Quality and Safety Forum. We would also monitor via work undertaken with partners in promoting well-being and integration especially via the Public Services Board and Regional Partnership Forums.

Duties to Promote Cultural Change – Duty of candour

Impact A duty of candour will require organisations and the individuals working in them to be open and transparent in their relationships with service users. This will mean gaining an understanding of the characteristics of the service user and ensuring the approach being taken reflects

Where children and young people have capacity, then the Duty of Candour would apply equally to them as to an adult. Duty of Candour will still apply to a child or

Communicating with individuals in Welsh is an essential part of providing a safe, quality service. The approach to be taken will need to reflect Welsh

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cultural and other requirements.

young person who lacks capacity but this would need to be worked through with the person with parental responsibility.

Language requirements.

Monitoring & Review

We would expect to monitor the effect of a Duty of Candour through looking at the number of complaints, at all levels, about communication and complaints handling. In particular a large number of complaints to the Public Services Ombudsman for Wales are about the way in which complaints have been dealt with. We would expect more openness and transparency at organisational level to result in fewer concerns being taken forward through the formal channels.

Person-centred Health and Care - Common Standards

Impact The standards that underpin care should have common principles regardless of whether the focus is health care or social care. Care and the standards that underpin care needs to be perceived principally through the eyes of the person receiving care and not through the eyes of the organisations delivering the care. Introducing common standards should therefore have a positive effect in improving service delivery by improving equity and allowing a focus on individualised care.

Common standards will apply to services provided to children and young people and will improve equitable access to services.

Welsh speakers and Welsh speaking communities are likely to benefit from common standards and the contribution they will have in improving service delivery and person centred care.

Monitoring & Review

We would expect to monitor the effectiveness of common standards through the quality of inspection reports produced by the inspectorates and health and care organisations would also do so through their self assessment and other audit-related processes.

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Person-centred Health and Care - Joint handling of health and social care complaints

Impact The proposal for joint handling of complaints is likely to be of general benefit, although we anticipate that older people and others with care and support needs, carers and people with disabilities in particular would see positive effects, given that services often need to work together to provide packages of care. In dealing with complaints, organisations should ensure they have taken into account any specific characteristics relating to the complainant and family to ensure the best outcome from the investigation.

We would anticipate that children and young people will benefit from joint complaints handling, in particular those who need joint care packages or those moving between children and adult services.

Welsh Language speakers are likely to benefit from joint complaints handling as teams within organisations will be able to pool Welsh Language expertise and resources to offer more tailored approaches through the medium of Welsh.

Monitoring & Review

We would expect to see fewer complaints about health and social care being taken to the Public Services Ombudsman for Wales and we would monitor this to see the effect of the proposed changes.

Effective Citizen Voice and Clear Inspection

Impact The proposals for more effective continuous engagement with local communities as well as those for a renewed citizen voice model will benefit all sectors of the community. Health boards will be held more closely to account on their duty to engage with the population and the focus they place on the diverse range and specific needs of individuals and minority groups, including BAME communities, gypsy traveller communities and others. The proposed changes to the citizen voice arrangements will mean more flexibility for the new body to secure a diverse

As set out in Article 12 of the UNCRC, children have the right to say what they think should happen, when adults are making decisions that affect them, and to have their opinions taken into account. We would expect organisations to take this fully into account when engaging with citizens and in the way they are represented.

Continuous and active engagement with local communities noted under equality and diversity will include the Welsh speaking population and communities and this should be offered in through the medium of Welsh. The More than just words framework for 2016- 2019

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cross-section of volunteers, suited to local needs. Clearer legislation for Healthcare Inspectorate Wales will be of overall benefit to the community as there will no longer be any regulatory gaps. In terms of the proposed new body for inspection, regulation and patient voice, this will be a powerful check and balance in holding the health and social care to account.

includes actions on regulation and inspection including the audit and mainstreaming of inspections on the provision and experience of Welsh language services.

Monitoring & Review

We would expect to monitor the effectiveness of these new proposals through regular reporting and liaison activities with individual organisations and the proposed citizen voice body. In terms of service change, the effectiveness of the new arrangements and of continuous engagement will be measured by the number of decisions which need to be called in by Ministers. We would expect these to be low in number.

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IntroductionIn July 2015 the Minister for Health & Social Services (Mark Drakeford) published a Green Paper setting out a number of proposed reforms to the Welsh NHS. The Welsh NHS Confederation submitted a detailed response to the Green Paper on behalf members in November 2015.

The White Paper “Services Fit for the Future, Quality and Governance in Health and Care in Wales”, was launched on the 28th of June and it includes a number of proposals designed to support and encourage more integrated ways of working and better decision-making.

The proposals include common standards and joint complaints handling; better decision-making across health boards through a new Duty of Quality for the Population of Wales and a clearer process for service change; as well as further promoting a culture of openness in the health and social care system through a new Duty of Candour. There are also proposals for strengthening the way the public is represented across health and social care, and for regulation and inspection.

This briefing provides an overview of what is included in the White Paper. The Welsh NHS Confederation will be responding to the White Paper on behalf of members by the 29th of September. We will be sending further information in the next week in relation to the process of gathering Members views.

Background to the Green PaperThe purpose of the Green Paper was to set out the current systems in place to support quality and governance in the NHS in Wales.

Part one of the Green Paper set out issues in relation to NHS quality. The Green Paper invitedcomments about what legislative measures the Welsh Government could take to improve quality further. Some of the key issues raised included:

∑ Improving quality through duties and embedding it through common standards;∑ Promoting openness, honesty and candour; and∑ Improving the independence of the inspectorates, including the possibility of merging

Healthcare Inspectorate Wales and Care and Social Services Inspectorate Wales and the future role and functions of Community Health Councils.

Part two outlined a range of NHS governance, finance and functions provisions which have arisen since the reorganisation of the NHS in Wales and highlighted a number of potential legislative options. In particular, it focused on: ∑ Considering the alignment of the powers, duties and accountabilities of Health Boards and

NHS Trusts; including whether we should give Health Boards borrowing powers; and

Briefing for Welsh NHS Confederation Members providing information around the White Paper “Services Fit for the Future, Quality and Governance in Health and Care in Wales”.

Contact: Nesta Lloyd – Jones, Policy and Public Affairs Manager, the Welsh NHS Confederation

[email protected] Tel: 02920 349857

Date created: 28 June 2017

4.1.4 Appendix 4 NHS Confederation briefing White Paper


http://gov.wales/newsroom/health-and-social-services/2017/governance/?lang=en

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∑ Improving the leadership and governance of NHS Wales, including looking at health board and NHS trust board membership.

The White PaperThe proposals set out in the White Paper are:

1. Effective Governance: Including Board Membership and Composition and Board Secretaries;

2. Duties to Promote Cultural Chance: Including duty of Quality of the Population of Wales and Duty of Candour. The introduction a Duty of Quality for the Population of Wales which will focus on health boards working together to meet the needs of the population in the planning and delivery of quality healthcare services;

3. Person-centred health and care: Including setting and meeting common standards and joining investigation of health and social care complaints; and

4. Effective citizen’s voice, co-production and clear inspection: including representing the citizen in health and social care, co-production and services with citizens and inspection and regulation.∑ Strengthening of the voice of citizens – this includes proposals to replace the current

model of Community Health Councils with a new independent arrangements which would represent the interests of citizens across health and social care;

∑ A clearer process for service change - introducing an independent mechanism to provide clinical advice on substantial service change decisions, with advice from the proposed new citizen voice body, which will encourage continuous engagement and increase the pace of strategic change; and

∑ Improving inspection and regulation – including improving the legal framework for the inspection and regulation of health services and questions about whether a new independent body for patient voice and regulation and inspection should be established.

1. Effective GovernanceFollowing from the Green Paper the White Paper is a further opportunity to review the Governance arrangement of Local Health Boards to support improvements and ensure robust governance framework. The proposals in relation to Governance include:∑ Board membership and composition, including number of independent members and the

number of executives, and also flexibility for Welsh Minister’ to make particular Board member appointments for limited period of time, for example under special measures or organisation underperforming.

∑ Statutory protection of the role/ function of Board Secretaries to ensure independence and standard job description.

QuestionsBoard Membership and CompositionThe Welsh Government believes that the Boards of both health boards and NHS trusts should share some core key principles which are outlined including delivering in partnership to deliver person centred care and a strong governance framework to enable the Board to work effectively and meet its responsibilities.

All Boards should have Vice Chairs in order to support focussed and skilled leadership.

The Welsh Government also believes that Ministers should have the authority to appoint additional Board members on time limited appointments if an NHS Health Board/Trust is under



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performing or under escalation procedures in accordance with the NHS Wales Escalation and Intervention arrangements.

The Welsh Government believes that Board Executive Officer membership for local health boards should probably include some key positions which are consistent across local health boards but also allow some flexibility to appoint based on remit and priorities.

∑ Do you agree with these proposals? ∑ What further issues would you want us to take into account in firming up these

proposals?

Board SecretaryIn order to deliver on the key principles outlined the Welsh Government believes that the role of Board Secretary should be placed on a statutory basis and have statutory protection to allow the role to be independent with safeguards in place to challenge the Chief Executive of an NHS organisation or the Board more widely.


proposals?

2. Duties to Promote Cultural ChangeConsiders how LHBs and Trusts can be further supported to work cross boundary and bring more focus to decision making. Areas proposed includes;∑ An enhanced and extended duty of quality to better reflect the integrated system. The duty

could encompass the needs of population of Wales to facilitate collaborative, regional and all Wales planning and solutions to service change and delivery including extending the powers of LHBs and Trusts to work in partnership. The White Paper could include extending the powers of LHBs and Trusts to work in partnership.

∑ As highlighted in the Green Paper, a Duty of Candour across health and social service toconsolidate existing duties and encourage individual and organisational openness and transparency.

QuestionsDuty of Quality for the Population of WalesThe Welsh Government believes that the duty of quality should be updated and enhanced to better reflect our integrated system. This duty should be sufficiently wide in scope to facilitate the needs of the population of Wales to facilitate and enable collaborative, regional and all-Wales solutions to service design and delivery

NHS bodies should also be placed under a reciprocal duty with local authorities to co-operate and work in partnership to improve the quality of services provided.

Welsh Government also believes that strengthening the existing planning duty will make sure health boards work together on the needs of the population of Wales in the planning and delivery of quality healthcare services.


proposals?



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Duty of Candour The Welsh Government believes that the development of a statutory duty of candour across health and social services in Wales would consolidate existing duties and be in the interests of a person centred system.

∑ Do you support this proposal? ∑ What further issues would you want us to take into account in firming up this

proposal?

3. Person-centred health and careConsiders that the current system consists of separate standards for NHS health care, independent health and social care. Areas proposed includes:∑ Common standards/ principles across all locations of care (NHS, including independent

health sector and social care sector where appropriate), which organisations are required to comply with.

∑ A requirement for organisations to work together to investigate and resolve complaints which cover both health and social care (including independent providers).

QuestionsSetting and Meeting Common StandardsThe Welsh Government believes there should be a common set of high level standards applied to health and social care and that the standards should apply regardless of the location of care.

Do you support this proposal? What further issues would you want us to take into account in firming up this proposal?

Joint Investigation of Health and Social Care ComplaintsThe Welsh Government believes that requiring different organisations to work together to investigate complaints will make it easier for people to complain when their complaint is about both health and social services. We also believe it will encourage organisations to learn lessons to improve their services.

∑ Do you support this proposal? ∑ What further issues would you want us to take into account in firming up this

proposal?

4. Effective citizens voice, Co-production and Clear InspectionHow the system of inspection and regulation and the representation of the citizens views should support the direction of travel towards more integrated/ seamless services. The White Paper proposes: ∑ A new arrangement for citizen voice replacing the existing Community Health Council

(CHC) model to focus on how organisations are held to account for the way they engage the public.

∑ A clearer process for service change decision-making through introducing an independent mechanism to provide/ receive advice.

∑ Consider addressing the legislative gaps underpinning Healthcare Inspectorate Walesthrough having a clear legislative framework for HIW to foster closer integration and joint working with CSSIW.



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∑ Possibly having a new independent body to bring together inspection, regulation and citizen voice in health and social care.

QuestionsRepresenting the Citizen in Health and Social CareThe Welsh Government believes that local health and social care organisations should be working with the public to co-design and co-create services and that the way they do this needs to be independently monitored. We propose replacing the current statutory CHCs and their functions with a new national arrangement to represent the citizen voice in health and social care, to advise and provide independent assurance. The new body will work alongside Healthcare Inspectorate Wales and Care and Social Services Inspectorate Wales and have autonomy to decide how it will operate at local level.

∑ Do you support this proposal? ∑ Can you see any practical difficulties with these suggestions?

Co-producing Plans and Services with CitizensThe Welsh Government believes that introducing an independent mechanism to provide clinical advice on substantial service change decisions, with advice from the proposed new citizen voice body, will encourage continuous engagement and increase the pace of strategic change through enabling a more evidence-based, transparent process and a more directive and guiding role on the part of Welsh Government.

∑ Do you agree with this proposal?∑ What further issues would you want us to take into account in firming up this

proposal?

Inspection and Regulation and single body The Welsh Government believes that ensuring a clearer underpinning legislative framework for HIW will help to foster closer integration and joint working with CSSIW and at the very least this should be taken forward.

∑ What do you think of this proposal? ∑ Are there any specific issues you would want us to take into account in developing

these proposals further?

However we also believe there could be merit in considering a new body – for example, a Welsh Government Sponsored Body – to provide more independence in regulation and inspection and citizen voice.

∑ Would you support such an idea? ∑ What issues should we take into account if this idea were to be developed further?



Prosperity for All: the national strategyTaking Wales Forward

4.2 Prosperity for all - the national strategy


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Delivering prosperity for all is the mission of this Welsh GovernmentProsperity is not just about material wealth – it is about every one of us having a good quality of life, and living in strong, safe communities.Our long-term aim is to build a Wales that is prosperous and secure, healthy and active, ambitious and learning, and united and connected. Our Programme for Government, Taking Wales Forward, sets out the headline commitments we will deliver between now and 2021.

This strategy takes those key commitments, places them in a long-term context, and sets out how they fit with the work of the wider Welsh public service to lay the foundations for achieving prosperity for all.

It acknowledges that how we deliver is just as important as what we deliver, and in order to make a real difference to people’s lives, we need to do things differently and involve people in shaping the services they use every day.

We have produced this short, focused document to better direct the energy and resources of the whole public service. Working with the people of Wales, we will bring our combined efforts to bear on the most fundamental challenges the nation faces. Many of the actions in the strategy will be delivered by the end of this Assembly term, others are about working in a much more collaborative and integrated way, designing solutions for the future – together.

This will involve a radically different way of working for us and our partners. Although government is complex, our objective is simple – to help and support everyone to live healthy, prosperous and rewarding lives. Wales in the 21st century is a diverse place - people’s needs vary across the country and at different stages in their lives.

As a nation, Wales has come a long way since devolution in 1999 – growing in confidence and asserting a distinctive Welsh identity in a way that would have been impossible before.

There is much to be proud of, but many challenges remain, and it is only by being honest about these that we can tackle them.

We created and supported nearly 150,000 new jobs during the last government term. Still, too many people lack meaningful employment. This affects their health, and prevents them from reaching their full potential. Sometimes this is beyond their control, but this is where the whole of the public service needs to focus its efforts on helping people across Wales to prosper.

The NHS in Wales is employing more doctors and nurses, treating more people, and people are living longer. But many people are affected by the stubborn legacy of ill-health. The impact on people, families and the economy is vast. We must break the cycle, and help everyone live longer, healthier lives.

Pupils’ results are improving, and the performance gap between rich and poor children is narrowing. We cannot accept that many children, and disproportionately those from disadvantaged backgrounds, leave school without the skills they need to get a job. We need to instil ambition for learning into every one of our young people, and leave no one behind.



Prosperity for All: the national strategy | 3

We have a strong record in driving up recycling rates, putting us first in the UK, second in Europe and third in the world. However, climate change is set to continue, and this means we will have to reduce carbon emissions further, actively managing the risks that climate change presents to health, well-being and to communities.

Although Wales as a whole has grown strongly out of recession, there are areas of the country which have not seen the full benefits of growth. This has left some communities struggling to prosper and feeling isolated from other parts of Wales. Government has a key role in stimulating economic growth in areas of greatest need.

Our communities remain a national asset, and we will invest to re-connect them, physically and digitally, to build a more united and connected nation.

We know that secure employment makes it more likely that people will enjoy good health, education will shape people’s employment opportunities and people value the strength and quality of their local communities.

Underlying all of this are complex and interdependent factors. To reflect this, we have developed this strategy, to join up the things we do that most affect people’s lives, recognising that government can only support people towards these goals by working differently.

Key ThemesTaking Wales Forward provided immediate clarity about the government’s pledges for this Assembly term. Set out in four chapters, it outlined the main commitments that will make a difference to the people of Wales, despite the impact of a decade of cuts to the Welsh budget, and the uncertain impact of Brexit.

The four key themes of this strategy are the same as those in Taking Wales Forward. We have set out our vision for each theme, showing how they will contribute to prosperity for all, and how delivering in a more integrated and collaborative way can enhance the well-being of the people of Wales.

Prosperous and Secure – Our aim is to drive a Welsh economy which spreads opportunity and tackles inequality, delivering individual and national prosperity. We will enable people to fulfil their ambitions and enhance their well-being through secure and sustainable employment. We will break down the barriers many face to getting a job, and create the right environment for businesses to grow and thrive.

Healthy and Active – Our aim is to improve health and well-being in Wales, for individuals, families and communities, helping us to achieve our ambition of prosperity for all, taking significant steps to shift our approach from treatment to prevention.

Ambitious and Learning – Our aim is to instil in everyone a passion to learn throughout their lives, inspiring them with the ambition to be the best they possibly can be. A prosperous Wales needs creative, highly skilled and adaptable people, so our education from the earliest age willbe the foundation for a lifetime of learning and achievement.

United and Connected – Our aim is to build a nation where people take pride in their communities, in the Welsh identity and language, and in our place in the world. We are building the vital links that make it easier for people to come together, for the economy to grow, and for us to become a confident nation at ease with itself.




Priority AreasIn developing the strategy, we recognised five areas which emerged as having the greatest potential contribution to long-term prosperity and well-being. They reflect the times in people’s lives when they may be most in need of support, and when the right help can have a dramatic effect on their life course.

They are priority areas where it has been shown that early intervention - tackling the root causes, rather than treating symptoms - pays dividends. Only a fully co-ordinated response from public services can prevent problems escalating; too often barriers between different services and organisations stand in the way of a truly preventative approach.

If we are to realise the full potential of the Well-being of Future Generations Act, then integration and collaboration between services, with an early intervention and people-centred approach, is essential to delivering long-term outcomes. This is a significant change, and therefore we have decided to place particular focus on five priority areas where we believe, by improving how services are delivered, there can be the greatest initial impact, paving the way for further action over the longer term.

Early Years: an individual’s experiences in childhood play a significant part in shaping their future, and are critical to their chances of going on to lead a healthy, prosperous and fulfilling life.

Housing: the bedrock of living well is a good quality, affordable home which brings a wide range of benefits to health, learning and prosperity.

Social Care: compassionate, dignified care plays a critical part in strong communities, ensures that people can be healthy and independent for longer, and is a significant economic sector in its own right.

Mental Health: one in four people in Wales will experience mental ill health at some point in their lives, getting the right treatment at an early stage, coupled with greater awareness of conditions, can in many cases prevent long term adverse impacts.

Skills and Employability: the better people’s skills, the better their chances of getting fair, secure and rewarding employment, and the stronger the skills base is in Wales, the more chance we have of attracting new businesses and growing existing ones to improve prosperity.

These are by no means the limit of government’s activities, and we will not lose sight of the day to day running of vital public services, while adapting and improving them to reflect this new approach.

Working DifferentlyThis strategy is far more than a list of actions that we will take. This represents a new way of working, one that recognises the challenges we face today, the Wales we want for the future and the steps that need to be taken to make it a reality.

The Well-being of Future Generations Act acknowledges the contribution that everyone can make and gives us a basis for driving a different kind of public service in Wales.

At the heart of this strategy is a recognition that public services and voluntary sector partners want to work together towards common objectives, to focus on the needs of people, at all stages of their lives and in all parts of Wales.

There are already many innovations that support us working this way, such as the Public Service Boards which bring together all those delivering services in communities, to work with them to understand local needs and priorities and decide how they are best delivered.




Through the Valleys Taskforce we are gaining a clearer and deeper understanding about what people really want from their public services, and how we can respond to the barriers which can hinder those services.

Ultimately, the Taskforce is about how we can collectively support the aspirations of people, in one of the areas of greatest need in Wales - and how we should deliver services locally and seamlessly – messages that we will adopt more widely as we deliver this strategy.

Local authorities will be an important partner in delivering this agenda. Achieving our ambitions for Wales will require a different relationship not just between the Welsh Government and local authorities, but also between local authorities themselves. It is only through closer working, on a consistent regional basis, that the resilience and responsiveness of services can be maintained in the future.

Focusing on the five priority areas will help us integrate these services and programmes better, and give clearer direction to our partners. More widely, we can draw on levers that we have as a government and use them to deliver our central goal of prosperity for all: planning, investment in infrastructure, procurement, and tax powers.

Planning decisions affect every area of a person’s life. They determine where homes are built, where services are provided, and the quality of the local environment; and they promote

sustainable economic growth and access to open space. The right planning system is critical to delivering our objectives in this strategy.

The way we plan our capital investment decisions can have a big impact on the economy, help different organisations to deliver their services in a single place, and minimise the individual’s need to travel. Throughout this strategy we commit to co-locate services and this can only happen if we integrate the way that we make our investment decisions.

Each year, devolved public services spend £6 billion procuring products and services, with more of this than ever being spent in Wales. By planning better and understanding which products and services are bought over and over again, we can support small and medium businesses to win more of these contracts. The economic benefits will stay in Wales, but our buying power can act as a springboard to develop greater added value to high performing businesses, and their supply chains, who can export products further afield.

New tax raising and varying powers for Wales will strengthen the link between economic growth and funding for services in Wales. These powers will provide the government with additional ways to deliver its ambitions for Wales, but it will be important that we use them in a way that supports businesses to thrive and is fair for all.




‘Taking Wales Forward’- The Programme for Government 2016-2021

The strategy sets out how we will deliver for Wales during this term- and set long-term foundations for the future.

The programme sets out what we will deliver for Wales during this Assembly term.

‘Prosperity For All’- the national strategy

Key Themes

Well-being Objectives

Well-being of Future Generations Act

Support people and businesses to drive prosperity

Tackle regional inequality and promote fair work

Drive sustainable growth and combat

climate change

Prosperous& Secure

Deliver quality health and care services fit for

the future

Promote good health and well-being for everyone

Build healthier communities and better

environments

Healthy &Active

Support young people to make the most of

their potential

Build ambition and encourage learning for life

Equip everyone with the right skills for a

changing world

Ambitious& Learning

Build resilient communities, culture,

and language

Deliver modern and connected infrastructure

Promote and protectWales’ place in the world

United &Connected

The Act sets out the need for a long-term focus, and five ‘ways of working’ to guide the Welsh public services in delivering for people.




Our aim is a Welsh economy which delivers individual and national prosperity while spreading opportunity and tackling inequality. Through this, people can fulfil their ambitions and enhance their well-being in secure and sustainable employment. A crucial role of government is to break down the barriers many face in getting a job, and create the right environment for businesses to grow and thrive.We should not see economic growth in isolation. It underpins the ambitions we have for every person and every community right across the country. Safe, secure employment is key to better health and better life prospects.

Economic growth generates the taxes that enable the delivery of high quality public services and helps communities to prosper.

Increasing productivity and competitiveness are central to our economic future. High quality skills, the key role of cities as engines of growth, and the right digital and transport infrastructure will all help us in achieving this goal.

The Welsh Government does not hold all the levers affecting the economy. However, with prosperity for all as our central goal, we are committed to working in a more integrated and focused way to have the greatest possible impact. This means harnessing the efforts of the whole government in health, education, and the environment as well as economic development.

Different parts of Wales have different economic strengths, and therefore we need to take an approach to promoting growth and development which reflects this.

We will support the businesses of today to work more efficiently and sustainably, while ensuring we create an environment which will nurture the businesses of the future, building on Wales’ human, creative and natural resources, and improving our economic and environmental resilience. Building a sustainable economy reflects the importance of leaving a strong legacy for future generations.

Therefore our three objectives are delivering the right support for people and businesses, addressing regional inequalities and promoting fair work, and driving sustainable growth.

Prosperous and Secure




Support people and businesses to drive prosperity

We will enable people to develop the skills they need to get the jobs they want, supporting businesses to start, innovate, and grow, creating decent, secure employment.We can all benefit from a growing and prosperous Welsh economy, and businesses, individuals and public services all have vital – and reciprocal – roles to play in delivering this. We will formalise a new partnership approach setting out clearly what businesses can expect from us, and what we as a government then expect from them.

Our pro-business approach means we always want to back businesses with the potential for real growth through targeted direct business support and quality skills programmes. We will also use the spending power of infrastructure investment and public service procurement to benefit Welsh-based businesses.

We look, then, to business to work with us and to invest in their own development, and that of their workforce, treating their employees fairly, and contributing to the wider community.

Economic resilience will be particularly important over the coming years, as depending on the terms of our withdrawal, leaving the European Union is likely to have a significant impact on the Welsh economy and businesses.

Some sectors and regions could be particularly hard hit by issues such as market access and migration, which is why it is vital that they are supported to adapt quickly to new economic conditions following Brexit, maximising opportunities to find new markets.

We will:

• commit to a new ‘Economic Contract’ between business and government to stimulate growth, increase productivity, and make Wales fairer and more competitive.

• simplify and rationalise the range of financial support we offer to companies, ensuring it is clear, easily understood and responsive.

• develop a modern, regulatory framework, through smarter regulation to ensure competitiveness and the right economic environment for them to grow.

• establish the new Development Bank of Wales, improving access to finance for businesses, alongside high quality support services and management advice.

• maximise the value of Welsh public service procurement to Wales, while ensuring that employees get a fair deal for the work they undertake funded by public money.

• use our business support to build capacity and innovation within our home grown businesses including local supply chains, to enable more to be procured from businesses in Wales.

• further develop engagement between universities, industry and the NHS and social care to drive economic growth through applied research and innovation.

• develop a new employability plan for Wales, focusing on the diverse needs of individuals, and responsive to the particular skills needs of each part of the country.

• implement our 30 hours of free education and childcare to support working families across Wales and make it easier for people to take up and retain jobs.




Tackle regional inequality and promote fair work

We will target interventions to the different economic needs of each region of Wales, ensuring all parts of the country benefit from growth, and promoting every worker’s right to a fair deal.We must focus on the strengths of each part of Wales and use these as a springboard for growth, while ensuring that emerging opportunities are grasped and supporting stronger, regional centres of growth.

This makes social, as well as economic, sense, because regional inequality and insecurity act as a brake on national prosperity; making Wales fairer will make its economy stronger and more resilient.

This new regionally-focused approach is reflected across all areas of our work, including local government reform, which will better equip public services to be an active partner with industry on everything from skills to planning to transport.

We will also promote prosperity for all through seeking improvements in the pay and conditions for those in low-paid and insecure employment through our Fair Work Commission.

The exciting major projects planned across Wales over the coming years must bring with them significant benefits for their regions, and leave a lasting legacy for the people, infrastructure and economy of these areas.

We will:

• introduce a new regionally-focused model of economic development, working with each region to determine and drive its own sectors according to its strengths and opportunities.

• focus on a smaller number of national sectors where there are particular challenges or opportunities across Wales.

• support rural businesses to diversify and take advantage of supply chains, including the need to increase their processing capacity and add greater value.

• ensure the new ‘made in Wales’ successor to EU structural funds is fully integrated with our overall approach and delivers maximum added value for individuals, regions and Wales as a whole.

• design major Welsh Government infrastructure projects to join up public services and other developments, to maximise regional benefits.

• harness the opportunities of major infrastructure projects, such as Wylfa Newydd and Swansea Bay Tidal Lagoon.

• provide more effective support for the development of local supply chains and clusters, so that economic value is retained locally, and more employment opportunities are created closer to home.

• take the steps needed to make Wales a fair work nation, building on the work of our Fair Work Commission.

• ensure commitment to ethical employment from every business supplying the public service.




Drive sustainable growth and combat climate change

We will build prosperity in a way that supports and sustains Wales’ stunning natural environment, ensures that current and future generations will continue to benefit, and makes a tangible contribution to the fight against climate change.Economic resilience underpins our ambitions for Wales. It is only through innovation that businesses can adapt and improve their productivity and sustainability. At the same time, we need to create an environment that nurtures the businesses of the future, and responds to the need to further develop a low carbon economy.

Our abundance of natural resources is one of Wales’ greatest assets, and has shaped our economy over centuries. Today, it supports a range of sectors, including a vibrant tourism and leisure sector, an agricultural industry that sustains viable rural communities and a world-class, home grown food and drink sector.

Our aim is to realise the economic opportunities of Wales’ natural resources, whilst building their resilience to support future generations. Low carbon energy generation and greater use of renewable energy sources, including community energy schemes have the potential to cut carbon emissions while benefitting local areas.

Cutting the amount of energy that we use reduces costs for businesses, but can also save money for householders. Improving the energy efficiency of houses brings health benefits, creates jobs and supports local businesses.

We will:

• introduce a new National Development Framework, setting out a 20-year land use plan for Wales, guiding strategic development and supported by the National Infrastructure Commission for Wales.

• set out a low carbon pathway providing clarity and certainty for action and investment around the low carbon economy through setting targets for 2020, 2030 and 2040.

• accelerate the decarbonisation of our public services, creating new opportunities for businesses in Wales in the transition to a low carbon economy.

• establish a bespoke infrastructure consenting process which is responsive to business and community needs, to support sustainable economic growth, and to decarbonise our energy supply.

• set out a route map for a more resource efficient economy, building on our success in recycling and reducing the environmental impacts of production and consumption.

• deliver a post-EU agricultural and fisheries policy for Wales, designed with stakeholders to reflect the needs of the modern Welsh agricultural and fisheries sectors and to manage the impact on the environment.

• work with everyone affected to prepare for a world outside of the European Union and for a resilient agricultural sector.

• as part of our new economic contract, expect those businesses which receive our support to commit to reduce their environmental impact.




Our aim is to improve health and well-being in Wales, for individuals, families and communities, helping us to achieve our ambition of prosperity for all, taking significant steps to shift our approach from treatment to prevention.This will help secure sustainable health and care services for future generations, improving patient experience and the well-being of the whole population – placing as much emphasis on people staying fit and well as on treating them when they are ill.

The Welsh NHS will continue to be the single largest area of this government’s expenditure, reflecting its value to the public, and the importance of rapid treatment for people when they need it, as close to home as possible. It is innovating all the time, leading cutting-edge research and adapting to our changing health needs. However, as with the rest of the UK, our NHS is under unprecedented pressure, through rising costs and public expectations. In order to safeguard the health service and meet its wider responsibility for health improvement, we need to increase the pace of innovation and integration, especially in relation to its critical place in the overall health and care system, and its contribution to raising prosperity.

Many of the conditions treated by the health service every day are avoidable, and everyone should play an active part in shaping their own health. Government also has an important role to play in creating the conditions which improve local environments and make it easier for people to give up smoking, take more exercise and eat a healthier diet.

The Welsh NHS is a significant employer in its own right – delivering services within communities brings with it quality employment. It also has a wider role to play in the delivery of this government’s objectives, using its financial scale, professional expertise and track record in innovation to drive research and development across the public and private sectors.

Alongside the government, the NHS, schools, housing, local authorities, social care, the voluntary sector and businesses can all help to create an environment where good health is seen as a natural asset for everyone. We will take action to join up services, rooting them in communities, and deliver a seamless approach through both treatment and prevention.

Therefore, the three objectives are: delivering quality health and care services, promoting good health and well-being, and building healthier communities and better environments.

Healthy and Active




Deliver quality health and care services fit for the future

We will deliver high-quality, timely treatment, as well as supporting and promoting good health, well-being and independence, recognising that future sustainability requires everyone to play an active part in shaping their own health.Changing social demographics and more complex and serious conditions pose a significant challenge and place new and different demands on health services. It means that we need to look again at our models of treatment, to make sure they are responsive to patient need, and carried out in the right setting.

The Welsh NHS and care system is constantly innovating, with new treatments and services being introduced all the time. There are also many examples of local innovation in terms of integration and service delivery, but in terms of long-term sustainability, there is a need to accelerate a smaller number of models on a regional or national basis where the delivery of care can be significantly improved for the long-term.

New procedures and technologies mean treatment can be closer to a patient’s home, often removing the need for a hospital stay.

This shift must accelerate, to ensure that hospitals are treating only conditions that cannot be dealt with elsewhere.

Over a lifetime, people’s health and care needs will vary greatly, often becoming more complex as they age. Having the right support when needed is crucial to living independently and ageing well – it should not matter who the service is delivered by, as long as there is a seamless experience as a whole.

We will:

• continue the drive to improve further the standard, quality and timeliness of treatment across the NHS, ensuring access to the services people need, delivering good health outcomes for all.

• further integrate health and social care, building on the work of the Parliamentary Review into Health and Social Care, and publish a long term plan for the NHS and social care in Wales.

• deliver a tangible shift in the provision of health and care services into communities, and away from hospitals, and shift the emphasis from treating illness to well-being.

• invest in a new generation of integrated Community Health and Care Centres, building on the success of the 64 primary care clusters across Wales, which focus on the specific needs of their local areas.

• ensure that organisations delivering health and care services pool budgets and commission jointly, delivering a genuinely seamless service for those who need it.




Promote good health and well-being for everyone

We will support people to adopt healthy lifestyles, breaking down the barriers that ill-health place on employment and opportunity, and tackling the generational cycle of poor health and inactivity.Good health starts before conception, and is developed through pregnancy, childhood and adolescence. Too many children are becoming overweight in their early years, so in line with our focus on the best start in life, working with partners, we will promote the benefits of a good diet and an active life to all parents and children.

Schools also have a critical role to play in encouraging healthy lifestyles and building activity into the day. Embedding healthy lifestyles from the earliest age, and maintaining them through adolescence, will bring benefits throughout people’s lives and will also make an essential contribution to a sustainable health system in the decades to come.

We need to prevent as many people as possible being held back by ill-health, too often caused by poor environments and ingrained lifestyle habits such as smoking, lack of exercise, and unhealthy diets. We will continue to increase resources available to the health service, making sure it is there to treat illness. However, people’s lives will be better if we work with them to help prevent avoidable diseases, and tackle the causes of chronic conditions.

Good health in old age should be an achievable ambition for all of us. We will reap the benefits of healthy choices and environments throughout our lives, and our communities will benefit from the valuable contribution that active older people can make.

We will:

• support and encourage a substantial increase in people’s physical activity, adopting a collaborative approach from all agencies involved in the promotion of healthier lifestyles, and drawing on Wales’ significant natural resources.

• develop innovative, community approaches to encouraging more active lifestyles and improving nutrition through the Well-being Bond.

• deliver an integrated public transport network which supports our aim to enable people to travel more actively, by combining different types of transport with walking and cycling.

• introduce a step-change in public health campaign work, with measurable outcomes and targets, focusing on avoidable diseases, and building awareness of the positive benefits to people of healthier lifestyles.

• work with and support the business community to improve the health and well-being of workers and help people to remain in employment, with a specific focus on mental health and musculoskeletal conditions, including through the economic contract.

• work with NHS Wales to provide people with digital ways of accessing health and care services and information, helping empower patients and carers to take greater control of their health and well being.

• deliver an In Work Scheme with rapid access to early, work-focused interventions for a range of conditions, helping people to stay in work or return to work more quickly from long-term sickness absence.

• agree new 10 year priorities for Public Health Wales based on the most recent evidence of the burden of ill health.

• invest in homes to improve their warmth and energy efficiency, to improve health and reduce the costs of fuel.




Build healthier communities and better environments

We will tackle inequalities between communities and deliver more services closer to home, acknowledging the importance of communities and the wider environment for good health and well-being.There are unacceptable variations in the levels of good health between different groups and communities in Wales, which has an impact in all areas of people’s lives. This is sometimes caused by the continuing shadow of post-industrial legacies, but also the stubborn impact of poor economic, social and environmental conditions. Too often, it is hardest to access services in the areas they are needed the most.

GP and primary care services are at the heart of their communities, and the main gateway to wider services. We will build on the innovative model of primary care clusters, where a full range of services that support good health, can be accessed from a single location. We will build on this approach to tailor and adapt services to the needs of specific local communities.

The contribution made by the environment to good health cannot be overstated. Air quality, good housing, access to green spaces and energy efficiency schemes each have a part to play in creating the right conditions for better health, well-being and greater physical activity.

We will:

• work to tackle health inequalities both in terms of individual well-being and access to services.

• build on the emerging primary care clusters working across service providers to tailor public services to local needs, and improve access to a full range of health services.

• co-ordinate housing, health and social care capital programmes to provide innovative, affordable, accommodation and nursing care building on the Integrated Care Fund approach.

• expand the community health and social care workforce, with innovative new roles, such as ‘community connectors’ that support social prescribing and more formal partnerships with volunteers and the third sector.

• through planning, infrastructure, regulation, and health communication measures, we will reduce emissions and deliver vital improvements in air quality.




Our aim is to instil in everyone a passion to learn throughout their lives, inspiring them with the ambition to be the best they possibly can be. A prosperous Wales needs creative, highly skilled and adaptable people, so our education from the earliest age will be the foundation for a lifetime of learning and achievement.Inspirational teaching produces ambitious learners, helping them to absorb ideas, knowledge and experiences, shaping their outlook and expectations of what they can achieve and who they can be.

Our education system must stretch the brightest, while at the same time making sure everyone attains the essential level of skills to build on in later life. This needs to build on a home environment that supports learning and development from the earliest age.

The pace of global technological change has never been as great, meaning that learning and adaptability are at a premium. Skills learned in school must be a solid foundation, and equip young people for life. Still, there is too much variation in the attainment of school leavers, which means without the right skills some risk being left behind and wasting their potential.

In the longer term, the Welsh economy requires the right balance of skills and opportunities, which can only be delivered through partnership between schools, colleges, universities and businesses. The best research and innovation, whether public or private, is driven by people with broad horizons and a global outlook. Converting that research into economic value for Wales also requires the right ambitious and entrepreneurial spirit.

Therefore the three objectives for this strategy are: supporting young people to make the most of their potential, building ambition and encouraging learning for life, and equipping everyone with the right skills for a changing world.

Ambitious and Learning




Support young people to make the most of their potential

We will provide the best start in life for all, with support from birth, through education, and beyond, making sure everyone has the chance to fulfil their natural potential.All the evidence suggests that early years are the most crucial time in shaping life chances, which is why we have made this one of the cross-cutting government priority areas. Getting this right for every child means they stand the best chance of benefitting from the move into formal education.

A child’s educational journey should be one of the most enriching and rewarding times of their life. They should leave school equipped with the academic, personal and social skills needed to make a success of their lives.

We need an education system that stretches high achievers, and leaves no child behind. Every child should leave mainstream education with reading, writing and numeracy skills. Teachers play a central role in children’s development, inspiring them and helping them to achieve their best. They will often be amongst the first to notice problems, and it must be made easier for them to draw on the widest range of support, addressing issues quickly as they arise, and preventing them getting worse.

Ultimately, we need to be confident that children have the attitudes and learning they need for the rest of their lives, and that teachers have the flexibility to respond to the different ways in which children learn.

Our school system will be centred on a new curriculum designed to give children a broad and enriching learning experience, and to develop the best teachers and leaders to deliver it successfully. This is the basis for progression to post-compulsory education and learning throughout life.

We will:

• focus relentlessly on driving up every pupil’s attainment, transforming the standards teachers must achieve, and reducing the variations between schools – particularly the gap between higher and lower performing schools.

• establish a National Leadership Academy to support the school leaders of the future who will be the driving force behind our reforms.

• ensure more effective workforce planning systems to deliver a sufficient supply of teachers to work through the medium of Welsh which will be a key contributor to our target of one million Welsh speakers over the coming decades.

• enrich the learning experience for every child through changes to our curriculum that will incorporate the right range of subjects, flexibility for teachers and develop the wider resilience and well-being of young people, helping young people develop into healthy, confident individuals.

• support every learner to overcome the barriers to reaching their full potential.

• introduce a new model of Community Learning Centres, providing extended services with childcare, parenting support, family learning and community access to facilities built around the school day.

• provide targeted careers advice to help young people to access jobs, particularly in new and growth sectors and also entrepreneurial opportunities. Fast track the introduction of a new Education Business Exchange Service and account executives who will work with schools and colleges in the Valleys.

• reform our approach to additional learning provision, to place learners, parents and carers at the centre of support and develop the skills of the workforce to deliver effective, specialist support for learners at key stages in their lives.




Build ambition and encourage learning for life

We will widen people’s horizons and lift their aspirations by creating a dynamic, entrepreneurial culture and ensuring they have opportunities to grow and achieve more throughout their lives.Education is the springboard that launches everyone into adult life. Many will enter the world of work immediately, others will continue in education, tailored towards the path they want to pursue, be it academic or vocational. The role of government is to support everyone’s aspirations, and work with businesses and education and skills providers to put in place the right range of opportunities for all.

Further education in Wales has historically been at the heart of communities, and provided opportunities for individuals to build and fulfil their ambitions. Today, they are offering a wider range than ever of vocational and academic courses, in first-class facilities, deeply rooted in communities. As the diversity of roles people can expect to play during their working lives increase, linking their contribution to the needs of people and business will become more important than ever.

A vibrant higher education system is a crucial partner in building the Welsh economy, equipping individuals with the highest levels of skills required as well as building the public service workforce of the future. Welsh universities undertake cutting edge research every day, and this needs to be increasingly geared to commercialisation and economic growth, supporting the development of our key sectors, as well as the future social cultural and environmental needs of Wales.

A central element of our economic ambition is supporting the creation and expansion of Welsh businesses. This depends on having people with the right entrepreneurial flair and ambition, the right economic conditions, and the right support from government.

We will:

• introduce a new strategic planning system for post 16 education, which plans the provision across sectors and responds to the needs of Wales.

• deliver coherent progression through and between the different post 16 education sectors, so that the individual’s learning pathway meets their needs and aspirations and is not defined by artificial boundaries between academic and vocational routes.

• significantly increase the maintenance grants available to Welsh higher education students, breaking down barriers to university and ensure that across grants and loans all students have the equivalent of the National Minimum Wage.

• bring together all research funding and ensure that funding decisions reflect Welsh priorities, including the needs of the national and regional economic sectors.

• ensure closer working between industry, schools, universities, colleges and the NHS to raise ambition and increase investment in research, developing the jobs and technologies of the future.

• draw on Wales’ assets to develop a population based approach to health and care research through Healthwise Wales.

• focus our business support schemes on building an entrepreneurial culture in Wales, and establish targets for the numbers of school, college and university leavers starting companies, as well as targets for their sustainability and growth.




Equip everyone with the right skills for a changing world

We will enable people to develop their skills in line with the rapid changes in the global economy, to keep Wales competitive and secure employment in an uncertain world.Lifelong learning has never been more important, both for national prosperity and individual development. The advent of the fourth industrial revolution is bringing profound changes to the economy, environment and society, and the challenge for our future resilience is to position Wales to benefit. This means ensuring sufficient opportunities emerge in the new economy to replace those that could be lost in the old economy, and to ensure that people are equipped with the skills to exploit them.

Digital skills will be a particularly vital part of the new economy, and as well as building coding and other aspects of digital literacy into our new curriculum, greater support will be needed for people already in work, or seeking work, to develop these skills.

Good employers place a premium on highly skilled workers and will themselves invest in developing and adapting their workforce. Government also has a critical role in providing the training that people and the economy need.

As part of the move to supporting regional growth priorities, we will be more responsive to variations in skill needs across Wales. To adapt effectively to this changing world, we need to get the often complex interplay between business, government and educational institutions right.

We will:

• work with the regional education consortia, universities, business, industry and the third sector to expand the network of code clubs in every part of Wales.

• enhance our support for part-time and postgraduate students to make it easier to obtain the higher level skills our economy needs.

• work with the Regional Skills Partnerships to anticipate future skills needs, focusing on priority growth sectors identified within regions and aligning our programmes to those needs.

• deliver 100,000 all-age apprenticeships aligned to economic requirements and use them to raise overall levels of skills in the workplace.

• review all existing skills and work-based learning programmes to ensure they meet the current needs of the economy and can respond flexibly to emerging requirements.




United and ConnectedOur aim is to build a nation where people take pride in their communities, in the Welsh identity and language, and our place in the world. We are building the vital links that make it easier for people to come together, for the economy to grow, and for us to become an ever more confident and outward looking nation.It is the strength of the links between people, within families, neighbourhoods, workplaces or wider communities, which gives us our sense of belonging and well-being. Government cannot create communities, but just as with the economy, we can foster environments where these links are broadened and deepened.

Communities prosper where people can participate fully and play an active role in shaping their local environment, influencing the decisions which affect them. People can play many different roles within their communities, and they need to be empowered to do the things that really make a difference.

We want a Wales of connected communities, and that means making sure that all the links needed are in place to bring them together. Transport and digital infrastructure are critical to providing the services we all need to stay healthy, to learn, to access employment, and to build prosperity.

Wales’ connections with the wider world are equally important, not least as we tackle the uncertainties of EU exit. The strength of our overseas relationships and connectivity will determine our ability to forge new markets and maintain our position as an attractive and competitive place to invest and do business.

Therefore the three objectives for this theme are: building resilient communities, culture and language, delivering modern and connected infrastructure, and promoting and protecting Wales’ place in the world.




Build resilient communities, culture, and language

We will build a country characterised by vibrant, welcoming and cohesive communities, with pride in the present and ambition for the future - a truly bilingual nation, celebrating its unique culture, heritage and diversity.The strongest communities have people who want to step forward to get things done. These are individuals who often seek no reward, other than seeing their community prosper. Government’s role is to support and empower those who want to make a difference, and to make sure they have the space to pursue their vision.

Public assets within communities are often key in enabling innovative local initiatives to become a reality. How these are made available to community groups can unlock the potential for communities and leaders to enhance local areas.

We will:

• work with communities to help maintain local facilities that bring people together, including pubs, libraries, museums, green spaces, arts centres and leisure centres, helping communities take ownership of assets in their local area.

• identify opportunities for more people to volunteer, including working with the WCVA and the third sector on the roll-out of a unified volunteer programme, Volunteering Wales.

• work with communities across Wales to promote and facilitate the use of Welsh in a positive and inclusive manner, improve systematic planning of Welsh language provision, and provide a robust regulatory framework.

• build the capacity of communities as places which support better health and well-being using approaches such as social prescribing.

• ensure schools take on a more wide-ranging role as community hubs, offering not just education but a much wider array of community activities, helping to join up their communities and the services people need.

• build a sustainable relationship with the Voluntary Sector, based on the outcomes we all want to achieve for communities and the right funding model to deliver them.

• develop a transformational approach to the learning, teaching and assessment of Welsh with the aim of ensuring that, in future, all learners will be able to use the Welsh language when they leave school.

• trial reforms to the democratic process, modernising the elections process and backing votes for those aged 16 and over.

• improve the way we work with community groups and the police to develop safer communities.

• work with communities, the voluntary sector and local services to counter the threat of extremism and hate crime in communities.




Deliver modern and connected infrastructure

We will invest in the 21st century connections we need to thrive and compete, joining up people, communities, businesses and services to drive prosperity.High quality, modern infrastructure is a key enabler of competitiveness and productivity. Investment can act as a catalyst for wider regeneration and supporting vibrant communities. The investment needs to be intelligently planned and well delivered to have maximum impact.

Our approach to regional strengths and diverse economic needs is reflected in our programme for investing in infrastructure. Some developments, such as superfast broadband and comprehensive mobile coverage, are nationally important programmes. In other areas, there are specific projects which support and enable the growth of regional economies.

Digital connections that anticipate the needs of the future can help us to change our working patterns, reducing congestion, and supporting our aspirations for lower carbon living.

Our attitudes to, and expectations of, transport are likely to change in ways that we cannot currently anticipate. With the geography of Wales and the needs of sparsely populated rural communities, cars will remain important, but new powers over buses and the rail franchise mean that we can take a more joined up view across all types of transport, enabling us to reduce our carbon emissions, promote active travel, and get the most from our spending on public transport.

We will:

• introduce the new National Infrastructure Commission for Wales to strengthen the governance and strategic planning of major infrastructure investments.

• require co-ordinated planning of new homes, facilities and infrastructure by local authorities, health bodies, housing associations and other key partners.

• deliver a single National Transport Plan supporting improvements to all the transport infrastructure for Wales, balancing travel needs with the aim of reducing emissions.

• create an integrated public transport network, covering the rail and bus networks, which is safe, reliable, affordable and low carbon.

• deliver the South Wales Metro, underpinning the region’s economic development, and spreading jobs and prosperity through more rapid transport, and ensuring that all new and significant developments in the region are sited within easy reach of a station.

• continue to develop the North Wales Metro and deliver transport improvements that complement it.

• deliver a significant improvement to the M4 around Newport, as well as enhancements to the A55, the A40 in West Wales and other trunk roads.

• deliver fast reliable broadband to those parts of Wales not currently served by the market.

• work with the mobile industry and OFCOM to deliver usable and reliable mobile phone connectivity across Wales.

• help people and businesses make the most of digital connectivity by investing in digital skills and through our business support programmes.

• support increased use of low emissions vehicles, through investing in a network of charging points.




Promote and protect Wales’ place in the world

We will ensure Wales remains outward-looking and fully engaged on the European and global stage, fostering new relationships for trade and investment, and promoting the best of our nation world-wide.EU exit marks a fundamental shift in our international environment. Although the shape of a final deal remains unclear, the implications are far-reaching and long term. Fighting for the best outcome for Wales is a top priority of this government.

Wales is a globally engaged and trading nation. Our prosperity depends on international relationships. We now need to deliver a step change in our international performance, building on the close relationships already established with nations and regions around the world. The introduction of long-haul flights connecting Wales with the Far East and beyond will be instrumental in improving our international connectivity.

Tourism creates a growing share of our wealth, and recognition of Wales around the world is crucial. International sport, and excellence in culture and research, have helped define modern Wales around the world. Promoting Wales with renewed energy will make the most of our economic opportunities, and help maintain Wales’ current competitive advantages after EU exit.

With two thirds of Welsh exports currently going to the European market, we will do everything possible to maintain a relationship with the European Single Market that allows companies to maintain free and unfettered access.

Our international offices and trade advisers work closely with Welsh businesses to help access new markets in North America, the Middle East, the Far East and elsewhere.

We are leaving the EU but we are not leaving Europe. Our reputation as a leader in areas such as sustainability, culture and research must be maintained, and Wales will remain an engaged European – and global - nation.

We will:

• build on the successful Wales brand to reinforce a contemporary, compelling and engaging identity for Wales that drives the nation forward as a place to do business and study and that inspires the people of Wales to create their future with confidence.

• take a strategic approach to the expansion of our international offices, based on an assessment of economic opportunity for Welsh businesses.

• modernise our global digital presence through a new digital gateway at wales.com, comprising of a network of integrated, international websites that promote a consistent story about Wales.

• work with the Department for International Trade to support our exporters to find new markets globally.

• continue to press the UK Government to prioritise full and unfettered access to the EU Single Market and work with the UK Government to promote Wales’ interests as new international Free Trade Agreements are prepared.

• develop new ways to build and maintain European partnerships through investing in networks and bi-lateral co-operation with partner countries and regions, especially neighbours such as Ireland and Brittany.




Early Years

VisionWe want children from all backgrounds to have the best start in life. Our aim is that everyone will have the opportunity to reach their full potential and lead a healthy, prosperous and fulfilling life, enabling them to participate fully in their communities and contribute to the future economic success of Wales.

There is substantial evidence to suggest that delivering the right support for all children, particularly those from deprived backgrounds, is the best means of breaking the poverty cycle, and raising aspiration and attainment for everyone. This underpins our central ambition of creating prosperity for all, reducing inequality, and promoting well-being. Investing in early years is an investment in the economy and workforce of the future. By tackling problems early, we are far more likely to stop children encountering difficulties at a later stage, when they can be much harder to solve.

ChildhoodThe first few years of a child’s life are critical to laying the foundation for lifelong well-being. They determine how well children perform in school, how well they relate to others, and ultimately shape the adult they become. A series of adverse childhood experiences (ACEs) can have a devastating effect on development. This is why it is so important to lay successful foundations from the earliest age.

ParentingConfident, positive and resilient parenting is fundamental to preparing children for life. Parents have by far the greatest influence on their children, but it can at times be an overwhelming experience. This is when help and support needs to be on hand, in order to help them create supportive and enriching environments for their children. Our approach is shaped by the understanding that needs vary between people, and vary over time.

InequalityThere are still significant gaps between the educational performance of different groups of children, with persistent under-achievement by those from more deprived and disadvantaged backgrounds. These are children who will benefit most from a concerted programme of support to give them the best start – an advantage they will carry with them for the rest of their lives.

We will:

• build on our current early years programmes and create a more joined-up, responsive system that puts the unique needs of each child at its heart.

• ensure that the early years provision in the new curriculum builds strong key skills, and embeds health awareness, well-being and resilience in children from the earliest stage.

• ensure consistent regulation and delivery of pre-school provision.

• deliver extended, coherent support for parenting, drawing together family support programmes, focused on positive parenting and early intervention.

• provide working parents of 3 and 4 year olds with 30 hours of free education and childcare for up to 48 weeks a year, delivered in a way that works for parents and children.

• legislate to ban the physical punishment of children.

• create ‘ACE aware’ public services which take a more preventative approach to avoid ACEs and improve the resilience of children and young people.

• pilot Children First areas, to support the better integration of services to reduce the numbers of ACEs and improve the resilience of children and young people.

Five Cross Cutting Priorities




Housing

VisionWe want everyone to live in a home that meets their needs and supports a healthy, successful and prosperous life. Good quality homes are the bedrock of good communities, and form the basis for individuals and families to flourish in all aspects of their lives.

Investment in improving the quality of housing is proven to reduce pressures on other public services; notably health and social care. There is significant evidence showing links between cold, damp homes and respiratory disease and asthma. These health problems can contribute to adverse childhood experiences as well as having a negative impact on children’s ability to learn.

Providing secure, affordable housing is the strongest basis for supporting vulnerable individuals to overcome mental health and substance misuse issues. Investing in housing, quality local environment and energy efficiency brings significant economic benefits, creates jobs, and builds stronger communities.

HomelessnessIt is unacceptable that people are forced to sleep on the streets in a prosperous society. Wherever possible, we will tackle the root causes of homelessness, recognising that prevention plays a major part in avoiding the spiral of decline caused by losing a home. But when crisis strikes, we must act swiftly to provide a strong safety net, and get people back on their feet as soon as possible. Those living rough often have complex needs and we need to respond to all of them, providing a joined up service, and recognising that not having a home can severely impact the ability to get help.

Affordable HousingThe housing market in Wales, like that across the UK, is under extreme pressure. There is a complex picture of provision, and the challenges that people face vary significantly, depending on income and where they live in Wales. Government intervention, therefore, needs to be specifically targeted, using all the levers at our disposal, and working with housing associations, local authorities, private house-builders and the private rented sector to maximise supply and respond to different needs.

Independent LivingGood housing plays a critical role in healthy, independent ageing. Enabling people to stay in their homes for longer brings significant health, social and economic benefits. We need the right kind of housing in the right place that matches people’s needs. In some cases these will be purpose-built, in others, through adaptations to existing homes.

We will:

• deliver our target of 20,000 new affordable homes by 2021, and make more homes available at affordable rent in every part of Wales.

• make buying a home more affordable through the Help to Buy scheme and Rent to Own scheme and bring buying a home in high cost rural areas within reach of local people through Homebuy.

• accelerate our support for new and innovative housing designs to meet challenges including pressing housing need, fuel poverty, climate change and demographic change.

• end Right To Buy and Right to Acquire in order to protect social rented housing for those in need, and give councils and housing associations the confidence to build.

• work with local authorities to begin council house building at pace and scale for the first time in decades.

• significantly reduce the number of people forced to sleep on the streets by focusing on the individual support needs of rough sleepers, and deliver earlier and more effective interventions for those at risk of becoming homeless.

• unlock the potential of SMEs to build homes and deliver local skilled jobs in all parts of Wales.

• incentivise housing providers to build homes which respond to the challenges of an ageing population and which enable people to live independently and safely in their own homes for longer.

• link new housing with major new infrastructure developments, for example the Metro and Wylfa Newydd.




Social Care

VisionWe want Wales to have a high quality and sustainable social care sector, with preventative and integrated services in the community, supporting people to lead independent lives. With an ageing population, the demand for and cost of care is projected to increase. In a sector which can struggle to recruit and retain workers, our aim is to ensure that this demand is met, and care is affordable, whilst improving quality.

Stepping in to take early action is essential to help children stay in families, and to reduce the impact of physical and mental ill-health. It also reduces abuse and neglect and leaves fewer people needing care.

Children Children in care should have a secure place to live, receive a good education, safe contact with their family, and be protected from abuse and neglect. They should expect to be listened to and be helped to develop positive relationships. We need to ensure looked after children receive as much help as possible and enjoy the same early years support and life chances as other children.

Adults Vulnerable adults may need help to access services, and engage in work, training, education or volunteering. They may need assistance in finding suitable housing, along with physical and emotional support, in order to be able to live full lives. In particular, young care leavers need intensive support at this key transitional stage of their lives, with attaining appropriate skills, improving employability, and access to safe, secure homes.

Older people Maintaining a good level of physical and mental health into older age aids independence, and reduces social isolation. It helps society benefit more from the contribution older people can make, capitalising on their knowledge and experience. Many older people will need additional support to live independently and our goal is to enable them to stay in their own homes for as long as possible. However, if that is no longer possible, we need a care sector which is

sustainable, and treats individuals with dignity and respect.

We will:

• invest in a new innovative care delivery model in the community, building a more diverse sustainable care sector in Wales, working with private and public sector partners.

• establish centres to co-locate support, advice and treatment services, taking advantage of innovative new technologies.

• assist care providers to create sustainable business operation models in the heart of our communities, including advice and support from Business Wales and the Development Bank of Wales.

• develop innovative funding models to ensure that funding is available in the future to meet social care needs.

• recognise and incentivise high quality care through the development of Inspection ratings and funding for Qualification Credit Framework training for care workers who are over 25, encouraging care providers to share good practice and to be centres of excellence.

• raise the profile and status of social care workers, through improving employment conditions and remuneration, so social care becomes a positive career choice, where people are valued and supported responsibly.

• implement an accredited qualification for carers.

• build more purpose built housing developments that would allow people to live independently within a protected and sheltered environment, located close to easily accessible public transport.

• raise the educational attainment and improve life chances of children in care, adopting a child centred approach, through the collaboration of education, social services and others.

• strengthen edge of care services to provide families with timely support to reduce the numbers needing care provision and provide assistance in the key transitional phase post 16 to access further education, jobs and housing for those leaving care.




Better Mental Health

VisionWe want to ensure that mental health problems are not a barrier to achieving potential in all areas of life. One in four will be affected by mental health issues at some point during their lives and for many the support of their family and friends will be enough.

However, when more intensive support is needed, we need a system which is easily accessible, and focused on identifying and treating as early as possible, before crisis point is reached.

ChildrenWherever possible, we will give children and young people the tools to cope with the stresses of growing up in a rapidly changing society, where online bullying is a new and worrying phenomenon. Referrals to child mental health services have almost doubled over recent years, reflecting greater awareness but also placing a strain on services. Schools are in a unique position to identify problems early, and provide support for children and a rapid gateway to further support where appropriate. The deep intergenerational and family effects of mental health issues should be recognised, and the adverse childhood experiences that can result.

AdultsMany people suffer from mental health issues but do not feel able to talk about them openly, or seek help. Again, there are positive signs of social change, but more still needs to be done to break down the stigma surrounding mental health conditions. Forty per cent of work-related illness is reported as stress and results in an average absence of 24 days. Mental health issues vary in their severity, and responses should always be appropriate, proportionate and timely including approaches such as social prescribing, rather than simply treating with medication.

Older PeopleRemaining mentally and physically active into old age is critical to reducing the risk of developing dementia, other health conditions, and depression as a result of loneliness and isolation. Giving people opportunities to remain active provides a benefit to our communities as well as helping people enjoy positive mental health well

into their old age. However, with more people living longer, the number of dementia cases will continue to rise. Alongside dignified care for the individual, we need to recognise the impact on families and carers.

We will:

• continue our programme to improve mental health services for all in Wales, improving the quality and integration of services, addressing mental and physical health needs in tandem and enabling a better transition between different services.

• build on the work we have done which has enabled nearly 140,000 people to access support from the new mental health services in primary care since the introduction of the Mental Health Measure, by improving access to psychological therapies in both primary and secondary care for both adults and children.

• design our new curriculum and assessment arrangement in schools to place real and meaningful focus on well-being, and developing the mental resilience of children and young people.

• make sure teachers have the help and support they need to respond to children experiencing difficulties, by ensuring effective links and joint working between schools’ counselling services, education psychologists, children and adolescent mental health services and neurodevelopmental services and designated support for clusters of schools.

• deliver a new community perinatal mental health service and review the need for inpatient facilities in Wales, to stop post natal depression worsening and to allow mothers to form a strong early bond with their child.

• help people with dementia and their families and carers to access information, advice and support to maintain their independence by a joint health service/local authority ‘team around the family approach’.

• deliver a pilot to explore how social prescribing can help to treat mental health conditions.




Skills and Employability

VisionWe want an economy founded on high quality skills, giving businesses the resources to grow and innovate, and people the ability to prosper. Every person should be equipped with the skills they need to get a job and the opportunity to develop new skills through their working life.

Low skill levels are the single biggest barrier to building the Welsh economy we want, and often the biggest barrier for individuals in securing meaningful work. It is critical we tailor skills support to individuals’ needs, while addressing other barriers such as poor health, transport and caring responsibilities to drive up prosperity levels for all.

Employable PeopleGood skills are a key factor in determining whether people get good jobs. We need to make sure that everyone has access to the training they need throughout their lives. People can follow many routes to higher skills, for example apprenticeships, work-based learning, and further and higher education. All of these options need to complement each other to enable people to pursue the careers they want. Our new approach to employability will deliver a seamless referral and support service for people who need basic skills, and people who need to raise their skill levels to get a job or progress in their career.

Skills for BusinessGood skills unlock growth and innovation for businesses, which means they need to be able to recruit workers with the right skills. Businesses also have a responsibility to invest in their workforce to benefit themselves, their workers and the wider economy. As a government we are committed to link the training we provide even more closely to the needs of the Welsh economy.

Strong EconomyGood skills make Wales a more attractive destination for investors, bringing with them the higher-end, higher-paying jobs we need. Better and more transferable skills help people to move more easily between jobs, progressing from lower-paying roles with limited prospects. The higher the skill levels, the more resilient our economy will be, and better able to ride out economic shocks.

Leaving the European Union will mean we must redouble our efforts to build an even more competitive economy, and higher skills are at the core of this. Automation remains a growing threat to jobs, but the best defence will be people with the ability to work better and smarter than machines and able to solve the problems they can’t.

We will:

• deliver a school curriculum which meets the skills needs of individuals and the wider Welsh economy.

• ensure that our skills provision through schools, further and higher education and work-based learning reflects current employer needs and keeps pace with the economy of the future.

• promote closer links between schools, colleges, universities and employers and businesses, public services, and the NHS to better anticipate the skills needs over the coming years.

• reform our economic development and skills provision to work on a regional basis, building on the three employer-led Regional Skills Partnerships.

• reconfigure our current offer into a new employability programme that is simpler and more responsive to the needs of individuals and employers.

• set out a common approach to identifying the needs of the individual as part of a new approach to employability, identifying those with employment support needs at the earliest possible stage and making the referral process more seamless and less daunting.

• provide tailored, community outreach for those who face multiple barriers to work.

• use the Valleys as a test bed for a place-based approach to enhancing employability, including extending the Flexible Skills Programme to drive a focus on engaging employers in deprived areas.

• improve health and employment outcomes through employers, health services and employment services working together more effectively, including supporting employees at risk of long-term sickness to stay in work through our In Work scheme.



Welsh Government Llywodraeth Cymru

NATIONAL JOINT PROFESSIONAL ADVISORY COMMITTEE (NJPAC)TERMS OF REFERENCE AND CONSTITUTION

Last reviewed June 2017

1. Name

1.1. The name of the Committee shall be the National Joint Professional Advisory Committee (known as NJPAC).

2. Aims and Objectives

2.1. To provide an over-arching co-ordination function to the work programmes of the individual Statutory Advisory Committees (known as SACs), including:

2.2. To monitor the activities of and direct progress to achieve the outcomes of the SACs and any task and finish groups they see fit to create.

2.3. To act as a sounding board to the Chief Medical Officer in the production of his annual report to Welsh Ministers on the health and well-being of the people of Wales.

2.4. To facilitate the circulation of knowledge and best practice pertaining to the health services professions and to supplement the communication of related issues between the Welsh Government and the health professionals.

3. Membership

3.1. The Committee shall consist of the following members:- The Chief Medical Officer for Wales- The Secretariat- the Chairs (or Vice Chairs) of the 7 SACs- the Chairs (or Vice Chairs) of the 7 Local HPFs- The SACs Welsh Government Chief Professional Advisors (or Deputy)

4. Welsh Government

4.1. The Chief Medical Officer shall act as Chairperson and Lead Official for the committee in his/her role as principal professional advisor to Welsh Ministers on health related matters.

4.2. A secretariat service shall be provided by the Welsh Government for ordinary committeemeetings.

4.3 NJPAC - 2017 - Committee TOR - June 2017 HPF 2 Oct 2017


4.3. The Chairperson shall be the principal point of contact for Members in relation to the activity of the Committee; however, for administration of the Committee, the Secretariat shall be the first point of contact.

4.4. The Secretariat shall arrange meetings, provide a meeting room, prepare and circulate papers, brief the Chairperson in writing or in person on the delivery of the Committee meeting, prepare a minute of the meeting and publish the finalised minute to the Committee webpage.

4.5. The Secretariat shall maintain the Committee Constitution, Membership list, Register of Interests and record of expenses.

5. Deputies

5.1. In the event of any member being unable to attend, the members should arrange for a deputy from the represented group, who would have the authority and status of the absent member.

5.2. The member must inform the Secretariat at the earliest practicable time and is responsible for fully briefing their deputy in advance of the Committee meeting.

5.3. Should a deputy not be available to attend, the represented group should provide a written update, to be tabled at the meeting, outlining any developments relating to any items on the agenda.

6. Term of Office

6.1. Members of the committee shall serve on the committee for the duration of their term of office of their represented group.

6.2. Represented groups should arrange for an alternate from the group to represent the group during any vacancies at the end of a member’s term of office.

7. Meetings

7.1. The Committee should normally hold not less than 3 meetings each year, to be scheduled annually by the Secretariat and approved by Members, with variance subject to the agreement of the Chairperson.

7.2. A quorum for meeting shall be one third of members with the proceedings of the Committee not being invalidated by any vacancies in membership.

7.3. Payment of reasonable travel and subsistence to members of the Committee shall be at the discretion of the Welsh Government and any extraordinary expense will not be paid unless approved by the Welsh Government in writing in advance.



7.4. All expenses incurred should be wholly in relation to the delivery of the Committees agreedaims and objectives, as set out in this constitution.

8. Duties and Powers

8.1. The Committee has no statutory duties and fills no executive function.

8.2. Members may take no action or act as representatives of NJPAC without the authority of the Chairperson.

9. Review

9.1. This Constitution shall be reviewed no less frequently than every four years.

9.2. Recommendations to amend the Constitution may be proposed by Members.

9.3. Amendments to the Constitution will be treated as approved once two-thirds of the total memberships have voted in favour in a ballot conducted at a Committee meeting



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