Cynulliad Cenedlaethol Cymru

Good morning. Welcome to today's meeting. In the absence of the Chair, the first item on the agenda is the election of a temporary Chair until the end of the summer term. So, under Standing Order 17.22, I invite nominations for the temporary Chair.  

James Evans. 

Thank you. James Evans. Are there any other nominations? No. I see there are none. Therefore, I propose that James Evans is appointed temporary Chair of the committee until the end of the summer term. Are there any objections? No objections. Therefore, James Evans will take the chair.  

Thank you, and thank you, Members, for nominating me as temporary Chair. Bore da. Good morning and welcome to the meeting of the Health and Social Care Committee today. We have got an evidence session today with Llais. So, I'd like to welcome you to the meeting today, and also to Members who are attending in person and Members who are attending on Zoom. We have one apology today, which has been received from our usual Chair, Peter Fox. I'm sure I share with other Members in wishing Peter a speedy recovery from his recent knee operation, and we hope to see him back sooner rather than later. I would now like to ask Members if there are any declarations of interest. No. I don't see any declarations of interest. 

I'll move on, then, to today's evidence session. It's a general scrutiny session with Llais, which is operationally known as the citizen voice body for health and social care Wales. We do offer simultaneous translation today between English and Welsh, so if you'd like to contribute yn Gymraeg, please feel free to do so. I'd just like to ask the witnesses to introduce themselves, and I'll start on the end with Ben.    

Hi. I'm Ben Eaton. I'm a strategic director at Llais for organisational strategy, communication and engagement. 

I'm Alyson Thomas. I'm the chief executive of Llais.  

Bore da. I'm Joanne Bolton, the strategic director of operations and corporate services. 

Diolch yn fawr iawn. Thank you very much. So, we'll get straight on now with our scrutiny session, and I will start, if that's okay. As a general question on the priorities and awareness raising of what you do, I'd just like to know what the main priorities and objectives are currently for Llais. How do they work with the public and partners in deciding the vision and priorities for the organisation? Would you like to start, Alyson? 

I don't know whether the chair might need to start. 

Or the chair—whoever would like to start.  

At the heart of our work, as an independent body, is making sure that we deliver for the voices of Wales. At the heart of that engagement, we secured and, hopefully, had consistency in the context of our engagement, and our priorities in the context of listening to the people of Wales—you will have seen this in the evidence presented for 2024-27—are driving a national conversation, making sure that the voices of the people are at the heart of reflective practice in developing policy in the context of health and social care, and also pushing for services that people need and are at the heart of our communities. We are hearing, and I am sure you will receive more evidence later, that at the heart of everything we do is making sure that those voices within their communities are engaged with the relevant bodies. I am particularly keen to focus that we listen to the silent voices of the communities of Wales—those communities, those individuals, for whatever reason, that don't have that opportunity to engage. We can't create a more inclusive, better structured health and social care system without that reflective engagement, listening to everybody.

We also, of course, need to be mindful of the importance of the digital agenda. You will also see, as part of our priorities, growing and developing the organisation. This is a very young national body, two years into its creation, and at the heart of that is setting solid, good governance, setting the framework, and making sure that the impact is there and delivering for the people. Also, we see effective engagement then with our partnerships and, hopefully, reflecting then in conversation with Government.

Diolch. Anything?

Just to add to that, fundamentally, as a new organisation, it was really important to us that our strategy and vision was born from what we hear across Wales locally. In terms of establishing the organisation, it was really important to us, in terms of our organisational design and our strategic approach, that we build from that local engagement and involvement across all of our communities in Wales. We very much took a bottom-up approach, so those national priorities have been drawn from the conversations that we've had and what we've heard from people across our local communities in Wales, to identify the common themes and issues and make sure that we can add most value nationally by bringing those common themes and issues together at the same time as creating space for our regions to respond to the local issues that come up that sometimes can't be planned for, particularly things like service change proposals, et cetera. So, allowing the space for our regions to be responsive to those local needs and issues as they arise has been built in and baked into our planning approach.

Thank you. How confident are you that you can meet your priorities and your outcomes that have been set? One thing that's very important to all of us is, actually, how they're measured as well. Can you explain a little bit more about how you are confident, or if you are confident that you're going to meet your priorities, and how you're going to measure those in the long term as well?

There are a few elements that drive that. We are very conscious that, as a new organisation and still a relatively small organisation, given the size of the remit that we have—. Excuse me, I've just realised I'm hearing myself twice.

They echo in your ears, yes.

Once is enough. [Laughter.] 

In terms of the scale and the remit that we have, it's really important to us that we set both an ambitious agenda and one that we are confident that we can deliver. So, in developing those plans, we take into account a range of factors in terms of things like, for example, what's the real added value that we can bring as an organisation, whether that be in terms of working in partnership with others—it's fundamental to us, in terms of our ability to deliver on our agenda, that we work in partnership with others—so we think about those things. We look at what others are focusing on and doing and, when we have reached agreement on what those priorities are, then we set, in terms of the organisation, expectations and more detailed plans on which we can judge our performance and our progress against those plans.

It's taken us a little while, because, as a brand-new organisation, we didn't have any of the systems in place to enable us to do that, and we haven't always got it right first time. It's taken a little while to try different things out. But, we've now introduced a performance framework within our organisation that enables us to be clear, both within our organisation and the public, about what we want to achieve and how we'll judge that success. Ultimately, the public will judge the success of our impact, in terms of the impact on their individual circumstances and lives, and the difference that we make to their communities.

That's generated some questions from Members, so I'll bring in Mabon ap Gwynfor.

So, the budget is not quite double, but it is substantially increased. That recognises a range of aspects in relation to the difference between Llais and the former community health councils. So, for example, as an independent, stand-alone Welsh Government sponsored body, we had to introduce a whole corporate infrastructure around things like our finance, our human resources, our own data and digital systems, that previously were provided as part of us being a hosted organisation. So, Powys Teaching Health Board were our employers and provided all of that infrastructure stuff, and Digital Health and Care Wales provided our digital systems. So, we've had to create an infrastructure to enable us to operate on a stand-alone basis, and that takes additional money.

Also, of course, in terms of expanding our role into the social care sector, that requires additional resources, so there was recognition of that from the Welsh Government. So, for example, we received additional funding to enable us to increase our staffing in some key areas, and that's in our complaints advocacy service. That complaints advocacy service is a demand-led service. It was really important that we were able to both support our complaint advocates to deliver that service effectively within social care, and make sure that we give enough resources to that social care side of things as well. So, a whole number of factors that are influencing our budget.

In terms of the value for money, if you like, for that, then I think we can demonstrate that in a range of ways. One of the benefits of being brought together as a single organisation, operating locally, regionally and nationally, is that we do have the opportunity to do things once, rather than seven times over, which is what the previous CHCs struggled to do. So, some of those corporate activities and functions we can do once.

There's a real benefit in terms of learning from each other across Wales. So, developing common, consistent approaches that allow us to apply that differently, locally, according to different circumstances, means that we're not reinventing the wheel. And then, fundamentally, it means that we're developing that infrastructure that allows us to make those connections across Wales quicker and easier than the former community health council movement would have been able to do. So, identifying where there is good practice across the health and social care sector in Wales, and using that to share across our organisation, to challenge other organisations, and to spread and adopt that good practice, is one area, but also identify where that inequity is, and, again, to challenge health services and social care services to learn from each other. It's really important from a public perspective. They get quite frustrated when different parts of the NHS don't necessarily work in the same way, because, as they see it, it's the NHS, not seven different local health boards, and three.

So, bringing us together in this way enables us to make those connections quicker. We're still on a journey. We're two years in. Some of that infrastructure doesn't quite support us yet, as much as we would like it to, but we are making progress and getting there. Colleagues will have seen that, for example, in terms of some of the reports that we've produced nationally around things like emergency care, dentistry, et cetera.

Lovely. Medwin, do you want to make a brief point?

Diolch. Thank you. 

This question, I think, will probably lead on to my next question, actually, which is around engagement and how Llais engages with the public to make it more visible, so people know that they can access Llais to act on their behalf. I'm just interested in the work you are doing around that and how we can get more people using it, really. I do not know if—. Ben, I know you are on the engagement side of Llais, so perhaps I'll start with you, if that is okay. 

Yes, sure. The model we've set up in the last couple of years tries to go to the people rather than asking them to come to us. We go into communities—we’ve coined it 'Llais local'—so each of our seven regions, they host local events in towns and cities and they embed next to community-based organisations that are already there. They engage with people for a few weeks and they build up that intelligence and then they move around the region to try and get a regional picture.

On top of that, we do national-based events such as the Eisteddfod, the Urdd, Pride, and we go and we try and show and demonstrate that we're there for people, and that gives us the opportunity to explain a little bit about what we do as well. On top of that, we've done some paid-for campaigns, some advertising. We've also approached some print and online outlets to try, especially in the early days, to just raise awareness of what we do. We've tried partnering with other organisations to do guest newsletters, like with the Nursing and Midwifery Council, and we're working with the health boards and the local authorities to provide them with assets so they can do that as well, so they can promote our awareness and describe what we're doing.

Good. Pushing that point a little bit, if I can, about the views of under-represented groups as well, and making sure the views of everybody right the way across Wales are represented, not just in our urban centres, but rural communities as well, and people from ethnic minority backgrounds, making sure they're represented, I'm just wondering whether you're satisfied with the engagement that you're doing in that area. Do you think more could be done? If so, how do you think you can get there? 

Certainly more can be done.

Certainly more can be done, as in any organisation. One of the key things that I think is very interesting in the way that we've developed this model, as I've already mentioned, and Ben notes, is the hyperlocal. At the heart of good effective engagements in communities is going in and making sure that the leaders of those communities are empowered to tell their stories, and that is so true in the context of the diverse cultural communities we have, multicultural communities in Wales.

You asked how could we build on this. One of the things that we're realising from our engagements in developing volunteer strategies is that you empower the communities to tell their stories. This has been so important. If I give you one example: the maternity work, going into communities, multicultural communities, where they then engage. In the past, they haven't had that opportunity, and that voice hasn't been heard. In an inclusive Wales, that has to be at the heart of all our representations. As we develop this strategy now, we want to make sure and empower communities.

Just to add to that, one of the really important things for us in terms of taking forward this agenda and reaching under-represented groups, where maybe the CHCs weren't quite able to do as much as they would have wanted to previously, is having that geographically dispersed model located within our communities has provided us with the opportunity to work with other organisations, third sector organisations and other representative groups, to develop and build trusted relationships.

One of the first things that people said to us when we engaged during our first 100 days was, ‘Don't just come to us and harvest us for information and then go away again.’ You have to be part of the picture. You have to be there on a consistent basis. So, building those relationships, earning that trust, takes quite a lot of time. That investment and that value of other local organisations sharing their time, sharing their expertise, sharing their knowledge with us has been fundamental.

That partnership ethos, that partnership approach is what we are working on. As Medwin says, there is more to do, but that is absolutely where we want to position ourselves as an organisation. We don't and can't know everything. We have to be part of the fabric of our communities, and we need to be working with the elements in those communities to actually amplify people's voices. 

And be prepared to try new things. If you take youth, how do we make sure that we are empowering youth, young citizens, to have the confidence to come out and tell their stories in the context of health and social care? It is an exciting opportunity to empower those to be future leaders in the context of telling their story, and how that relates then to policy development.

Lovely. One final question from me before I hand over to Members. One thing that gets raised with me a lot, actually—and I'm sure other Members as well—is Llais's independence from Welsh Government. I am just interested in how you maintain that independence from Welsh Government, considering Welsh Government set you up. That's something that gets fed back to us quite a bit. I was interested in how you manage that relationship and the independence from Government.

We have no problem at all with it. We were created by Government under law, but it is an independent body, and we fail if we do not engage in the context of that clear framework of independence, supporting and engaging, mindful of the development of policy, but always starting from a position of considering what we've heard as evidence from the people of Wales, reflecting on that, and then engaging with the partners.

How do you think that's understood by the public? Sometimes, the public don't quite understand that it is independent from Government. I'm just interested in how you manage that, really.

It's key that we make sure in our narrative that we are really clear on that context. I think that independence—. And I think we've proven it in some of the national engagement programmes that we've looked at. Emergency care, maternity, these were very difficult issues, and we presented hopefully with honesty, with integrity, identifying where the problems were, and we weren't afraid of making those comments known. It is good to see how various partners within the organisations of health and social care reflected on that, and that included the Government as well. So, we are here as a partner, a partner of all those engaged in health and social care, but never afraid—never afraid—of making a statement should we have to.

Lovely. Diolch yn fawr iawn. Thank you. I'd like to hand over to John Griffiths.

Diolch, Cadeirydd. So, in terms of your general work and the complaints advocacy service as well, could you give committee a picture of what are the main issues for health services in Wales that are current at the present time?

In relation to the NHS, you won't be surprised to hear what I'm going to say; I'm sure that you are hearing them on a day-to-day basis. It's the fundamentals for people in terms of the things they value the most from their NHS, and the things that bother them then when those things are not there. So, being able to access services where and when they need them is fundamental. We hear an awful lot on a day-to-day basis around access to GP services, being able to get an appointment when you need it, to be seen quickly enough. Getting access to a dentist, that is also something that we hear an awful lot about and continue to hear, although there has been some movement around some of the GPs. It's more variable now, but that is still something that is really important to people, and very frustrating and worrying for them when they can't get that access.

Things around feeling listened to and having the time and space to talk about their health and well-being, and feeling that they are genuine partners in their health or social care journey is fundamental to them. When that doesn't happen, then that's where they will raise concerns with us. People are worried about the distance that they have to travel to get to the health services that they need, and they get frustrated when changes to services often mean that they move further away. If that isn't done in conjunction with, for example, transport systems or in conjunction with those communities, then that causes significant concerns for people, and we hear about that an awful lot.

Having services that are people centred, so having services that respond to people's individual needs, so taking time as services to understand what those specific and individual needs are and responding to that, and doing it consistently. Too many times, people might have a really good experience in one part of the system, and then they move along on that care pathway, and some of that information hasn't been shared with another healthcare professional, et cetera, so it doesn't feel joined up, seamless, or integrated in the ways that it should. It's really important that services are provided in a way that is genuine partnership. Those are the main areas that we hear about consistently.

There are other aspects that come up from time to time. So, again, very community focused, but pharmacy services is one that people really value in terms of the importance and expanding role of pharmacies. But we're also hearing that, actually, those services are under pressures, and there are concerns about hours shortening, medicine shortages, all kinds of things that make the system feel fragile. Those are the aspects that people want to talk to us about most when we're out and about, whether that be in our open engagement or through our complaints advocacy service. I'll look to Ben in case he's got a bit more detail to add.

No. I think the only other thing I'd add, which I think you'd all be aware of, is that the concerns around discharge, emergency care and maternity are really strong at the moment—the sentiment around those.

And the fundamental one I missed as well that comes up all the time is waiting times—so that waiting for care and treatment, whether that be diagnosis, whether that be assessment, or whether that be the treatment itself. Those are the things that are frustrating, and, if people aren't involved and communicated with and kept up to date in a way that works for them, that's when they worry about whether or not a service is going to deliver what they need.

Medwin.

One of the benefits of having a national institution we've just heard now in the context of very clear, targeted examples, but then the role of Llais is to take that up one stage and just to consider, 'Right, what do we hear? What are the lessons of all of this?' One of the things that I've noted, I think, over the last two years is the vulnerability and I think how the people of Wales find it difficult to navigate the whole bureaucracy of the system. But I think we're also hearing a sense of maturity by the people that, although—. They understand, in the context, all the constraints, but they really want to be part of a conversation, a national conversation, an honest conversation, that notes what's feasible and realistic in the context of system change. I think that's something we really need to focus on. I'm really keen, in the context of Llais, of its national conversation, on how do we bring that together, because that's so key in the context of any Government that works for Wales, and, with our health boards, our partners, how do we set up a better understanding of the rights, the obligations and the responsibilities of the citizen as we look to a prudent healthcare system for the country? And that readiness to engage is something we're hearing across all of our communities.

I think there's a supplementary question from Mabon.

It's a really important element of our work. People take the time to share their views and experiences when they believe it's going to make a difference. So, we have a big responsibility as an organisation to make sure that we don't only take the time to listen to what people say but then we use what we hear to hold a mirror up to organisations and to drive change. We do that in a lot of different ways. So, we are involved with health and social care services on a daily basis. So, it could be, for example, the work that we do sitting at public board meetings, where we will review and respond to the proposals and the issues and inform the decisions that are taken by those public boards. So, we will bring the views and perspectives of people, communities and service users, into that discussion to inform the decisions. We might raise it on an individual level, for example, in relation to our complaints advocacy service. So, we will make representations based on what our clients want to do on a daily basis in relation to individual complaints. In relation to service change, it's really important that we are visible in terms of people knowing that there is an organisation to speak up for them in terms of how they feel about proposals to change services and to make sure that information is fed in to health services or social care services and that those organisations pay due regard, set out in the legislation, to the issues that we raise. So, whether it be a local authority or whether it be a health board or an NHS trust, they are legally bound to reflect on the issues that we've raised, which are based on what we're hearing from people, and respond to those issues. So, it's really important that we have an ongoing relationship with those organisations, to make sure not only that they listen and understand, but also that they respond to those issues. We are there to make sure that they respond to all of those issues that are raised, and we will do that in a variety of different ways. Sometimes it's at meetings, sometimes it's in person, through individual discussions, and sometimes it's in writing, whether that be through a report of what we've heard, whether it be through feeding information in a more accessible way, videos et cetera. Health and social care bodies, then, are duty bound to respond to those things to us, so that we can then play that back to the people who took the time to share their views and experiences with us.

Lovely. Thank you. John.

In terms of those experiences that people have, hopefully there are quite a lot of positive experiences as well as negatives and problems and difficulties that people experience. So, where it is positive, do you have a role there in bringing that to deliverers of public services and decision makers around health services? Is there an element of sharing good practice involved?

Absolutely. If we're listening in an honest, truthful way, it's about identifying the areas that we need to work together on to improve, but also the storytelling of what works, and a lot does work in the context of engagement. It's really important that we have that balanced approach in our storytelling, and none of our stories are based only on us as a legal entity; all our stories have to be based upon what we hear. And I think, as you'll see within our PR, it's also a very clear strategy of engaging to support, develop the system, but also celebrating in the context of what has worked in the context of system change. And there are examples, in the context of health and social care, of good practice. You might have seen some of our videos. Again, we are telling the story of the people, how they've engaged, and what's really good is to see when they come back. You raised a very important question, Mabon, about the outputs, the allbynnau, and you referred to some really key regional conversations that are happening now. What I really realise in the context of our work—and it's a privilege that we have—is it's working on those big national conversations, but there are hundreds and hundreds of individuals that come with their particular story, and it may be a very small part, but if we can work through advocacy, through engagement, with the partners that make a difference—it may come initially in your post box, but—then, in the context of driving the change, that is as valuable as in the context of the big picture change. Because, at the end of the day, the citizen has the confidence to come to us, to note the concern, and hopefully we can help them on that journey. That's the value of a national organisation that can co-ordinate that in an effective way.

And people were very clear with us, when we engaged with them in our first 100 days, how important it was to them that we didn't just raise the things that weren't working, that we did take the opportunity to celebrate what works well. Both health and social care play such a fundamental part of the fabric of our communities. Almost everyone is touched by—well, everyone is touched by—the NHS, and, those who rely on social care services, it's so important to the way they live their lives. It's fundamental. They place huge value on it. That's why they are so passionate about it, because it plays such a major part in their lives. They feel it is their NHS, it's their social care services, so it's really important that we recognise where things work well and celebrate that. And they place huge value on the staff, who work tirelessly day in, day out, to provide care for them. So, that is something that we make sure that we do in all of our interactions with health and social care services.

I know we'll go into those policy areas in more detail later. I'd like to bring in Joyce Watson, if that's okay.

Managing expectations. Because you're right, you go into communities and people give their stories and then expect some outcome, which you might not be able to deliver. So, therefore, managing expectations so that your body—corporate body—doesn't suffer a lack of confidence because you can't change something that's beyond your ability. And I would have thought that that's a key part of everything you do in explaining your remit, your scope of influence, however you exert it, to those people at the very outset. So, I'm quite interested in how you manage all of that.

From a board perspective, it has to be very clear, in setting our strategic plan, the honesty of the engagement linked to the framework of the Act. We were created by Government to do a particular role. We are there to be the conduit, to engage, and I think how we do that has to be very clear in the context of the conversations we have of setting the framing of it. And also, I think, there's a responsibility on us, as an independent body, to frame that in the context of an independent assessment of the difficulties in the context of the system of health and social care, and the difficulties in the context of the public purse, of investment. I'm mindful, in the context of the Auditor General, his report, of the significant funding that has been given in the context of this area over the last 10 years, and yet there are problems. And I think we have to navigate that in the context of an honest, realistic way—always listening, but framing what we can do and encouraging people. I'm sure Alyson can give you some examples as well.

Yes. I think it's really important. So, the way we build our relationships, both with individuals, whether that be in relation to our complaints advocacy service and what that can deliver for them and what it can't, that's really important. In relation to our role in service change, for example—. So, it's about the conversations that we have with communities and it's about some of the information that we make available to people in ways that are accessible as well to help understand. But it's also about those expectations in relation to health and social care services as well, because we are a relatively small organisation that is needing to look across the health and social care system and make sure that we make decisions about where we can have the most impact, and that sometimes means that we can't be everywhere all of the time. So, that sometimes does mean that we need to have a conversation with health services and social care services about what the level of our involvement might need to be in terms of driving that impact for people. So, it's a daily conversation that we have, both with the public and with health and social care services.

You referred to service change. One can envisage, over the next couple of years, significant additional issues coming to service change. And what is reasonable and what is appropriate in the context of Llais? We're there to support, to facilitate, but then setting those frameworks in place is extremely important, and that must start with good governance of the organisation. Because, unless we've got the right expectations, the right frameworks of governance, then we can't expect our colleagues within the organisation to take it forward. So, we're very mindful of the honesty and the realism that's required in difficult areas.

John.

Yes. Just one more question from me, then, Cadeirydd, around your reports and position statements. The Swansea bay maternity services, dental services and emergency care, for example, are you content with the responses, the improvements that needed to be made, whether they have been made, whether there's been sufficient progress?

I think it's really important to recognise that some of those national reports talk about long-standing system issues, so the ability to fix it quickly might not be there. The important thing for us is the recognition of the things that people have shared with us, the commitment to work with us, and to involve us in discussions around some of the solutions to those issues, and the ongoing communication and updates to us about how it's responding to the things that we raise. In all of those aspects, we can say that we are comfortable that those ongoing conversations happen. We're in the rooms that we need to be in in order to keep a focus on those things that people have said.

For example, in relation to our position statement on dentistry, some of the issues that we raised have been fed through and formed part of the current consultation. That doesn't mean it's necessarily perfect, and we've raised further issues in response to that consultation, but we can see movement, and we're able to play that back to people. It does mean that we need to keep a close eye on following up on those things. For an organisation that gets involved both proactively and responsively, it's really important that we keep the conversation continuing in those areas, so we keep following up to make sure not only that the committed actions move forward, but, fundamentally, that it's making the difference that people want to see.

Sometimes you can try some ways of fixing things, and it doesn't work, so it's really important that we have an effective follow-up system to make sure that we follow those issue through, right through to the 'so what?' from a public perspective. That's the basis on which the public judge things, not the commitment to action—the difference it then makes based on that action. We need to do a bit more in that area to make sure that we track that. We are developing our infrastructure and systems to enable us to keep a closer eye on those and to check in on some of those things more frequently.

The classic example is the emergency care report we did. We're all enjoying the good weather now, but winter will be here soon, and the question then, in the follow-on that we ask, when we go back to our colleagues in the health boards, is, 'These were the issues identified, how are you now preparing in the context of winter?' So, that continuity of good system change evaluation, we need to make sure that that conversation continues, we consider what was said, what we identified. Again, that reflective dialogue to improve the system for health and social care.

Okay, diolch yn fawr.

Diolch. Thank you, John. I'd like to hand over to Lesley Griffiths.

Thank you, Chair. Bore da. Good morning, everyone. As you know, we've been doing an inquiry into GP services. Alyson, you alluded in an earlier answer around people's concerns in accessing GPs. Access was one of the concerns, not being listened to. I was just wondering what other chief concerns you get from patients.

In terms of GP services, one of the main areas that people remain concerned around is not being left behind. Whilst there is a desire for lots of people to access services more digitally—it can make life so much easier for them, it can save them time to access services digitally—for others who don't have access to digital services or are unable to use digital services, it's really important to them that their GP service understands and responds to those different needs. So, that's an area that's fundamental.

It's having the time. It's not only about having access to an appointment, it is also about making sure that the time is available to them to share how they're feeling and their issues in a way that they feel safe, and in a framework that they trust that individual who's providing them with the care. So, continuity of care in relation to GP services is fundamental. And that's not just about wanting to see the same person because you've always seen that same person. For lots of people, when you get under the skin of why it's important to them, what they're actually talking about is speaking to somebody who they know knows them as a whole person. So they might present a condition on any one day, but they know that that person has access to their wider circumstances and is able to understand the issues that they're presenting in those wider areas.

I think there are some other aspects in relation to GP services. People would like more support for GP practices so that they can better understand their needs. For example, we’ve heard a lot from the trans community that when they are looking to access support in relation to moving things forward for them, actually there isn’t always that knowledge and understanding of their needs. So, it’s really important that local services, GP services, take the time and have the framework of support in place to understand people’s individual needs and respond to those.

Alyson, you mentioned continuity of care as being of concern. Obviously, people really value that, don’t they? What other things would you say they value in their relationship with their GP?

They value a relationship that is based on trust. They value a relationship that is based on a system that’s connected with each other. They are also very well aware of the pressures that are on GP services. One of the concerns that we have is that, because people understand the pressures on their local GP services—they know them, they’ve built long-standing relationships with those GPs—sometimes people might wait too long before they look to access an appointment and raise a concern. So, it’s really important that the communication and ongoing dialogue between GP services and their communities works well, so that people do not wait too long before they access that GP service.

We also think it’s really helpful if GP services have that ongoing dialogue with their population, to talk about the things that they are doing to respond to some of those challenges, and to involve people in that. Patient participation groups, for example, have been a long-standing part of the infrastructure, but they don’t work consistently, they’re not necessarily supported well enough to play that part. One of the things that we want to do in the year ahead is to focus more on what we can do to help support GP practices and their communities to come together on an ongoing basis to talk about the services together and to design and develop those services together. That brings a greater understanding of some of those challenges and what that means in terms of how patients can engage with that practice, but also how that practice can develop its services to meet those needs. Those ongoing conversations can be incredibly empowering within communities. We’re going to need to do, I think, a bit more work around that. But fostering and supporting that ongoing communication is fundamental.

We’ve seen some very interesting examples. If I give you one down in Pembrokeshire, in St David’s, where there’s a consideration at the moment of changes to their GP services, the conversation there is about integrated community hubs, or bringing a range of partners together, and again, through co-curation, where you have the citizen, the patients, involved, and developing a very different model of engagement that’s taken forward also in conversation with the health boards. If those are successful, it allows us, I think, to focus far more on an integrated strategy for primary care for the future.

Alyson, you mentioned—

Hold on, Lesley, just two seconds. I've got a question from Joyce Watson. Thank you.

As somebody who lives in Pembrokeshire, I certainly know about St David's, but what I also know is that you had a group behind it who were well equipped to advocate for themselves. So, I put that on the table. Hopefully the outcomes will be what they require, but what about the groups who can't advocate for themselves so professionally in the way that you've just described?

That's where, hopefully, Llais offer the added value. How do we engage—

Have you got an example of that?

There are examples that we've been engaged with in the context of ethnic communities, where there were concerns about the nature of going to see doctors, issues of translation. That there were examples where we tried to facilitate and engage in that. That's the real value that we give, that added engagement to empower people to be part of that co-curation.

One of the examples that we can give is the work that we did in relation to homeless people in west Wales. Because of the nature of our organisation, we were able to work with community connectors to get access to people who were homeless to talk to them about the issues that they have. One person took a bit of time to pluck up the courage to talk to us, because again it's about trusting us to take the information that they share with us and do something with it to make a difference.

This gentleman raised his concerns about, as a homeless person, accessing GP services because of his particular individual communication needs. He had a stammer, and that meant that when he was having to phone to get an appointment, sometimes he was told that he was drunk and to phone back again, and there was a real lack of understanding in terms of giving somebody with a stammer the time to be able to give the information that they needed to give.

We shared that story with the health board, and the health board acknowledged and recognised that there was some work that they needed to do in terms of fostering a greater understanding of the needs of people who have a stammer, and they are rolling out a comprehensive programme of learning from STAMMA UK. We also recognised that this would benefit our own staff in terms of fostering that understanding, and so we've rolled out that training as well. So, giving that one individual the time, creating that space so that they trusted us to share that information with us, has made a difference for the broader community.

Thank you. Lesley Griffiths.

Thanks, Chair. Alyson, you mentioned that one of the concerns of patients was being left behind from a technical point of view. Certainly, I've got a case at the moment where, at one GP surgery, you can only get an appointment by filling in a triage form online beforehand. Would you say that GPs are doing enough to help patients who are not able to access services via technology? What more do you think they can do? And, again, how big an issue do you think that this is across Wales?

It is a real fear that we hear an awful lot. I think that there's lots that needs to be done in terms of providing support. For some people, it is about feeling confident to use services digitally. So, there is work that needs to be done to help to equip and enable people to access services digitally. Similarly, in relation to NHS staff, there's work to be done to build confidence in using services digitally for them as well. So, I think that there is more work that needs to be done there. But I think that the key thing for us as well is that there will always be some people who are going to be unable to use services digitally, or not confident in using services digitally. So, alongside developing those digital services, it's really important that the health sector thinks about how it's going to develop those services for those people who are unable to, even with support, access services digitally.

And do you think that's being done?

I think that it's important that we keep reminding services of that. And when we do remind services of that, we do get a response that says, 'Yes, let's talk about that', but it is something that we need to remind them of constantly—that there's a real drive. There are obvious benefits for what can be the majority of a population using those services. And even more important, then, for those people who can't, is that sufficient time and effort is given to both understand what their different needs are and to respond to those individual needs. So, I think it's really important that we continue to be in those conversations, providing that reminder and seeking that assurance.

In your response to our consultation on GP services, you talked about—and you mentioned it in your initial answer to the Chair—the fact that there is a variable picture across Wales. I absolutely get that, because there's a variable picture just across my constituency—it's very, very varied. So, there are some people who are really struggling to access GPs. What do you think that GPs can do—because ultimately I think it has to be led by the GPs themselves—to make sure that their services are equitable? You just talked about digital, but what more do you think they can do?

I think there's something about, not only GPs, but other parts of the primary care system coming together to identify what can be done collectively. And there's much more that can be done in terms of sharing that learning. So, there's an awful lot of work and activity that's going on in relation to primary care clusters. It's really important that those conversations are comprehensive. It's really important that those conversations involve everybody who can help make that difference and drive that development.

But it's really fundamental that those primary care clusters, and the things that they try that work, get identified and spread out as quickly as possible. And there's a role for the NHS executive and others to be able to identify that and challenge health services in terms of the extent to which they are spreading that good practice. There's nothing more frustrating for people to know that they are in a practice where they can actually get an appointment, and that their mum, who's 10 miles down the road, has to go through an enormously difficult journey—that feels very different to them, and they naturally don't understand why that's the case. So, having the space to share that, but actually being judged as organisations as to how well you are doing in spreading that learning, is really important. And I think there's absolutely a role for Welsh Government in assessing health organisations' performance in working effectively together, in learning from each other and in spreading that learning.

Just picking up on that view that Welsh Government have a role in assessing performance, some of the responses that we've had to this inquiry are giving examples of patient dissatisfaction with GPs. Would you agree with that? Do you think there is increasing dissatisfaction with services? And again, obviously Welsh Government—you've just mentioned that you think they have a role in monitoring that. But there is a role for the GPs here. You mentioned patient participation groups. I'm not aware of any in my constituency that meet regularly at all. So, what more do you think GPs should do? I appreciate that you said there's a role for Government, but going back to the GPs, who, after all, are independent contractors: what do you think that they should be doing?

Well, I think that working with the Welsh Government is key in terms of taking forward some of the aims in terms of improving access and delivery of services for the public. So, taking the opportunity to review the access standards, for example, and understanding what that means for individual practices, and then individual practices responding to those standards is key. So, I think it's really important that GP practices work effectively together, as a profession, but also with other parts of the system to make sure that that improvement is sustainable. And I think that that is really key. Having those conversations, though, with the population that they serve, listening to the things that matter most to their patients and the issues that their patients have, and taking time to respond to that, have to be fundamental in terms of building that trusted relationship that people want to have with their GP services.

Medwin, do you want to come in quickly?

Yes. I think you'll see within the evidence we presented that one of our priorities for our conversations for the next year is to listen to the views of the people in the context of integrated primary care hubs within the community.

I think you asked the question about the local GP: the fact that it is the local GP in the context of real integrated services and looking to placemaking—I think there's a very important role also. Where is the conversation happening in the context of our regional partnership boards? How do we then see from that integrated engagement? I think more work needs to be done to make sure we've got the joined-up thinking in that context as well.

My final question is picking up what you said about all aspects and parts of the primary care system working together. I think there's a lack of public understanding about the different elements of it. So, a patient only wants to see a GP, whereas they'd probably be better seeing the practice nurse or advanced nurse practitioner or the pharmacist. What more do you think can be done so that people understand that not always do they need to see the GP? That would obviously help get over a lot of the barriers that you've just been discussing.

The communication piece there is in describing the role of the different healthcare professionals that can play a part in somebody's healthcare journey, and that's more than about producing leaflets and producing information. That is important, but it is about that fostering of the understanding of those different roles, so I think there is absolutely work that can be done. Those GP practices, for example, that have the most positive relationship with their populations are the ones that spend the time to explain and communicate to people about why, for example, the person who they are used to calling a receptionist, who previously would have just been the person who put them through to the GP, is now asking more detailed questions about their care. If that explanation is there about why it's important, for example, to get that information so people can be signposted to a different healthcare professional, then people are understanding of that.

So, providing that advice and information and fostering that understanding is about providing information in a whole variety of different ways, but it is fundamentally about that conversation between a healthcare professional and the person that they're seeing about the different parts of the system and how they can all work together to support that person.

Diolch. Thank you, Lesley. We've got under half an hour to get through quite a few questions that Members have still got, so if answers to questions could be succinct, I'd be very grateful, to make sure we could finish on time. That would be lovely. I'll hand over to Mabon ap Gwynfor.

I think it's fair to say that our relationships with the NHS are more mature because of the long-standing relationships that the former community health councils had with the NHS, and because former CHC staff moved across into Llais, there's been a continuity in relation to those relationships and an easier and quicker understanding of the role of Llais, because those organisations were used to working with the CHCs previously. So, those relationships, by and large, have continued.

It has been a real challenge for us as a small organisation to build and develop those relationships in social care, not because there hasn't been a desire from ourselves and social care services to do so, but simply the scale of it. We are talking about a single organisation developing new relationships with 22 local authorities. So, there's been a learning piece for us in terms of understanding the social care sector, and that's been really interesting from our perspective, in terms of the language being different and obviously the structure is different. So, understanding how best we relate to local authorities in terms of their governance has taken time. Building and developing that understanding, building that trusted relationship is taking time. So, we've still got work to do in that area.

So, I'm not sure about the—. We sit on the regional partnership boards. So, Llais has a space on the regional partnership boards. I'd need to check and provide you with some more information—

Mabon, really quickly, can I just jump in? Do you think corporately, within your corporate centre, if you were given more teeth that you've got the resources to actually deliver some of those asks? That's a question, probably, to Joanne.

I think it's about working smarter sometimes. We've increased our workforce with advocacy staff to help on the ground. It is demand-led, as Alyson mentioned earlier, so there may be scope in the future, if—. We might need more resource for that. But I think there are ways we can work smarter using data, perhaps, from other partners, rather than using our own, and working better in that regard.

Okay. Diolch. 

One of the ways, Mabon, in terms of that playing back of what we've heard and then facilitating a discussion about what the solutions might be—. We've adopted that, for example, through our Llais local approaches, so we will spend some time in an individual community engaging with people in that community to find out the issues that matter most to them. And what we've started to do—and we are doing it in more parts across Wales now—is, at the end of that, bringing health and social care services together in the same room to share what we've heard and to facilitate a conversation about the response to that, and that provides a real-time opportunity to respond to communities, because the members of the public who shared their views with us are able to attend that, but it also has third sector organisations there and a range of partners that can get under the skin of some of the causes of the issues that people are raising and come up with joint solutions together. Doing more of that I think will address what people have asked of us, which is, 'Don't just identify the problem, but facilitate and support the solution with communities.' So, there are a number of ways in which we are planning to do that this year—not just through Llais local; there are some health and social care summits that we’re doing that with, and, hopefully, our communities can see, then, that the information that they shared is facilitating that conversation and focused on the solution.

I think the—. Bear with me, again, sorry. I think our work in relation to dentistry. So, the consultation that Welsh Government put out in terms of changing the dental contracting arrangements in Wales reflected and responded to some of the key issues that we've raised. So, I think there is a demonstration there. The work that the Welsh Government is moving forward in terms of changing its complaints system, the 'Putting Things Right' system, in terms of listening to people, that also reflects and responds to the issues that we've raised in relation to some of the challenges that people face in raising concerns about their health services.

We've also seen, in the context of ministerial statements and in directives for the development of health, I think, certainly, far more focus on person-centred, co-ordinated care. I think that's something that we've seen. And certainly, the representations that we've made in that area over the last two years have been consistent, and we are seeing that in the context of the very clear directives that are coming from Government, as partners develop the health system across Wales.

Diolch. Diolch, Mabon. The final set of questions is from Joyce Watson.

I'm going into social care, now, and, of course, it's a new remit for yourselves, which means that you had to build relationships and confidence and awareness. So, I'd be quite interested to know, as a consequence of having done those things, how you've managed to promote that more locally, because CHC was definitely health, and people knew it, particularly when it came to advocating on behalf of people in this area. 

I think that the key to that from our perspective is working with other organisations in the community. We're already operating in social care, so we've got links with other advocacy organisations, other third sector organisations—so, having early discussions, conversations with them about the nature of our role and the support that we can provide in relation to our complaints advocacy service has been key. So, we've got signposting arrangements so that other organisations can signpost to us. Of course, it's really important not to forget the responsibility of local authorities themselves in terms of their legal duty to promote our role and our activities in social care as well. So, we've obviously done work to make sure that they signpost people to our services as well. 

I mentioned earlier that our presence in local communities is really important. We can produce as many posters or as many information leaflets as we like, but often it's word of mouth. We also have our volunteers, who are working hard for us across our regions, and they play a part in signposting people to our complaints advocacy service through their networks and through their engagement activities as well. So, that day-to-day involvement, the day-to-day relationship that we have within communities is helping to spread that awareness and understanding. 

There is some complexity around that, because the nature of the support that we can provide in relation to complaints advocacy is not that simple in terms of the boundaries. So, we've worked hard to talk about that with our colleagues and other organisations. But that's, by and large, the approach that we've taken: it has been a very personal, relationship-building one to foster that trust and understanding in our role. 

Because the other side of this is your understanding of the social care sector. And you're right, it's complex. It's mostly private in most places. So, how have you dealt with building up your own knowledge of the sector and the understanding of the constituent parts? You talked about building relationships with local authorities, and that's okay where they're a key provider, but how have you built up that understanding and the relationships more widely?

We've taken our time. One of the pieces of advice that we had from partners in that sector was, 'Don't rush in and be ill-informed, because actually that will not help anybody.' So, what we did is we pulled together—. And certainly our staff were also needing support to feel confident to support others. So, we developed a comprehensive learning programme in relation to the social care sector. We're incredibly grateful to all of the organisations—third sector, statutory sector organisations—who invested time to come to talk to our staff about the social care sector, about the part that they played in that social care sector, so that our staff and our volunteers built up that understanding of the sector, because the language is different, the structures are different. 

In relation to providers, then, of social care—for example, care homes—we invested time. We know how important it is that we give people an opportunity to hear from them where they might not be out and about in their communities. So, our ability to visit care homes, for example, is a really important one for us, but actually what we needed to do first was to build up that understanding amongst care home providers about what our role is, the part that we play in terms of providing, for example, an individual complaints advocacy service, and what our role is in terms of spending time to listen to people about their experiences. So, yes, time creating a relationship with those individuals and that sector has been really important for us.

So—. I know I'm pushing on, but we've got a short time and there are certain things we want to find out about. So, what are the main concerns that you're hearing?

In—?

In the care sector. 

In social care. So, we hear an awful lot from unpaid carers about some of the challenges that they face as unpaid carers. And that's been a consistent theme pretty much from day one. Some of the main aspects in social care are similar, actually, to some of those in the NHS, and that's about access and having access to the support that they need, whether that be an assessment in the first instance and the timescales for some of that.

Some of the challenges around how the health and social care sector works effectively together come up quite a lot. So, people not having the care packages, for example, put in place when they need them to provide them with that independence comes up quite a lot. Continuity of support and being able to build trusted relationships—so, the staffing challenges in social care affect people's experience of the support that they have, and that comes up quite a lot as well.

The joined-up integrated nature is something that affects people quite a lot. It's really interesting in terms of the language that we've learned to use, actually, in terms of providing people with space to tell us about their social care services, because so many people don't identify a service as being social care. They talk about the person who comes in to look after them in the morning and get them ready and stuff, but they don't necessarily know that they receive social care services. So, one of the things that we learned early on is to get our language right to create that space for people to tell us their experiences. But it is very much about the nature of the relationship that an individual has with that service that is important to them.

Medwin, do you want to add something?

Yes, I think, reflecting on the two years in developing those relationships, there are five points that I'd note in what we've heard from the individuals, from the families. The first would be the importance of co-creation in the context of what is right within that social care setting. That's so important for the individual, that he or she feels they're part of the decision making, that it's not something that is done to them—it's that real, engaging process. I think there's also the focus upon clear outcomes of benefits to the individual. The third for me would be to make sure that there is transparency in the commissioning processes, that everybody's involved in that context; it's a dialogue or it should be a discourse in the context of that engagement. And then the fourth for me would be quality, not cost. At the end of the day we're dealing with people and we've got to make sure that those services are structured in an appropriate way. And then the last one is that it has to start from the story of the individual, of the person. Each person has a specific story and a context that needs to be considered in looking to those social care settings, and that's what we're starting to understand more, I think, in the context of this work.

Diolch. Joyce.

What I would then be interested in, and I know it's early doors, is: you've obviously made representation to relevant bodies and policy makers in this area—have you seen any outcomes from those representations and have you seen further actions that you would like to pursue?

I think we've made representations on lots of different levels, whether that be through our complaints advocacy service and making representations in relation to an individual's complaint—. There is a structured approach that makes sure that that happens. So, we've certainly seen impact from that, not only in terms of achieving the outcome for the individual, but also in identifying learning that can bring about more systemic change. We need to do more of that in relation to our complaints advocacy service and the representations that we make on behalf of individuals that have a bigger impact, potentially, in terms of improving the service overall.

In terms of our other representations, sometimes it feels like it’s a long time before the representations we make come through into action, and we are well aware, as are the public, of the pressures on health and social care services, so we do have an ongoing dialogue about the timeliness of some of the representations that we make and how action can be taken that can make an immediate short-term impact for people, but also recognising that some of the changes are more systemic in nature and will take longer. So, it's really important when we make those representations that we have that conversation about what can be improved now and what are the stepping stones to improvement in the longer term.

Right, I've got five minutes, and I really want to get to the complaints process and 'Putting Things Right'. So, what are the weaknesses of that particular process that might prevent the satisfactory resolution of complaints, and what are the strengths?

So, in relation to the current 'Putting Things Right' system, I think the weaknesses that there are currently relate to timeliness, so it often takes an awful long time for people to get their complaint responded to and to get an understanding of the issues that they've raised and the outcome that they've wanted. The process lends itself to go through an investigation process and achieve an outcome, but that isn't always necessarily linked to what that person wants as an outcome from their concern and complaint. So, sometimes the complaints process, because of its structure, can feel less human than it needs to. It can feel a little bit formulaic; sometimes the language used in some of the responses to complaints is both legalistic, but also clinical and medical, and that's not necessarily what people need to feel satisfied with the outcome.

So, taking the opportunity of the new arrangements to take a real people-centred approach that focuses strongly on what the person wants as the outcome from that complaint is fundamental, I think. There are significant pressures on complaints teams; we know that a number of the complaints teams across Wales are short-staffed, and that's leading then to delays, more concern, more stress, more anxiety for people who want answers. Most people who come to us who want support, what they want out of that ‘Putting Things Right’ system is to have their story heard, to have an assurance that their experience isn't going to be repeated, so the learning from that experience is vital, and we're not seeing enough of that at the moment through that system.

There are two sides, of course, to a complaint. The person that's complaining—the complainant—and the complained against, and both need timeliness because they both affect the individual, but one could affect another person's career. So, do you look at both sides? I know you advocate on behalf of the complainant, but do you look at the other side, advocating on behalf of the complained? How is that working? Because it has to work for both.

It does have to work for both. In terms of our role, we are very clearly a client-led service. So, our complaints advocacy service is responding to the needs of our clients. There are others in the system who need to provide support for the complained-about, and it's really important that they have that. But our role as a complaints advocacy service is set up and framed around supporting the person who is raising the complaint to achieve the outcome that they need to.

You do make an important point, and while the clarity of what Alyson has noted, that is our role, but I think for a mature organisation, we should always be based on the test of reasonableness in the context of what is considered. And while we will always be there for that individual, I think the honesty of the framing of that, that's important as well, that we are there very clearly to support, as you noted.

Thank you.

Indeed. And finally from me: do you think there should be an independent complaints service that's separate from health boards to investigate and resolve complaints about the care provided by the NHS in Wales?

There's an obvious attraction from a public point of view in terms of having an independent body from outside the organisation looking in. What I would say is, in terms of the people who raise their concerns with us, sometimes the who is doing the investigating is important to them, but much more fundamentally, the how that investigation is carried out is what matters most to them. So, what they are looking for is whoever is investigating that complaint to do it openly, transparently and to do it in a trauma-informed way. Some of the people who are raising concerns have already been through enormous trauma. It's really important that whoever is investigating those complaints, and whatever the investigating system is, that it recognises and responds to that in a people-centred way. So, I don't think we've got a firm view one way or the other. What we are absolutely looking for is the ‘hows’ that people raise with us, which are, ‘Listen to me, put me in control, give me what I'm looking for from that complaints process and understand my needs.’

I think it's really important that that system, wherever it sits—. At the moment, that process very much, going through that, sits within the organisation, within the NHS. It's really important that there's oversight of that and it's really important that there's transparency about how that system works. So, there's, again, a role for the Welsh Government in that, and there's obviously a role for the Public Services Ombudsman for Wales in that. But how that system works is where people want the change, and it's really important that the new arrangements deliver that, and have the right resources to enable that to be delivered. That includes resources for us as well, because there's a significant impact on us from the changes, because it means that as a complaints advocacy service, we will need to refocus our ways of working to make sure that we are available to respond to that early intervention. So, we are continuing to have conversations with the Welsh Government to ensure those resource implications for the system, and for us as an advocacy organisation, enable it to work. The proof of the pudding for people is in how they feel when they enter and work through that complaints system.

Thank you.

That's probably a lovely place to end our evidence session today. I know some Members may have got some additional questions—I know I certainly have—but we'll send those to you in writing. If you can respond to those, that would be great.

I'd just like to thank you very much for coming in to give evidence to committee today and thank also Members for their questions. So, thank you very much. You will be sent a transcript of the evidence session to check for accuracy, but thank you very much again for your evidence session this morning. Thank you.

So, Members, we now move on to item 4, which is papers to note. There are five papers to note in your packs. One I just wanted to highlight was correspondence from the Legislation, Justice and Constitution Committee to the Cabinet Secretary for Health and Social Care in relation to the legislative consent memorandum on the Terminally Ill Adults (End of Life) Bill. We will be discussing that with the Cabinet Secretary with evidence on 16 July, with a reporting date of 19 September. Other than that, Members, is everyone happy to note the papers in the pack?

Yes.

Lovely, lovely. Grand.

And moving on to item 5, which is a motion under Standing Order 17.42 to resolve to exclude the public for the remainder of today's meeting. So, I propose in accordance with Standing Order 17.42 that the committee resolve to exclude the public for the remainder of today's meeting. Are Members content? Members are content, so thank you everyone from around the globe watching committee today and we will now proceed to meet in private.