The Health and Social Care (Quality and Engagement) (Wales) Act: summary

On 1 June 2020, The Health and Social Care (Quality and Engagement) (Wales) Act became law.

Welsh Government is now working to bring the Act into force in spring 2023.

 The Act will:

• strengthen the existing duty of quality on NHS bodies and extend this to the Welsh Ministers in relation to their health service functions;

• establish an organisational duty of candour on providers of NHS services, requiring them to be open and honest with patients and service users when things go wrong;

• strengthen the voice of citizens, by replacing Community Health Councils with a new all-Wales Citizen Voice Body that will represent the interests of people across health and social care; and

• enable the appointment of Vice Chairs for NHS Trusts, bringing them into line with health boards.

In 2018, the Parliamentary Review of Health and Social Care in Wales set out a number of recommendations including those relating to improvement in the quality of services and closer integration of health and social care.  These form key threads within the Welsh Government’s response: A Healthier Wales: our Plan for Health and Social Care and are supported by provisions in the Act.

Continuous improvement in quality will be key to making the health and social care system in Wales both fit for the future and one which achieves value. And the establishment of a Citizen Voice Body, covering both health and social services, will ensure that the voices of citizens are engaged, listened to and clearly heard. This will support the delivery of health and social care services that are designed around the needs and preferences of individuals.

Quality is more than just meeting service standards; it is a system-wide way of working to provide safe, effective, person-centred, timely, efficient and equitable health care in the context of a learning culture. To help achieve this, the Act:

• places an overarching duty of quality on the Welsh Ministers; and
• reframes and broadens the existing duty on NHS bodies.

This ensures the concept of “quality” is used in its broader definition, not limited to the quality of services provided to an individual nor to service standards.  

The Act will ensure the Welsh Ministers (in relation to their health functions) and NHS bodies exercise their functions with a view to securing improvement in the quality of health services.  

The duty is not intended to deliver a particular outcome or to ensure a particular level of service is attained; it will require that, when the Welsh Ministers and NHS bodies make decisions about health services, they must actively consider whether the decision will improve service quality and secure improvement in outcomes. This approach supports the five ways of working as set out within The Well-being of Future Generations (Wales) Act 2015, by encouraging long-term thinking and integrated and collaborative action that works to achieve the well-being goal of A Healthier Wales.

Additionally, the duty seeks to strengthen governance arrangements by requiring the Welsh Ministers and NHS bodies to report annually on the steps they have taken to comply with the duty and assess the extent of any improvement in outcomes.

The details of how the duty will work in practice will be contained in statutory guidance, which will be developed in partnership with stakeholders, and training will be developed to support implementation.

A culture of openness, transparency and candour is widely associated with good quality care. To help achieve this, the Act places a duty of candour on providers of NHS services (NHS bodies and primary care) - supporting existing professional duties.

The duty requires NHS providers to follow a process – to be set out in Regulations – when a service user suffers an adverse outcome which has or could result in unexpected or unintended harm that is more than minimal and the provision of health care was or may have been a factor. There is no element of fault, enabling a focus on learning and improvement, not blame.

The Act contains a power for the Welsh Ministers to issue statutory guidance in relation to the duty of candour. It is intended that this guidance will be a practical document, developed with stakeholders, to aid in the implementation of the duty. In particular, it is intended that the meaning of “more than minimal” harm will be set out in the guidance with examples and illustrative case studies in order to aid understanding and promote consistency in the application of the duty across Wales.   

The duty seeks to promote a culture of openness and improves the quality of care within the health service by encouraging organisational learning, avoiding future incidents.

The Act requires NHS providers to report annually about when the duty has come into effect - how often the duty has been triggered, a description of the circumstances leading to the event and the steps taken by the provider with view to preventing any further occurrence.

Using existing statutory powers, the Welsh Government also plans to make separate regulations (under the Care Standards Act 2000) to place a duty of candour on regulated independent healthcare providers. This will align the NHS and regulated independent healthcare, whilst complementing the duty placed on providers of regulated services (under the Regulation and Inspection of Social Care (Wales) Act 2016), to create a whole system approach to candour.

The drive towards closer integration of health and social services with improved public engagement is reflected in the aims of A Healthier Wales. This sets out the goal of ensuring citizens are placed at the heart of a whole-system approach to health and social care services and stresses the importance of listening to all voices through continual engagement.

To realise this ambition, the Act will replace Community Health Councils (who currently represent the patient voice in the health service only) with a new national body - the Citizen Voice Body ('CVB') - that will exercise functions across health and social care. The aims of the new body are to:

• strengthen the citizen voice in Wales in matters related to both health and social services, ensuring that citizens have an effective mechanism for ensuring that their views are heard;
• ensure that individuals are supported with advice and assistance when making a complaint in relation to their care; and
• use the service user experience to drive forward improvement.  

This new organisation will be established as a national body but it will be structured in such a way as to enable it to perform its functions at a national, regional and local level. The Act places duties on the new body, NHS bodies and local authorities to make arrangements to co-operate, with a view to supporting each other to promote awareness of the CVB. They are also under a duty to make arrangements to support the new body in seeking the views of the public in respect of health services and social services.

Welsh Government will publish a code of practice about requests from the CVB to enter health and social care premises to seek the views of individuals. There will also be statutory guidance to which NHS bodies and local authorities must have regard when dealing with representations made to them by the CVB.

At present, NHS Trusts are only able to appoint a Vice Chair from their existing Independent Members and these are only able to provide cover in times where the Chair may be unavailable or unable to undertake their responsibilities.

The new powers within the Act will provide for Welsh Ministers to appoint a specific Vice Chair role on the boards of NHS Trusts. This will enable Vice Chairs to fully contribute to the work of NHS Trusts, strengthen the capability of their Independent Membership, improve governance and decision-making processes, and provide consistency across Wales.

Appointment to a position with a defined role and greater time commitment may lead to widening the application pool and interest from candidates, with Ministers able to clarify a different and more appropriate skill set within the job description.