Equality and Social Justice Committee

Welcome back to the Equality and Social Justice Committee. I'm very pleased to welcome our next witnesses on the Stage 1 scrutiny of the British Sign Language (Wales) Bill. We've got Rhidian Hurle from Digital Health and Care Wales, who is joining us online, and Liam Williams and Kathryn Cobley from the Welsh Ambulance Services University NHS Trust. Thank you very much indeed for coming in.

I'd just like to start—to both of your organisations, but the responses are going to be somewhat different—by asking how you accommodate the needs of BSL users at the moment. Obviously, the ambulance trust is an emergency service, so you may or may not be aware. If so, how are you made aware if somebody is only a speaker of BSL? Would you, when you first speak, like to just say what your role is in your organisation?

Thank you. I'm Kathryn Cobley and I'm head of inclusion and engagement at the Welsh ambulance service. It depends which part of our service that you're looking at. We do have provisions already at the moment to accommodate the needs of BSL service users. If it's an emergency and somebody needs to call 999 and they're a BSL service user, we have an agreement in place with the telecoms companies, and that's right across the UK, so it's the same service that they get. They can contact 999 in an emergency, and that will be relayed to us through almost like a text relay type service.

We're also responsible for NHS 111, which is predominantly a digital front-end service in terms of healthcare and advice. We have some provision at the moment on our 111 website in terms of patient videos that we now have with BSL interpretation. We have built-in accessibility functions such as auto captions, subtitles on videos, that type of thing.

The third part of our service is the patient transport element. If somebody is pre-booking patient transport to transport them back and forth to appointments, that's the area of our service that I feel will probably need the most attention in terms of making a provision for a BSL service interpreter. Similar to 111, when we are triaging and there are call-backs involved in terms of whether it's booking an appointment or having a specialist clinician to call back somebody who's a BSL service user, that can be tricky in terms of how do we do that, because we are dependent upon some form of BSL interpretation, whether that's a BSL interpreter or whether that is a digital technology app or a video call, that type of thing. So, that can be a little bit more tricky, and I think that's the area that we will need to focus on going forward.

Do you keep any data on non-emergency services where you have or have not been able to obtain the services of an interpreter?

I don't believe that we routinely collate that information, and I'm thinking particularly about other languages as well. We will become aware of an issue when a service user raises a concern. For example, if they've pre-booked an ambulance to take them to and from the hospital for an appointment and that ambulance has then been cancelled, a voicemail might have been left on a telephone number that we have. If that's a BSL service user or if that's somebody who doesn't speak English, Welsh or BSL, it's very difficult, because they can't understand the voicemail that's been left. But again, there are solutions for that out there. It's about us being smarter—using text messaging, for example. That would have been much more useful. I think then that comes down to us really looking at our systems, because our systems do allow us to flag communication needs of service users. That is an area that we're improving upon all of the time in terms of flagging learning disabilities, communication needs. So, it's about us using the systems that we've got to implement suitable solutions for people who are unable to access services as everybody else does.

Before I move to Rhidian, is there anything you'd like to add, Liam Williams?

I guess the thing that I would focus on is the register that we have in place. We've been building registers where people have got particular needs, and we've become far more adept at using them, both in the emergency medical service—the 999 service—and in the 111 service. And just to complement what Kat was saying, we've now adopted, in the last few months, SMS as a form of communication, so it isn't down to voicemails for all of our communications out of the non-elective patient transport service. We are using SMS in increasing volume.

The final comment then is on how we are working with commissioners in Wales at the moment to think about what the future communication architecture looks like. So, we've had some support with the digital front ends of our website, our interface with the NHS Wales app, and thinking about how we can use those platforms to better aid communication in the routine sense, even if that doesn't necessarily help us in the first instance in the emergency sense.

What is your role in the organisation?

Apologies. I'm Liam. I'm the executive director of quality and nursing.

Thank you. Rhidian Hurle, obviously, all health boards and trusts rely on your services to be able to maximise the use of technology for identifying BSL users. What services are you able to provide at the moment?

Afternoon. Hopefully you can hear me. Apologies, I'm not there in person. My name is Rhidian Hurle. I'm the medical director of Digital Health and Care Wales. I'm also the chief clinical information officer for Wales.

We—'we' as in Digital Health and Care Wales—provide software that supports both acute and elective pathways across all health boards. Our major product that clinicians use, the Welsh clinical portal, provides access to a number of modules that contain information regarding patients' accessibility needs. And although we are not patient facing and we don't deliver direct services ourselves, as I said, we support services.

I did some statistical review of the software that we provide. We've got 44,000 users across Wales in NHS Wales. That includes some primary care and also the clinical hub in the Welsh ambulance service. The Welsh nursing care record and the Welsh patient administration system have facilities to record the accessibility need of British Sign Language. Currently, we have a completion rate of 0.05 per cent of all our patient population, which is in line with the 2021 census survey of NHS Wales, which was 0.03 per cent. We record that information with international coding of SNOMED, so that it's reusable across any of our software applications. Thank you.

To be clear, when you talk about 5 per cent of patients, are you talking about 5 per cent of patients being deaf or 5 per cent being BSL users?

Of the patients that we recorded on our system, 0.05 per cent had an accessibility need of sign language. As I said, that fits with the census prevalence of 0.03 per cent of the population in Wales who use British Sign Language, or at least registered that in the census as being their primary form of communication.

Thank you for that information. Okay. I'll stick with you, Rhidian, just for my next question, which is: what involvement, if any, have you or your organisation had in the development of this Bill?

We submitted a written statement in response to the request by the Welsh Government, which I believe you have. Our workforce and organisational development lead, Samantha Morgan, completed it on behalf of the organisation.

[Inaudible.]—Mark Isherwood, the Member in charge of the Bill.

I didn't quite catch that, sorry.

Yes, we seem to have a slight sound problem. So, that information was requested by the Welsh Government rather than the Member, Mark Isherwood, who's in charge of this Bill.

I haven't submitted anything directly to him, no.

Right, that's fine. So, if I come to Liam and Kathryn, what involvement, if any, have you had in the development of this Bill?

We've had some involvement, not necessarily in the drafting of the Bill, but once the Bill had been drafted, we did submit a response to Mark Isherwood on our views on how practical the Bill could be in terms of its implementation across NHS Wales organisations. We've also held some internal conversations and consultation amongst equality, diversity and inclusion leads across NHS Wales. We meet regularly every other month and there have been some tabled discussions around the Bill there, which we've used to inform individual health board and trust responses to Mark Isherwood.

And overall, what are your views on the Bill and its provisions that will affect your organisation?

I think it would be very, very difficult for any organisation to disagree with the principles outlined within the Bill. It's definitely something that I think is very, very important to BSL service users in terms of striving to create equality and improve health outcomes, more importantly from an NHS Wales perspective for our BSL service users. I think, listening to the previous session on the call for evidence, what Sarah Morley and Michelle Fowler have said in terms of some of the barriers to implementation in terms of resources, capacity and competing priorities in large and complex organisations, I think all of those comments were relevant, and are relevant from a Welsh ambulance service perspective as well.

But, equally, I was heavily involved in the implementation of and consultation on the Welsh Language (Wales) Measure 2011 and the Welsh language standards, so I think there are definitely comparisons to be made. We are talking about two very different communication needs, though, when we're talking about Welsh speakers and BSL service users. There are definitely comparisons to be made, and I think overall in terms of the Bill, it will drive improvements.

It's a long road ahead, I think, as Sarah Morley said, and nothing is going to change overnight. It is a progressive path to creating those improvements. I think the only comment that I would perhaps make is we've got other pieces of legislation that I think attempt to achieve the same thing. They might not be solely focused on BSL, but when you look at the public sector equality duty, the Equality Act, reasonable adjustments, human rights, the accessible communication and information standards that were published on 22 September, I think we've got multiple pieces of legislation, statutory requirements and action plans that are aiming to achieve the same thing, but they might not be solely focused on BSL service users. So, there's just a little bit of a question from me about: do we really need another piece of legislation when we've got existing pieces of legislation that perhaps are aiming to do the same thing? But in terms of the Bill, I completely agree with the principles of the Bill.

Okay. And Jane Dodds.

Thank you very much. Could I ask Kathryn or Liam? You're a public body. Do you gather data about those people who are deaf and who use BSL, and the times when you can't obtain a translator, perhaps? Do you gather that data? And if you do gather that data, is that something that the committee could obtain in the future, please?

We don't do it as a rule. So, we do collect data. The patient system can record any communication need of a member of the public, and then, once we know that a service user has a communication need, we can put in force some sort of plan or mechanism then to be able to deal with them. But we do not record data as a rule. It's more of a responsive thing to the needs of the public rather than being something that we do habitually.

Thank you.

I just want to follow up on what you said about the importance of the all-Wales standards that have been published last month. So, in your view, even if this legislation doesn't reach the statute book by the end of this Senedd, do you think we could achieve the same impact by using this guidance, plus other things that we're going to discuss a bit later down the agenda?

Because the standards originally—. The accessible communication and information standards, they were previously standards for people with sensory loss. I think the majority of people have been used to dealing with those previous set of standards, where they were very much focused on people who were deaf and people who were blind. So, I think that is an ethos and a grounding principle of the standards, which have now gone further, which include anybody with a communication need.

I think there is a slight risk, because the new standards encompass all different communication needs, that the BSL might lose a little bit of focus, whereas a specific BSL piece of legislation will provide that sole focus just on communicating with people who use BSL. They both aim to do the same thing for BSL service users, but I do think that the individual Bill will have more focus there, and it may slip in terms of the standards.

But I think my main concern—and I think it's already been raised as a concern—is then how we will be expected to report against it, whether we're going to have a set of BSL standards similar to the Welsh language standards, when we've got the reporting mechanisms already in place for the all-Wales accessible communication and information standards. So, I think that the general consensus amongst equality, diversity and inclusion leads, who are predominantly the lead persons in each organisation who are responsible for drafting and producing those reports, that we don't want multiple reporting procedures against two different pieces of legislation and statutory requirements that are aiming to do the same thing. I think that's very important and should be considered at the outset.

Good to have that on the record.

Yes, if I may, just to complement that. From a trust board perspective, when we're taking significant decisions, we would expect all pieces of work to have an equality impact assessment undertaken, and that's quite an important piece of work that takes place throughout the organisation. It complements the quality impact assessment for service delivery, and as part of that we seek advice, support and guidance to ensure that the changes that we're proposing are not going to disadvantage any particular part of the community, and if there are risks of disadvantage, then we understand what the mitigations may be and how we may be able to do things differently.

So, I think there are multiple pieces of legislation that, through the EQIA, we would look to present to our board, and demonstrate our consideration to the duty of quality and quality-informed decision making, but also recognising that quality-informed decision making is complemented by a full understanding of the population that we're serving.

So, I think there's an awful lot that goes in to try and make sure we do things in a way that is equitable across the population. Legislation helps because it provides focus. All of us would recognise that. I think it's ensuring that what comes forward genuinely enables us to do the right things for the people we're seeking to support and enable, and not get ourselves into a situation where you find yourself trying to balance off different parts of legislation or different parts of policy and regulation, and actually you miss the point of what we're trying to achieve.

Okay. I can go to Rhydian. When Digital Health and Care Wales does its equality impact assessment, how does your prioritisation of your work—? How is it informed by how we are able to meet the needs of the BSL community, many of whom have only BSL as their language?

We would look at the user interface that we provide for our healthcare professionals across Wales, and the signposting and, for want of a better word, nudging those healthcare professionals to understand that the individual with whom they have contact requires BSL. We do this for a number of other things, and a good example would be complying with the language Act, in that we use an icon associated with the demographic of the individual within the user interface that's in front of the clinician, so that they're aware that the preferred language of that individual is Welsh. So, we have the ability within the software to provide iconography or imaging agreed, whatever that may be, to nudge users, so that they will be aware of the requirement of the patient, the individual they're serving.

In the earlier session with Velindre and Cardiff and Vale health board, they did say that it wasn't always the case that somebody whose main language is BSL is being flagged up at any level of the health service, even Velindre, which is obviously a highly specialist service. I wondered if you could explain why the technology is not yet implemented in quite the way we obviously would all like.

The applications contain the data entry points to record the needs of an individual. The contact of the patient to the system requires that to be recorded by someone at some point. The integration, for example, from, perhaps, the primary care system into the different patient administration systems across Wales is not there. However, as I said, the ability to record at an individual local health board is there within the software that we provide. But, ultimately, if someone doesn't put it in, it's not visible.

Now I'd like to call Julie Morgan to have a look at some of the specifics of the duties under the Act.

Just to follow up that issue for a moment, we were told by Velindre, I think it was, that referring from one care body to another was not signalled. Are you saying there is the means to do it digitally, or not?

If you look at the Welsh nursing care record, which is a single instance, that means it's the same everywhere across Wales, that application records the accessibility needs of an individual, and should a patient transfer from one organisation across a health board boundary to another, then that is visible to the nursing staff and healthcare professionals who are looking after that patient. That's different to the patient administration systems, which no doubt Velindre and many other organisations have some frustration about, for want of a better word. Consider these tills that are configured differently across health boards, and therefore your ability to stock control, as it might be, is inhibited by the fact that not everyone records everything in the same way.

Right. It's complicated. I'll go on and ask these other questions. How confident are you that your organisations will be able to implement the requirements set out in the Bill, and how much time do you think it will take to make it fully compliant? I'll start with you.

How long is a piece of string? It's going to take some time. I'm confident that what the Bill outlines will drive improvements, and I think those improvements are much needed for our BSL communities. Very similarly, we saw it with the Welsh language standards. I know the comparisons have been made in previous sessions, but it definitely has driven forward improvements. But as you said, the Welsh language standards have been in place now for some years, and we're still not fully compliant because of, I think, the many, many barriers and the challenges I see to implementing this type of legislation in terms of communication.

They can be very much dependent upon a number of things, including the will of the organisation to implement them. I would like to think that for all NHS Wales organisations, the will is definitely there to implement them, and create and drive those improvements. But I think the biggest barrier and challenge is the resource and the capacity that might be required to implement elements of the BSL Bill and a set of standards that might come afterwards. But equally, I think there are solutions out there, but they will take time to implement.

My personal view is that we're not, perhaps, using digital technology advancements as best as we can in this space in terms of communication in general, but again, there are limitations upon NHS Wales, whether that's financial implications in terms of cost, whether that's compatibility with different pieces of software that are out there, that type of thing. So, I think it's just overcoming all of those challenges.

We've had a discussion as well around competing priorities. This is one area that we would like to improve in terms of hundreds of other areas that we would like to improve. When we've got limited capacity and resource given the current economic climate and the demand upon healthcare services, I think that will make it extremely challenging to make this particular set of standards and requirements a true priority for the organisation. I think that's where then the time aspect comes into it. I think we will be looking at a continual path to progression and improvements, rather than something that we can say, 'Within 18 months, we will have solved this and we will be fully compliant.'

I think there are layers. I think there will be more that we can do in the public health, public information space. I think we'll be able to move more swiftly in that space, because we can do that preemptively. We can work with partners and we can create content that is available and usable across the NHS and beyond the NHS for Wales.

There are digital technical solutions that are coming on stream, and some of those solutions will work for some elements of care, but there is an important differentiation between general conversational care, for want of a better phrase, and that which is related to clinical care, diagnosis and treatment plans. At that point, you need to be working at a particular grade to ensure that you are giving accurate information and doing so in a way that is understandable, and that will be different. Implementation will feel different in different settings.

For our remote care service, we may be able to find a mechanism by which we can make that more accessible. However, at this point in time, for our crews who are responding on the front line in a rural area, that's going to be more complex, because we wouldn't necessarily be able to rely on a digital remote solution, and we certainly wouldn't be able to have a workforce that is fully representative of the whole of society in that form. So, I think we'll find that there are some thresholds around how we can adapt technology. I'm a big advocate of what we could do from a technology perspective, but we need to make sure that we're doing it in a way that is safe and regulatory compliant, particularly to clinical communication and clinical standards.

A final area just to note is that, as healthcare bodies across multiple countries, one of the things that we've sought to do is ensure that we've got independence and consent in how we are working with individuals who are supporting communication. We've quite often in the past relied on family members, friends, people who were communicating, but there's been a shift away from that to ensure that we have the confidence that the communication that we're giving is of a high standard, that everything that is being communicated is truly being communicated, and ensuring that we've got informed consent from the recipient to the conversation that is taking place and that is two-way between the lead clinician and the individual.

I think, in that pathway that Kat has just set out, which is going to be an extended one, there will be some things where I think we will be able to work as an all-Wales NHS to move forward with a little bit more ease, but there are going to be areas where this is actually going to be more complex and require significant investment in one form or another, be that in human interpreter or be that in some of the digital solutions that are emerging at the moment.

Thank you. Rhidian, have you got any comments on this?

My comment would be that it's probably easier for us as a non-patient-facing organisation to enable changes in the technology and the software that we provide to contain information that helps healthcare professionals be aware of the accessibility needs. I'd probably divide it into three areas for simplicity with the committee. One would be the NHS app, for which DHCW are an integral delivery partner. The ability for a patient to enter their communication needs into the app may be one mechanism to increase the availability and visibility of the needs of the individual. There’s national software that DHCW provides, including a patient administration system and a portal. And, of course, we, as a statutory organisation, could respond to the legislation relatively easily to include that in the user interface.

But I would point out that there are electronic healthcare systems that are used throughout NHS Wales that are managed at a local level, that are not integrated into the national systems. Therefore, that information that you might record once—and we would wish them to comply with a 'tell us once' approach—about the needs of the individual may not flow along that patient journey. I’m articulating that because the situation is that we don’t have a common platform across NHS Wales that is configured in the same way everywhere, and it’s that complexity that might take some time to unravel.

Thank you for that. We need to take a break now for five minutes, to enable the interpreter to have some respite.

Julie Morgan, would you like to ask your question?

Right. Thank you very much. Before we went into the break, Rhidian, you were telling us that there is no unified system throughout the NHS. Could you tell us how difficult it would be to get a unified system?

It's not necessarily difficult. It requires the key stakeholders to align to a certain pathway. The cost involved in a single electronic record across Wales would be considerable. I believe current policy leads are exploring options. The analogy I used of tills being configured in a different way across different organisations could be resolved through direction, and that would require, again, policy instruction. These things always take time because there's a change management process, particularly in the health records departments across NHS Wales. These are the departments that are responsible for aligning appointments, particularly in the out-patients. I'm sure all of you are aware of the demand across NHS Wales and the long waits relating to out-patients. So, it's not necessarily difficult, but it does require direction.

And will from the stakeholders—is that what you were saying?

Yes, you could say willingness. My view would be that previous reviews sponsored by the Welsh Government—. I'm thinking of Eric Gregory who did the parliamentary review. He was in charge of John Lewis, for example, and he said, 'When you come and work for John Lewis, we don't ask you to bring your own till.' We should really align our administration systems across Wales in a unified, standard way.

Sioned Williams, you wanted to follow up.

Thank you. I'm just interested, really, in knowing why this has happened. Why are we in the situation that we're in? You said that we need to have policy direction and resources related to that to ensure uniformity across the health systems that we have and the health bodies that we have. So, what led to this in the first place? Is it that lack of direction? Does this go back further than devolution? Could you just give us an idea of why we're in the situation that we're in?

Yes, Sioned. It's due to local choice and how things are implemented at a local level. It's as simple as that. Change management is difficult. Configuring software to fit a local process is probably easier than changing the process. This would be a choice thing. Yes.

One last question, then. The Bill would require listed public bodies to report on the implementation of the BSL plan within 12 months of its publication. What are your views on these timescales?

I'm happy to go. Again, referring back to my previous comment, when you're working within this space, I know we're focusing on BSL here today, but, for me, BSL is one of many of the protected characteristics under the Equality Act, and we are coming increasingly under pressure to develop an individual plan for each individual protected characteristic, and you lose then the joined-up approach to creating equity and fairness for all by almost putting people into different boxes, and it creates multiple reporting, multiple action plans, multiple publications, and then the role of EDI leads within NHS Wales becomes quite bureaucratic in terms of preparing papers, because every time we publish a plan or a report there is a governance structure that they need to go through internally, which often involves multiple committees before it’s approved by the board. The bureaucracy then overtakes the principles, I think, of an action plan.

I think most EDI leads would advocate for one singular action plan, which we have already got under the strategic equality plan. So, the public sector equality duty sets out a list of requirements that public sector organisations have to comply with. We all have to have a set of published objectives. They are broad, they are overarching. I think we would prefer a system where we can include BSL actions or a requirement for us to include BSL action plans in that overarching strategic equality plan and use our annual strategic equality plan reporting mechanisms to report progress against the BSL action plan. It’s something that we find challenging in terms of the 'Anti-racist Wales Action Plan', in terms of having a separate local action plan for the 'Anti-racist Wales Action Plan', and then a set of reporting against that action plan. Then, within that action plan, you have also got your workforce race equality standard, and there’s another report for that. So, you can see how we end up in a situation where we’ve got multiple publications, plans and reporting systems for each of the individual protected characteristics.

If you break that down further, for example, disability, BSL, under the Equality Act 2010 would be classed under that sort of disability protected characteristic. Do we then separate out into other disabilities and have local action plans for varying disabilities? So, it becomes quite complex and places an onus, I think, on organisations to have these multiple reporting systems in place, when I think we could be clever here and use an opportunity to start aligning those reports and report under the strategic equality plan under the public sector equality duty. That would be my preference, and I think that would be the preference of equality leads across Wales as well, following the discussions that we have had in our equality leadership group meetings.

Right. Thank you. Do you have anything to add to that?

No, I think that Kat said it perfectly.

Yes, okay. Fine. I don't know whether you've got anything to say on that, Rhidian.

My clinical experience—and for 30 years, I've been working in NHS Wales, and I operate every Tuesday in the hospital—is that anything that prevents a patient from fully understanding the advice that they've come for and stops them from making an informed decision is a barrier to good care. It's been pointed out that the accessible communication and information standards outline the barriers to good communication. Communication is key to better medicine. So, I'd fully support anything that's put in place. I would point out to the committee that, where there is direction, for example in Welsh health circulars, they carry less weight than legislation, but the problem here will always be: how does one measure compliance and what mechanisms are in place to measure compliance?

In terms of the time frame, depending on the ask from a technical software point of view, we would look at the options and we would give feedback as to what could be implemented with the resources that we have in-house. But, as always, if there is additional resource to prioritise a particular function within the national software, that would be prioritised appropriately.

Thank you.

Thank you. Can I now bring in Mick Antoniw?

You've answered a number of the points that I was going to ask about, really, with regard to the national BSL strategy and guidance, so I'm not going to go into detail on that. You did say 'complexity'—I'm really addressing this to you, Rhidian, I suppose, because you said complexity might take some time to unravel—and what is meant to be a relatively clearly understood piece of legislation, as we go into it, clearly has an enormous amount of complexity to it, depending upon the detail of implementation and the guidance and so on. There's already a lot of guidance that's in place, but, of course, you have to engage with a whole variety of different public sector bodies to get some form of consistency in the way which you engage with them on this. How exactly will that work? I'm just thinking, Rhidian, this is very much a sort of process issue. What problems do you anticipate or what difficulties do you anticipate? How can we make things simpler?

Thank you for that question. The way to make things simpler is to have a single instance of an application across NHS Wales. When you have more than one, then interoperability and data standards and messaging standards become a debate. And once there's debate, then there often is compromise, and standards are not met. So, Digital Health and Care Wales, as the organisation that provides software for clinical care across Wales, has a number of subject matter expert stakeholder groups. These range from doctors and nurses to allied healthcare professionals—and of course, audiology is a good example of the AHP community. We would work with subject matter experts groups in that area to understand what their need is to provide better care, and we would also engage with those organisations that represent patient bodies, particularly if we were instructed to make functionality available within the NHS app that allows an individual to record their requirement of British Sign Language. So, that would be recording it. The issue, of course, is the availability of the service at the point of care. That is something that Digital Health and Care Wales can't really comment on.

Okay. Thank you for that. I do sort of get increasing concerns about what you're saying, because we know that other attempts to implement simple cross-body technology have turned out to be not only very expensive, but also incredibly complex to implement because of the varying standards and compatibilities that exist. I notice, for example, we still have difficulty transporting medical records from someone moving from England to Wales, for example, and vice versa. Has any work been done on this? Do you think this is actually quite a major piece of work that would need to be done to actually do this? Can you give me an idea as to really how difficult, how complex, how expensive what you're suggesting could be done actually would be?

Mick, apologies. Could you just go into a little bit more detail as to what you are asking me to answer?

Okay. We're talking about trying to have a simple system that goes across bodies, that is compatible with different systems, and my understanding is that we don't really have that technology there at the moment, so we would have to create it to get a sort of consistent application of guidance and accessibility. Does any of that work exist? How complex a process is that?

The ability already exists to record something specific to the patient, and I referred earlier to the Welsh Language Act and the ability to record patient preferences, but that is in the national software. The Welsh clinical portal provides clinical information to 44,000 users across Wales in all health boards. So, through the applications that are controlled directly through the Welsh Government and the instructions that come to Digital Health and Care Wales, that's relatively simple. To reiterate my comment, the interoperability with systems that are outside of that governance and those standards, and the legacy and the age of that software, for example, that becomes a barrier to, 'Tell us once and, wherever you go, that information about you will be available in that software that's used for that particular condition care event.'

I think that's partly where I was going, but I don't really want to take that any further with you, because, obviously, there are other public bodies that should be relevant too. Guidance will, clearly, be issued, and I would take it that there would be an agreement that this would be something that would need to be consulted on—that is, it would have to incorporate, ultimately, the views of various groups and users and so on. The Bill might also potentially include—well, it will include—direction by Welsh Ministers, the power to do that. What would you see as specifically the role of Welsh Government in actually seeing that they run out this legislation and its proper implementation? Is there a specific role that Welsh Government should be having within that?

Is that directed at me, Mick?

It's directed at you, but then also at Kathryn and Liam as well.

So, the process of delivery for Digital Health and Care Wales currently comes through a remit letter and instruction from Welsh Government. So, if the remit letter included the requirement to do a particular thing, then DHCW would respond appropriately.

Okay. Did anyone else want to elaborate on any of the complexity of problems that they envisage?

Just on behalf of the Welsh ambulance service, I'd say that the prioritisation for us—. So, the legislation would get passed, we would receive instruction through the joint commissioning committee as to what they are prioritising for us in the coming period, and, against those priorities, we would agree with them how we might go about implementing it.

On the first part of your question, I think, for public sector organisations, it's understanding the priority on which Welsh Government is placing this amongst other priorities that we are being requested to address, and there are many, which is right and proper. But there would be something then about helping us to ensure that we're meeting the priorities of Government accordingly, and subsequently then, leaning a little into Kat's earlier comments, it's then about having proportionate assurance that we are doing everything we can to meet those Government priorities in the round. So, I think that the assurance process is probably what I would anticipate we would need to agree with colleagues here and elsewhere.

If I may, I'll just make one further comment in the data field. I have worked in Wales now for far less than Rhidian—I've been here just over three years—but I've worked in systems where data flows far more cleanly. I just would reinforce Rhidian's point that the opportunity here is to ensure that there is direction over some of the information data standards and how that then drives local organisations with the technology, the digital suppliers they are using, to secure seamless transfer of information.

So, as a trust, we use the Welsh demographic system, we use the Welsh clinical portal. That primarily feeds our remote settings—so, our clinical contact centres and our remote clinicians—and that in turn then drives the information that our paramedics and our emergency medical technicians receive in the field. We are able to do that because we have been able to build our information flows in that form. So, it comes in through DHCW, we understand how they are producing the information, we've worked with our suppliers to then be able to receive that information effectively, and we've then worked with our suppliers to think about how that information can transfer on to front-line crews. So, there are solutions that are achievable, but I think, as Rhidian stated earlier in his evidence, there is a need to create the will for us to achieve that.

Okay, thank you. I don't have any further questions, Chair.

Okay, thank you. Can we now move on to Jane Dodds?

Thank you very much. Just one question from me, for both of you, if I may. Could I ask WAST first how do you collaborate and engage with deaf communities regarding the services that you provide? And looking to the future—and hopefully this Act will come into force—how do you see that happening in the future as well?

Thank you. Within the ambulance service, and within the other Welsh health boards, there are specific teams who are responsible for engaging with members of the public. So, within WAST, there's the patient experience and community involvement team, and they have established good relationships with our deaf communities—they have already done that—so that work will continue in the future. But I think that the Act or any sort of implementation plan will strengthen those relationships with our deaf communities.

Also, within the equality leadership group and NHS Wales, that group of people have good relationships with the deaf community. So, as you've seen, Michelle Fowler is part of the equality leadership group now, and she is making a real difference to the way in which health boards and trusts do see deaf communities, perceive them and engage with them. So, Michelle is a great asset, to tell you the truth, to NHS Wales in terms of creating relationships with the deaf communities.

Thank you very much, and could I ask Rhidian that question as well, please?

You're on mute, Rhidian.

I think, Rhidian, the sound engineer will unmute you.

He's not doing anything.

Oh, okay, he's not. Okay. So, Rhidian, do you think you could unmute yourself, please?

Yes, I can. Can you hear me now?

Yes.

Apologies, the screen was flashing up with a task and, when I did it, it muted me.

Going back to where I was, we don't provide patient-facing services, however, regarding the NHS app, we have both key stakeholder engagement with service users, and that includes public consultation at a local and regional level, and we take advice in our collaboration with NHS England. You may be aware that we originally took the code from NHS England for the app. I'd have to come back to the committee with the finer details of, specifically, engagement with the deaf community, as I don't have that information to hand, I'm afraid.

Thank you, and one further question to WAST. We heard from the previous panel that you were one of the bodies that had good practice in terms of collaboration with deaf communities. And one thing that I have an interest in is ensuring that there is accountability for deaf communities regarding the provision of services and so forth. How do you do that? How do you ensure that there is accountability for those deaf communities?

I'll take that and Kat will, I'm sure, fill in further, but, from an accountability perspective, one of the comments I was going to come in on, on the back of Kat's earlier evidence, was that, at trust board level and at trust committee level, there is a very clear line of sight to the work that goes on at the front line, and the work that the PECI team, the patient experience and community involvement team, undertake. So, we will frequently have thematic reviews, deep-dive reviews, that pick up on particular protected characteristics, but also clinical presentations and conditions, quality of care, and often what we will do is look to supplement the deep-dive evidence and data-driven insights with a video that shares the story, the experience, of somebody who has been in use of our services, and I can absolutely say that, having taken those now through our quality committee, our people and culture committee and into our trust board, they have a very profound effect on ensuring that we are, as a trust board, prioritising those that are most in need and those experiences that give us the most cause for concern. An example I will lean into in that space is that we, over the last couple of years, have had increasing numbers of experiences shared where people living with a learning disability have been approaching us who have found some of our systems quite difficult to work with—they can be quite challenging when you've got lots of different complex conditions and different communication needs. So, one of the things that we have done is move to employ an advanced clinical practitioner with a specialty in that field. That's really to help us understand how we can do things, particularly for people living with learning disabilities, but actually what that will also do is really drive a better understanding of how effective communication might better be drawn across the organisation.

So, I feel quite confident sitting here as the executive that is often held to account for how we are meeting the experience of people, the diverse needs of our people, that my trust board, my non-executive colleagues and non-exec chair, particularly, of the quality committee are very challenging of me and of my teams to make sure that we are doing the reach out, that we are thinking about how we innovate, that we're looking at the technology and looking at different solutions that we can adopt. I'm just thinking about Leanne, who is in our PECI team, who works very closely with Kat, works very closely with colleagues across Wales, and I think the most important thing that Kat and Leanne do in equal measure is to collaborate. There is an awful lot that we gain from learning across the NHS from communities, from different third sector organisations and bodies, which means that, actually, we can shortcut things, sometimes, in a positive way. If somebody's done something really well, let's just think about how we can adopt that and learn from that ourselves.

Just to add, within the past 12 months we've actually had a patient story be presented to some of our committees that came from a British Sign Language service user, which was quite powerful, quite impactful, because I think it really did give an insight into this is this person's lived experience, these are the challenges, and there were definitely some lessons learned from that person's experience with Welsh ambulance service. Also as well, we have a patient network, and I think the majority of health boards as well would have something similar, in terms of our patient experience and community involvement teams across NHS Wales.

However, I think the majority of NHS Wales organisations recognise that BSL communities cannot participate in those patient voice networks in the same way that the majority of other communities can participate, and they do need something specialised. I think there may be some inconsistencies across organisations in Wales in terms of how they communicate and engage and consult directly with deaf communities. Co-production and co-design is definitely at the heart of all of our patient experience and community involvement teams, so there is definitely a willingness, but equally as well I think we have to bear in mind that we are fortunate, I think, in WAST because we are an all-Wales, a pan-Wales organisation, which means that our PECI team are spread out across Wales and go into all of our communities. I'm just thinking in particular of the health boards, where they cover certain geographical areas. Obviously, the deaf communities will be very different depending which health board you are in, in terms of it being difficult in terms of them reaching out then. Because I think there is definitely an onus upon the organisation to reach out to those communities, and not the other way around, and I think that may be more difficult in certain geographical parts of Wales.

But again, as Liam has just said, Leanne, our patient experience and community involvement team leader, is very much linked in as well to those other health board networks there, and I think, yes, there's definitely an element of sharing experience when one person learns something or has a patient story to share that can be shared right across Wales, because the outcome is very much the same.

Diolch, Cadeirydd.

We need to take a break, I'm afraid.

Sioned Williams, would you like to ask your questions?

Thank you, Chair. The Bill does not make any provision in relation to complaints from BSL signers. So, could I ask you first of all what the current process is within your organisations to enable BSL signers to make complaints? Also, could I ask you your view on what measures should be in place in order to measure the compliance of a body—something that Rhidian mentioned earlier that is very important?

Happy to answer the first question on raising concerns. So, I think that most people will already be aware that, across NHS Wales, we have a 'Putting Things Right' policy. It is, to the best of my knowledge, quite accessible to all online.

As we touched upon, we did have a patient story within recent months that did go to the board, which was as a result of a concern being raised. So, I think that that did demonstrate—particularly, on behalf of the Welsh ambulance service—that, when somebody wishes to raise a concern, whether they are a BSL service user or not, we are able to communicate effectively with that person when they wish to raise a concern, and also take some lessons learnt and take some action off the back of that concern.

So, I think, in terms of people being able to raise concerns, I don't see it as an issue. I'm sure that there is always room for improvement, but in terms of our mechanisms within NHS Wales for raising concerns, I don't anticipate that being a particular problem, especially if we are moving towards increasing our engagement with our deaf communities. I think that will open up communication channels for people to raise concerns informally as well, without having to go through that formal process.

I would just acknowledge that there are currently changes to the regulations being taken forward across the NHS in Wales. The 'Putting Things Right' regulations have been amended; they come into force in April 2026, and they are setting a range of expectations to ensure that we are meeting all of the inclusivity duties that you would expect. They also ensure that some of the barriers that anybody in the population might feel in terms of raising a concern, seeking redress—. Actually, there are some really strong measures within those changes for us to work directly with families, and hopefully to be able to put things into a better place. As the accountable person for 'Putting Things Right', I would be really clear that I have a set of duties already set out from within Welsh Government and NHS policy that I am required to meet that have been adjusted of late, and it would probably be quite difficult to have a competing set of legislation or regulation in that space.

Thank you. And in terms of being held to account, we're talking here about the teeth that the BSL adviser has, and we know that the Bill will require the Welsh Government to appoint a BSL adviser. So, could you give us a view on the proposed duties and powers of the adviser in terms of what's been set out in the Bill? Is it clear to you what the relationship would be with your bodies?

Yes, we would welcome a national—

Sorry, I spoke English then. I would welcome a BSL adviser, as set out by the legislation. Comparing that, then, with the Welsh language standards and the role of the commissioner, I would prefer to have a BSL adviser rather than a commissioner. I think that bodies would get more from an adviser rather than a commissioner. We would have more guidance and leadership in terms of what we need to do or the pathways that we're aiming to achieve in terms of improvements. So, I would welcome an adviser rather than having a commissioner.

But in terms of ensuring compliance, and it goes back to the point that Jane Dodds made earlier about accountability, doesn't it, what do you foresee in terms of the powers of the adviser? How should the adviser, in your view, be able to hold public bodies to account? How do you foresee, in terms of the Bill as it is at the moment, that he or she will be able to do that, if we don't see significant progress in a certain area, for example?

To go back to an earlier point, I think the adviser will need to work with the Welsh Government to ensure that there is compliance with the BSL standards, or whatever the final legislation is and whatever the final requirements are. So, the adviser will then need to work with the Welsh Government to ensure that, in the annual SEP reports, there is a place for the BSL standards, as there is a place for the requirements in the 'Anti-racist Wales Action Plan'. That's one way in which they can really raise awareness of the standards, and ensure that public bodies are making strides to comply with all of the standards, rather than it being a separate report.

Thank you. I just want to ask about one specific point. Did someone else want to come in on that, sorry?

Yes, I just want to put a little bit of clarity into that answer. So, in terms of us being held to account as a statutory organisation within Wales, we are held to account by the NHS Wales Joint Commissioning Committee, which operates under the auspices of NHS Wales Performance and Improvement. That's the accountability line that we would have. We would demonstrate to them how we are meeting the various regulatory and legislative requirements. It's a subtle difference to the accountability that may flow through other public sector entities, but I think it's important for us just to clarify that that's the accountability line for our trust.

Thank you. I just wanted to make one other point before finishing: there is one section in the Bill that says that listed public bodies must comply with a request for information from the BSL advisor

'unless it considers that doing so would conflict with its duties or have an adverse effect on the exercise of its functions.'

Could I just ask you what your views are on this? Do you feel—? For example, we have heard evidence that this could be a little bit of a loophole. I don't know what your view is on that.

I think, as a trust, we often seek to, or we almost always seek to, work to the spirit of the legislation, and the regulation as well, to the absolute black and white. I am accountable for producing a number of annual reports, in one form or another, that service different parts of the NHS and the wider public sector. And I would expect that to be the case for our trust going forward. So, if there was a request that came through the appropriate routes, I would expect us to comply with that in spirit, as well as within the black and white, as a public sector organisation. We don't look for loopholes to get out of reporting. I think we are an incredibly transparent organisation, and we seek to learn at every opportunity from where we could do things differently, where we know we're not doing things as well as we could. So, I would give some assurance to the committee that we wouldn't be seeking those loopholes and that we would be reporting in a way that we do currently.

Thank you. Can I now call in Altaf Hussain?

Thank you very much, Chair. I will come to the last section, really, and that is the barriers to implementation. The Bill's regulatory impact assessment, RIA, estimates overall costs of up to £2.5 million to listed public bodies over a 10-year period to comply with the planning and reporting duties. Do you think additional funding will be required to cover the costs of developing and reporting on local BSL plans?

We would always welcome more funding in order for us to create more resource in order for us to meet any set of standards or requirements. I think that's a given in the current economic climate.

In terms of the barriers and challenges, I can recall—I was heavily involved in doing the RIA for the Welsh language standards—a similar figure was estimated when we did that RIA. Yes, a lot of money has been spent on implementing the Welsh language standards across NHS Wales. No additional funding was made available at the time the Welsh language standards were implemented, but organisations have found a way, I think, gradually to meet those standards and create systems where it allows them to implement that set of standards. I would anticipate something similar happening with the BSL Bill, which is why I said I think any additional funding that was made available would be welcomed in order for us to progress the requirements of the Bill more quickly, more swiftly.

But as I said, it's not just all about the money. We've talked about the shortage of BSL interpreters, but, for me, this BSL Bill isn't just about the number of interpreters that we have, training more BSL interpreters, which obviously will take some considerable resource, funding and capacity as well, I think it's about what else we can do to meet the needs of our deaf community. So, it's about utilising that technology, but recognising, then, that some of that technology, especially some of the solutions, the digital solutions that Rhidian has spoken about today, could be at an even greater cost, and I think in times where we are being asked to save money as NHS organisations, it will become increasingly difficult, I think, for us to allocate dedicated resource to implementing the BSL Bill. I think it's going to be a matter of being creative, as we have seen in the past with the Welsh language standards, but that is not to say that that creativity cannot be found to find a way to implement them.

Any other thoughts, Liam?

No, it's a prioritisation exercise. I think there will be things that we can do collaboratively across the public sector and across the NHS, particularly in some of those core resources. There will need to be investment in some form or other to meet the standards and the degree to which it is additional, that is dedicated to supporting us to meet the standards, and the degree to which we are in negotiations and discussions by reprioritising existing resource. That will be the journey that we will take as this Bill progresses.

Fine, thank you very much. Let me come to the last question, really. Do you see a role for NHS Wales Shared Services Partnership to help health bodies access BSL interpreters and video relay services?

Honestly, possibly. Again, I feel like I've referred back to my experiences with the Welsh language standards several times this afternoon. There were discussions around Welsh Government creating a central Welsh language translation service, and those discussions went on for a long time and there was a lot of consultation. I think at one point they were very, very close to establishing that centralised Welsh language interpretation service in Welsh Government, but at the very last hurdle, it didn't really materialise.

I think it's definitely worth consideration and discussion that we would have this centralised resource, whether that was shared services or another organisation that would be responsible for setting up that centralised resource. Again, given the complexities of the different nature of all of these systems that operate within and across NHS Wales, I think it might be more difficult, easier said than done, to just establish that centralised support system within shared services.

Can we hear from Rhidian?

Thank you. We did learn quite a few lessons during COVID, particularly telemedicine, and the barriers to telemedicine included the technical kit that was available to clinicians. We often, in our current practice, for those with specific language needs, have to use a telephone service. Telephones are relatively common, even within NHS hospitals and primary care. Appropriate video facilities are not. And so, there would be a cost implementation associated with that.

Furthermore, I'm not a fan of a non-digital organisation procuring a digital solution that requires integration. If one was to do this, then my advice would be that it is a digital program from start to finish, held on a once-for-Wales, all-Wales approach, therefore providing equity of service to all our citizens across Wales.

Thank you very much. Thank you, Chair.

Thank you. Thank you to all of you for your patience amidst the one or two technical challenges that we've had this afternoon. We will send you a transcript of your evidence, and obviously you will need to make sure that we've captured your information correctly. We may write to you if there's any additional information that we require, but we thank you all for your participation in this scrutiny of this BSL Act.

Members, there is one paper to note in the correspondence from Rob Jones to myself regarding Welsh justice data. Can we agree to note it? I see no disagreements. Sioned.

Just very quickly, Chair. I do think that we should be writing back to Dr Robert Jones and asking him, because he mentions that there are a number of important sources of data that are not part of those that have been released. So, I would like to understand a bit more about what those are. Also, perhaps we should write to the Cabinet Secretary to ask for her assessment of the implications of what we've learnt from what has been released and what actions will follow on from that.

Fine. I see no disagreement with that course of action. I'm sure we can manage to do that.

Could I now ask for your agreement that we exclude the public from the remainder of this meeting and from item 1 on the agenda for the committee meeting on 13 October? Before we go into private session, just to say that, on 13 October, we'll be taking evidence from the Welsh Local Government Association and the Cabinet Secretary for Social Justice, Trefnydd and Chief Whip on the Bill.