1. Purpose

This short paper sets out an issue which SHA Cymru Wales is exploring with the Welsh Government’s Director for Health and Social Care Wales.  Very constructive dialogue has recently taken place and the ongoing contribution of SHA Cymru Wales has been invited.

2. Background

2.1. There are unprecedented pressures  upon NHS Wales and the wider Welsh care system arising from an ageing population, an increased ability to offer treatments for a wide range of physical and mental conditions coupled with growing expectations, and severe financial pressures arising from the banking collapse of 2008. In Wales,  service  reconfigurations are required and have been under discussion for many months. Different approaches have been applied in the different parts of Wales and at the time of writing there remains much to be decided in South and West Wales.

2.2. SHA Cymru Wales understands the case for change and is keen to assist any sensible response to the pressures it now faces. Naturally, SHA Cymru Wales sees the broad principles upon which the NHS was based as needing to be retained, for these are seen as enduring values around which citizens, patients and staff can gather.

2.3. The following section deals with issues relating to planned capacities of various kinds. It is recognised that capacity alone does not fully describe the services needed, quality of provision is also essential. It is also understood that much of the work of the various service reviews has been geared to delivering safe and reliable services. It is also recognised that  qualitative measures are more challenging than quantitative ones. Nevertheless SHA Cymru Wales believes that some overall description of intended capacities of the main components of the care system is an important element  of planning if the care system as a whole is to be altered in a way that retains resilience.

3. SHA Concerns about the current process       

3.1. SHA supports much of the broad analysis of issues and options that have been contained in documentation describing  the various proposals for service change.  It accepts that some of the pressures now placed upon services may be lessened by better anticipatory/primary care and by transferring some of the present hospital caseload to other care settings, both by admission avoidance measures and by speedier discharge processes.

3.2. However it has concerns about two particular and inter-linked facets of the planning work done to date. These are:

3.2. 1. Most of the work done on service change has been undertaken at Board level. Much of this is appropriate. However, SHA Cymru Wales believes that there is a role for some further all Wales assimilation of local plans to ensure that they not only fit together (and relate to changes in NHS England) but have clear assumptions about the diagnostic and treatment / care capacities that are intended at some future point in time that are themselves based upon understood and intended wider changes across the care system.

3.2.2. To support the all Wales work described above, SHA Cymru Wales believes that further work is required to create an agreed strategic vision of the total care system towards which NHS Wales and its partners is working. Such a vision would be based upon a transparent and shared set of assumptions about the major ingredients of  service change and, in broad terms, the intended service capacities that the care service intends to achieve at an agreed future date. Here, it is emphasised that SHA Cymru Wales is seeking such an approach across the key ingredients of the total care system, including primary care. community care (NHS and Social care) as well as emergency and elective secondary and tertiary care supported by adequate mobile response services whether road or air based.

4. SHA Cymru Wales proposals          

4.1. The  following proposals are deliberately described in high level and indicative terms and the Association is keen to explore any alternative approaches that achieve similar objectives.  The key elements of the desired approach are given below.

4.2. Establishing the current position

We would wish to see the current Welsh “whole system”  captured and described across a number of key capacities and outputs. This stage would also capture key demographic data (population data by age and locality summed for the whole of Wales). In terms of key capacities we would expect to see the following:

  • primary care booked and open appointment slots, and out of hours home visiting slots
  • number of places in residential and nursing homes (if possible with dementia and medical places captured separately)
  • number of patients supported at home[1] for a) short term post hospital care and b) chronic conditions c) terminal care
  • diagnostic and out patient consultation capacity
  • secondary and tertiary care in capacity for elective work -in patient and day case – and in patient emergency admitting (in patient) capacity
  • emergency mobile response capacity (road and air)[2].

4.3. Agreeing the expected or intended changes and the “aimed for” date       

We would then wish to see some agreement – at the all Wales level –   on the expected or intended changes that are to occur  within the agreed planning time frame. It is likely that some of these will be driven in part by decisions made by the NHS but others will be caused by factors  external to the NHS.  Among the factors that could come into play are:

  • projected changes in the numbers of the whole population and significant sub sections of it (e,g. births and over 80’s)
  • intended impact of preventive and health promotion action
  • intended service changes aimed at reducing emergency demand on acute hospital diagnostic/assessment services – for example expanded primary care activity and mobile assessment services
  • intended system changes aimed at providing enhanced, non acute hospital, care settings – for example supported housing – aimed at avoiding admission to acute hospitals[3]
  • intended changes aimed at reducing lengths of hospital stay for, in the main, older patients whose discharge needs support from community based services, primary care or local authority services (e.g. aids and adaptations)
  • expected impact of emerging and significant morbidity[4].

4.4. Re-setting future all Wales capacities

For the  future planning horizon, we would then wish to see the likely or intended all Wales care capacities broadly computed to indicate an intended level of care capacity – in its diagnostic, treatment and ongoing care modes – within which the capacities determined by each of the local plans can be nested.  Any demand arising in Wales that is to be net from capacity supplied from England would also need to be factored in.

These capacities we would see as being conceived in each of the main NHS care settings  – primary, community, secondary, tertiary and “mobile” – and significant supporting services notably in key services provided by or through local government, in particular residential and nursing homes and community care teams.

Such an assessment would also indicate any areas where failure to maintain intended capacities might have a detrimental effect on other parts of the care system.

5. Conclusion

It is hoped that the foregoing  summarises the key capacity issues that SHA Cymru Wales wishes to explore. Officers and members are willing to assist any endeavours NHS Wales undertakes in this regard.


[1] For example, if the term “virtual wards” gains currency, we would wish to  capture broadly the capacity currently supported.

[2] Measured using a  suitable “currency” – for example patient miles per day.

[3] Plans drawn up by Hywel Dda Health Board assume a 20% reduction in acute medical admissions by, for example, creating further “virtual ward ” capacity.

[4] For example, the anticipated level of revision surgery needed to accommodate earlier orthopaedic implants.

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One Comment

  1. George Nieman says:

    It has all been well thought out and it can only succeed. The NHS has no alternative but this. Nevertheless it will work I feel sure

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