The interim Parliamentary Review, published in July 2017, observed the the Welsh NHS and social care has been subject to many well-considered reviews since devolution. They all shared the common fate of not to achieving transformational change as they never successfully made the transition from the page to the front line. In an attempt to address this it recommended that Welsh health and care services should concentrate on a limited number of significant innovations, evaluate the outcomes and implement the most successful ones with a sense of urgency.
Despite this the Final Report (January 2018) itself produces ten “high level”recommendation (with many supplementary “supporting actions”) over-ridden by what the Review calls “The Quadruple Aim” of improving population health, improving the quality and experience of care, better engagement with the workforce and increase value for investment through innovation, elimination of waste and implementation of best practice. This represents a massive “whole system” challenge and one wonders if this Final Report will itself become a victim to the fate as its predecessors and for the same reasons.
At the heart of the final report is the challenge of delivering a health and care service that will meet the growing pressures it faces despite the continuing under-resourcing of public services in a era of never ending austerity. The unstated conclusion is that the high level recommendations linked to the Quaduple Aims will achieve the type of efficiencies that are needed to deliver a sustainable service.
Everything suggests that this is a heroic assumption. Health care funding has historically grown at an annual rate of over 3.5%. Annual efficiency gains in excess of 1.5% are exceptional despite desktop exercises which claim that a vastly greater efficiency improvement potential. Despite the very many useful insights and recommendations that the Final Report provides there is nothing in it that would indicate that it will deliver where others have failed.
But even if this report is not capable of delivering everything there are many key recommendations that the Welsh Government needs to take on board to improve health and social care performance in Wales.
The Final Report strongly reiterates the views of SHA Cymru and the Nuffield Trust that the Welsh Government needs to be more actively involved in the executive delivery of policy as well as the setting of the strategic direction for health and social care in Wales. While it is crucially important that Welsh Health Boards deliver locally sensitive services their relatively small size make them captive to many “localist” vested interests which makes it almost impossible for them to implement the strategic decisions which are required in Wales.
Local health boards seem to be have an disproportionate focus on acute services. SHA Cymru has pointed out that following the abolition of the internal market in Wales most of the health board senior management came from acute NHS trust backgrounds which very much flavoured the direction that policy would flow and that non-executive health board members were failing to provide sufficient challenge to this approach. This was not helped by the failure of the Welsh Government itself to emphasise importance of a holistic approach. And as budgets became ever tighter it has become even more difficult to move the agenda beyond the immediate priorities of firefighting the latest high profile crisis.
In response the Final Report makes a number of recommendations including that the Welsh Government should use a range of initiatives and financial incentives to mould the activities of health boards. This intention is laudable but it is arguable if the recommendations will be sufficient to achieve the required outcomes.
Considerable emphasis is placed on the importance of delivering more cohesive health and social care. The introduction of Integrated Medium Term Plans are welcomed but are seen as been being excessively verbose and mistaking policy quantity for quality. Many obstacles remain to greater integration with the report not acknowledging the fundamental problems that exist between a free or means-tested service and the substantial cultural differences that now exist between sectors that are delivered though the NHS and local government. The progress that Local Service Boards and Regional Partnership Boards are achieving is recognised and the Social Services and Well-being Act (2012) has provided an important legislative catalyst for change. But the Review does not ask if the Welsh Government needs to consider whether a more prescriptive legislative approach is what is needed to achieve the more accelerated progress that is needed.
Wales needs a shared infrastructure to start to make this happen. IT systems have to reach across all health and social care. Common, shared pathways with national standards are needed while still capturing both local and individual sensitivities. This will require Welsh Government investment to achieve the qualitative change and staff skilling to make it happen.
Compared to the Interim Report more attention is given to health inequalities though it still remains a fairly peripheral issue in the overall scheme of things. The wider importance of public health measures are emphasised in passing through this is outside the Review’s terms of reference. Health boards are urged to make greater use of epidemiological data to inform and to recognise the importance of very early years in their planning but there are no practical recommendations on how “to follow the money” or to identify and evaluate the processes and outcomes that will diminish the effect of the continuing “inverse care law”.
There is a very strong emphasis on the need to use the patient experience to measure service quality and inform the planning process. Linked to this is the need to involve clinical and other front line staff. It is vital to empower individuals and communities to achieve a good health and well-being and it recognised that those with the greatest need and who are most disadvantaged are often most likely to find this difficult to achieve. This is a task where health boards and local authorities could usefully work together to achieve the best results.
Most of what is in this Final Report is highly commendable though it is much broader in scope than the streamlined, targeted and readily implementable actions that the Interim Report felt was needed. Equally it is totally unrealistic to believe that it will achieve the step change in Welsh and social care performance that obviate the need for substantial public service investment in both services.