Category Archives: Devolution

The National Assembly’s Finance Committee is undertaking an inquiry into the costs of care for older people. This is timely not least because the UK Government has promised us a green paper on social care finance by the summer 2018  thought there are media reports this could be postponed — it seems that the Brexit policy paralysis is contagious and spreading to other other areas.

No doubt in advance of the the anticipated green paper, there has been a flurry of papers and publications in recent weeks. They will add to the dozen or so commissions, green papers etc that have been published over the last three decades. With the exception of Scotland most have been filed under “too hard to do”.

Socialist Health Association Cymru Wales has made its submission to the National Assembly’s Finance Committee and it can be accessed here.

 

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In 2009 the internal market was abolished in the Welsh NHS. Seven unified Health Boards (and three trusts – Ambulance, Public Health and Velindre cancer services) took over the responsibility of the former 22 Local Health Boards and most of functions of the seven Trusts to both plan and deliver health care for the population resident in their geographical areas.

In the initial phase following the internal market abolition the acute hospital sector seemed to have “captured” the planning process. But as things have matured the Welsh Government has sought to re-balance matters with the introduction of Integrated Medium Term Plans (IMTP).

All NHS organisations are now expected to operate to three yearly IMTPs as part of their planning cycle. The latest framework covers the period 2018-2021 with yearly iterations providing firm plans for the initial year, indicative plans for Year 2 and outline plans for Year 3. At the heart of the process is the creation of a collaborative approach which will be sufficiently robust not only to withstand the continuing pressures of austerity but to deliver real improvement for patients, service users, carers and wider public health.

The planning framework ( http://gov.wales/docs/dhss/publications/171013nhswales-planning-frameworken.PDF ) and the IMTPs continue to be informed by the principles of “Prudential Healthcare” ( http://www.prudenthealthcare.org.uk/ ) and an emerging distinctive Welsh legislative backdrop including the Mental Health Measure (2010), Social Services and Well-being Act (2014), The Well-being of Future Generations Act (2015),  Nurse Staffing Levels Act (2016) and Public Health Act (2017).

The planning and delivery process needs to achieve the “Triple Aim” of improving outcomes, improving the user experience and achieving best value to money supplemented by the Parliamentary Review’s ( http://gov.wales/docs/dhss/publications/180116reviewen.pdf ) recommendation of enriching the well-being, capability and engagement of the health and social care workforce.

There are five priority delivery priorities outlined which represent a real effort to re-balance the Welsh NHS away from its initial over-focus on acute secondary care covering such areas as:-
Prevention
Tackling health inequalities
Primary & community care
Timely access to care
Mental health.

Each of these priorities are important in their own right. The prevention and tackling inequalities agendas acknowledge the social determinants of health but they also re-emphasise the importance of addressing “the inverse care law” which is about how the health service responds to the unequal health experience of people. Access to care is recognised as being both clinically important and a key quality measure of the patient’s experience. And as well as timely access to services the quality agenda requires that patients receive safe, effective, personal and efficient care in an equitable way.

Health boards and trust IMTPs must be the product of collective working that extends from the clinical experience of patients and NHS staff to engaging with a wider range of bodies outside the NHS family. Particular attention must be paid to the plans being developed by the primary care clusters ( http://www.primarycareone.wales.nhs.uk/primary-care-clusters ) as well input from traditional sources such as Public Health Wales. In addition participation in regional and local service boards, as well as bilateral discussions, must be used to co-ordinate planning and delivery with other public bodies such as local government, social care, education and housing.

The governance within the Health Boards and the wider NHS must improve if the planning process is to effectively identify and respond to local need. To date the record is not great. Health boards are not always adept at either identifying service failures or responding effectively to them. The Welsh Government has a clear pathway of escalating intervention when health organisations are struggling but even then improving performance has proven elusive ( http://gov.wales/topics/health/nhswales/escalation/?lang=en ).

The final report of the Parliamentary Review recommended that the Welsh Government itself needed to more pro-active in promoting innovation, evaluation and implementation of best practice across NHS Wales. The planning framework preceded the publication of the final report and its silence on the Welsh Government’s role in being a catalyst for service transformation is therefore missing. This needs to be rectified.

The abolition of the NHS internal market was widely welcomed in Wales. This in itself it does not provide automatic answers to all of the problems the NHS faces. But it allows for new ways of addressing them based on the principles of partnership, collaboration and public service values which are more clearly reflected in the latest planning framework guidance.

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Deborah Harrington’s interesting posting on “The Myths and Legends of Hypothecated National Insurance” (March 29 2018) in particularly relevant in the light of media speculation about hypothecated taxes or National Insurance contributions to pay for health or social care.

In Wales there is a further variation on this general theme with Professor Gerry Holtham (Dept. of Regional Economics at Cardiff Metropolitan University ) proposing the establishment a social care levy for Wales. (See link below)

The levy, based on weekly payments between £1.75 and £7, would differ from a tax in that the receipts would not go into a general government budget but rather into a separate social care fund with its own independent trustees. “A portion of ..(the fund) receipts would go to local authorities to expand social care provision straight away. The greater part of the receipts would be held back for future needs and meanwhile invested to grow over time and enable even greater social provision to be made in the future as the population ages.”

And following the National Assembly for Wales having secured its own tax raising powers at the beginning of October 2017 the Welsh Government Finance Secretary, Mark Drakeford, signaled that a levy to support social care was one of the new tax ideas he was considering.

Solving Social Care. And more besides

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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.

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The interim report on the Parliamentary Review on the Welsh Health and Social Care Service was published in July 2017 just before the National Assembly’s summer recess. Its main message was that both services needed to innovate and modernise at a much faster rate if they are to continue to provide quality care over the next five to ten years.

This is a well rehearsed and often repeated message. However, unlike previously, instead of encouraging “a thousand flowers to bloom”, the Review urges more limited and strategic approaches with a particular emphasis on the needs of the older population. These limited innovations should be properly and thoroughly evaluated before a wider general application across the two services….in summary a call to “innovate, evaluate and disseminate”.

But while this central message is clear the report itself throws up a range of issues which do not sit easily within the confines of this central recommendation.

The initial Welsh Government response welcomed the Review but highlighted this ambiguity when it  summarised the conclusions as

“Frontline staff, the public, and other public and voluntary organisations will be asked to work together to develop new models of care, to help hospital, primary care, community health and social care providers to work more effectively together. The models will be developed to work in different settings such as urban and rural, and take account of Welsh language needs. The Parliamentary Review interim report recognises that new models will need to be underpinned by action in a number of areas and makes further recommendations including the need for a step change in the way the health and social care systems adapts to the changing needs of the population the people of Wales, staff, service users and carers to have greater influence on new models of care with clearer, shared roles and responsibilities new skills and career paths for the health and social care workforce with a focus on continuous improvement better use of technology and infrastructure to support quality and efficiency streamlined governance, finance and accountability arrangements aligned for health and social care.”

This is in effect is calling for a total, rather than limited, system and culture transformation across the combined health and care service. The final report plans to provide a range of specific recommendations which will both inform and provide benchmarks for what the new service will look like. However the sheer scale of the change agenda will test the Review Panel’s ability to deliver its own objectives.

In undertaking such a broad ranging review, the interim report covers and comments on many areas which are central to the future sustainability of services but often they are just noted or merely mentioned in passing. While it might be argued that some of these findings are beyond the formal remit of the review they could provide an importance context in evaluating the prospects for success of the final detailed recommendations.

It reports that NHS spending in Wales will need an annual increase of 3.2% to 2030/31 with adult social care requiring 4.1% to maintain pace. In an era of continuing austerity this level of financial growth is a forlorn hope and consequently increasing service effectiveness and efficiency “is essential for future sustainability”. However the interim report does not quantify the possible impact of its recommendations on achieving the reduction in funding pressures which a sustainable service needs. This is a major gap which, hopefully, will be addressed in the final report.

But even if there were sufficient resources there are crucial bottlenecks and imbalances across the system. Staff recruitment and retention at all levels is vital but there is a growing problem with conditions of pay and conditions. The chaotic Brexit negotiations is only aggravating the uncertainty. In addition infrastructural investment needs to have a clear vision and sense of purpose. IT will be particularly important in providing the communication network though which new integrated, partnership working will take place.

The need to have a unified health and social care vision is reiterated on many occasions. It is acknowledged that looking at the barriers between a “means-tested” care system and “free at the point of use” health care system is beyond the remit of the review but there are areas where meaningful progress can be made. In responding to the report, the Welsh Health Cabinet Secretary pointed out that pooled budgets, facilitated by the Social Services and Well-being Act (Wales) 2014, will be rolled-out across more service areas from April 2017.

The imbalance between primary care and the rest of the health service is also highlighted. While innovation has taken place it still remains the case that despite a relatively older GP workforce, the number of GPs in Wales have effectively been static over the last half decade. This is in contrast to the hospital sector where consultant numbers continue to increase. This lack of growth inevitably means that community based health services are not achieving the type of outcomes which will make a difference to patients’ experience and well-being as well as the optimal smooth running of the overall system.

Addressing and reducing health inequalities in Wales was also part of the Parliamentary Review remit. It acknowledges the importance of the social determinants of health and the importance of other parts of public policy such as welfare benefits, housing and early years. However it is remarkably light in scrutinising the continuation of “the Inverse Care Law” in health and social care. This omission is glaring and addressing it must be a major priority for the Review in its final phase of work.

The review spends a lot of time considering how to make things happen and looks at the role of the Welsh Government in facilitating change without outlining specifics. A separate recent report on health and care services stressed the need for the Welsh Government to give a stronger lead. This is a bit challenge for them.

On the one hand Welsh Government is keen to promote more locally sensitive and delivered services. But clearly this approach has only had limited success in delivering the the scale of change that is required. In practice “localism” can be a barrier to much needed change when “parochialism” tends to dominate the debate and decision making. And with many of crucial “facilitators” of change in the hands of the Welsh Government, this will be a critical area for the final report’s recommendations.

The overall success of this Parliamentary Review will be judged on how useful its final report will be. In producing the final report the Review Panel is aware that other similar work has failed to make a comprehensive transition from the page to the clinical setting. It states its determination to make recommendations which will be meaningful, focused on outcomes, manageable and implementable over a reasonable timescale. Based on the interim review this will be a very tall order faced with continuing austerity in our public finances.

https://beta.gov.wales/review-health-and-social-care?lang=en

http://www.assembly.wales/en/bus-home/pages/rop.aspx?meetingid=4304&language=en&assembly=5&c=Record%20of%20Proceedings&startDt=10/07/2017&endDt=21/10/2017#C489167

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The announcement in February 2015 that local councils in Greater Manchester would be given a say in the management of the NHS in the conurbation generated a lot of publicity. This is an attempt to make sense of what has happened since.

The announced devolution of powers in relation to the NHS doesn’t amount to very much. All the laws, regulations and structures which apply in the rest of England still apply in Manchester. That is not the case in Wales, Scotland or Northern Ireland. This is more like delegation than devolution.

DevoManc

A Memorandum of Understanding was agreed by NHS England, 12 NHS Clinical Commissioning Groups, 15 NHS providers and 10 local authorities. It establishes a health and social care partnership board which manages the £6 billion annual budget and a £450million transformation fund. This gives local councils a formal role in the management of health care – something they have not had since 1974. The board are developing a common technology strategy, which is intended to to enable the sharing of patient records between different organisations. They have also agreed a common approach to public health – something which councils have been responsible for since 2012.

A strategic plan has been agreed in each borough, and these are developing independently. There will be some concentration of specialities into fewer centres, so, for example, it is proposed to establish four centres for elective orthopaedic surgery, and three centres for emergency surgery so these will not be provided in every borough. This concentration will require considerable capital investment and it is not clear where that will come from.

The intention is to integrate health and social care, and establish what are called local care organisations. These involve bringing adult social care staff into NHS organisations. This happened in Salford some time ago, and is developing in other boroughs. Social care is still meanstested. It is difficult to see what this means in practice. Given that the councils’ budgets have been reduced substantially it seems likely that NHS funds will be used to support social care, as it is much cheaper for trusts to move people into residential care, or pay for equipment than to keep patients in hospital. It has certainly meant that social care staff are under a lot of pressure to get services organised if they are needed to get people out of hospital.

In Manchester City itself involving local councillors has generated some radical changes. Three hospitals, currently run by three different NHS trusts, are in the process of amalgamating into a single organisation. The three Clinical Commissioning Groups have merged into one and are to move into the City Council. A tender has just been announced to run all health and social care services outside hospital. Over ten years this would amount to £6 billion. The hospital consortium is an obvious bidder. At the time of writing it is not clear if there will be any other bidders. This local care organisation would run social care and manage the contracts of voluntary organisations. According to the commissioners it will… “not only improve health outcomes and support people to live independent lives, but also gives us a way of addressing some of the financial pressures we face. “

It remains to be seen whether this approach will give better results than those taken in the rest of England.

This is a personal view.  It first appeared in The Pensioner.

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The NHS has no memory but the labour movement does, although it is sometimes patchy. A conference convened by the Institute of Public Policy Research and the London School of Hygiene and Tropical Medicine on May 9th illustrated how long-standing the issues now being debated around regional devolution of the NHS really are. Discomfort with devolution of powers is hard-wired into the NHS. Commitment to funding the NHS from general taxation inevitably leads to Parliamentary accountability, without the word ‘centralisation’ being used. Likewise, concern at inequities encourages central control to iron out variations in care.

Whilst politicians of all parties talk about local control of the NHS being a good idea, this is a rhetorical device, for the trend is towards ever greater centralisation of health services – described at the conference by Rudolph Klein as “the original sin of the founding father”. Bevan was a centraliser who (in collaboration with the TUC and the BMA) saw off the lobby wanting local government control of the NHS, and slowly his vision of a command and control structure for the NHS has been realised. Unlike the other nationalised industries the NHS inherited the pluralism of the inter-war patchwork of health services. In the beginning the periphery of the NHS – the hospitals- was strong and the centre – the Ministry – was weak and lacking in skilled personnel , but this changed with the arrival of New Public Management in the 1980s, with its performance indicators, outcome measures, economists and statisticians, and its endless data collection. Before this there were some attempts at directing medical labour, allocating resources according to need, and promoting service integration through the simple mechanism of co-location, but all struggled to have an impact.

With the neoliberal drive to modernise the NHS command and control became more effective and oppressive. Klein dismissed Blair advisor Paul Corrigan’s argument that there was command but not control in the NHS as untrue of the present time; what could be more controlling than special measures, he asked.

A presentation about campaigns against hospital closure reminded us that Margaret Thatcher proudly claimed to have ‘saved’ the Elizabeth Garrett Anderson hospital from closure; Labour has no monopoly on NHS salvation. Current campaigners have been through a bad patch when they were ignored by MPs and NHS practitioners, and looked like a middle class, white, retired Baby Boomer ginger group, but that had changed with the growth of ‘Health Campaigns Together’. The problems that campaigns in defence of the NHS have long experienced continue, however. The lack of democratic accountability in the NHS, and the opacity of its internal politics, mean that campaigners are prone to conspiracy theories and tend to conflate any change with privatisation, potentially paralysing service development. Hospitals remain the iconic sites in the NHS, which hampers any policy shift towards a primary-care led (or even based) health service. And there is a tension between local motivations – save our A&E! – and national opposition to neo-liberal ‘reform’, ‘modernisation’ and ‘reconfiguration’.

The IPPR/LSHTM conference made me think that we may be drifting back towards regional management of the NHS, with very different mixed economies in different regions, and plenty of scope for local jockeying for position to contract out services. Bevan’s centralised service may be approaching the end of its useful life, but it has to enforce decentralisation before it is done. Campaigners will not run out of things to do.

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A new, independent and broad-based citizens’ initiative – the People’s Plan – was launched in Greater Manchester last October and has now published its findings.  This extract covers health and care  – but other parts of the plan would also impact on health. 

People's plan

Since 2016 Greater Manchester has responsibilities for managing and integrating hitherto separate, centrally funded NHS services and local authority adult care services. Both services are in crisis: in adult care, austerity budget cuts have reduced numbers receiving home care by some 20% nationally; and in health services, the halving of the number of hospital beds over the past thirty years has created a fragile system that suffers with demand peaks or delayed discharges. The National Audit Office has questioned whether integration of health and care will save money or reduce hospital admissions; and this finding is ominous when Greater Manchester has a predicted £2 billion shortfall in health and care expenditure within five years. Against this background, it is unclear how Greater Manchester will find the policy levers, financial resources and political will to tackle prevention of ill health and low life expectancy in deprived localities.

Challenge 1:How to lever in more financial resources for health and care services, where social ownership and operation of free services should be defended

Event participants recognised that “services cannot be run without proper funding” and the first priority of survey respondents is levering in more public funding. In health, as in housing, what citizens want is public provision that depends on reversing austerity cuts. By implication, the Greater Manchester mayor and other Greater Manchester politicians need to change central priorities as much as manage local services; as a Bury event participant put it: “make it the Mayor’s job to fight for more money for local services”.

The other clear theme is that public funding should support socially owned and operated services. While voluntary and other third-sector providers are often complimented, references to private providers in health and care are mostly negative: “Resist the influence of the private sector, because it takes money out of the system”; other respondents had concerns for poor pay and conditions in outsourced adult care.

Pointers on what to do:

  • Lever in more public funding.

83% of all survey respondents agreed that ‘Greater Manchester should urgently seek a better funded deal for health and social care’ – with just 2% opposed. Here again, as in other policy areas, like housing, what respondents want the Greater Manchester mayor and other Greater Manchester politicians to do is not just manage the system within existing funding limits but claim more resources. For example, investment in training for ongoing supply of nurses in Greater Manchester services is an area where consequences of cuts to bursaries are a serious concern.

  • Use public funds to support not-for-profit and publicly owned and operated services.

Survey respondents and event participants were against further outsourcing or privatisation. Health and care services need new ‘step down’ facilities for discharged hospital patients who cannot go back to their own homes and do not have a care home bed; but 67% of all survey respondents believed such facilities should be built and operated by NHS providers and 74% also supported provision by other not-for-profit providers, with only 10% supporting private for-profit providers.

People's Plan

Challenge 2: Build a new kind of NHS as a civic institution which offers a wide range of stakeholders more participation in decision-making as well as providing more user-friendly services

Citizen attachment to the NHS is not all sentimental and uncritical. Ministers and managers have sought to restructure health and care services so that they meet user demands more effectively, but citizen critics go further and ask for a redefinition of the NHS as a new kind of civic institution where a wide range of local stakeholders would have a major influence over decision-making.

At a café-style event conversation about ‘Devo Manc’, participants posed a challenge to “find ways to put health and social care close to communities”. There is widespread dissatisfaction with current forms of consultation that are too often about changes already decided by service managers.

Pointers on what to do:

  • Experiment with direct public participation in decision-making.

65% of all survey respondents wanted direct participation by the public for proposed changes, through means such as online polling, for example, whose results could not be easily ignored.

  • Create an advisory board representing wider interests.

More traditional forms of representative democracy have even wider support. 77% of all survey respondents wanted a wider advisory board representing different stakeholders including voluntary and community organisations as well as provider groups. For example, representation for those with learning disabilities and their many challenges was strongly featured in the Health and Care themed event.

  • Provide more user-friendly services on a local community basis.

This is the point where citizen priorities align with those of politicians and service managers. At a Greater Manchester Older People’s Network event and in surveys, the GP and hospital appointments systems were described as “barriers” to access, with specific criticism about the availability of “on the day” appointments; and at a Wythenshawe event the complaint was that “public transport never lines up properly with health services”

Challenge 3: How to put more resources into prevention and into the inadequately funded ‘Cinderella’ services of mental health and adult care, which have now been damaged by austerity cuts

Many of the open survey responses and comments of event participants highlighted the problem of ‘Cinderella’ services. Some event participants thought hospitals were claiming resources that should have gone to prevention, primary and community provision; all agreed with the survey respondent who wanted “greater emphasis on prevention not cure” and worried about how austerity cuts in mental health and adult care had aggravated long standing problems about service provision. The result is pervasive insecurity about service availability, crystallised by the question at one Tameside event: ”will it be there when you or your family members need it?”.

Pointers on what to do

  • Stop cuts to mental health services and increase funding.

This connects with prevention because, as one survey respondent argued, with more funding for primary care, GPs should be able to prescribe more one-on-one counselling and for more than six weeks.

  • Revalue the workforce in adult care.

Some open responses registered the point that care workers are paid and trained worse than health service workers, although they had an increasingly important role in an ageing society. As one respondent argued: ”properly trained care assistants would help people to stay at home”.

David was  one of the people involved in contributing/drafting/editing/finalising the plan, but he is not the sole author

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Wales was the first health service in the UK to abolish prescription charges in 2007.  The NHS in Scotland and Northern Ireland subsequently adopted the policy.

The following article, written by Welsh Cabinet Secretary for Health Vaughan Gething, initally appeared in the Western Mail newspaper:-

 

 

This weekend we marked the 10th anniversary of free prescriptions being available in Wales.

 

When we took the decision to abolish prescription charges back in 2007 it was in light of evidence that some people with serious chronic conditions, such as high blood pressure or heart disease, could not afford their prescriptions so chose to have only part of the prescription dispensed.  This reduced the cost but meant some people were going without medicines they needed to keep them well.

 

It is for that reason we chose to make a long-term investment to improve people’s health, and since then, prescription medicine has been provided free in Wales.

 

All patients registered with a Welsh GP who get their prescriptions from a pharmacist in Wales are eligible. But the GP is just one of a number of frontline clinical experts able to prescribe medication. Others include pharmacists and nurses: prescriptions issued by these are also free of charge.

I’m proud that we were the first of the home nations to take the step to introduce free prescriptions. I’m delighted that both Scotland and Northern Ireland followed our lead.

 

We firmly believe by providing people with the medication they need helps to keep them well and out of hospital, thereby reducing the overall cost to the NHS.  It should never be the case that people with serious chronic conditions can not afford to collect their prescription.

 

Some have called for the reintroduction of prescription charges, but I simply don’t agree that is the right way forward.  That said, our free prescription policy does not mean people should expect to have whatever they want prescribed by their GP; clinicians must make the right decisions about when and when not to prescribe.  Where a medicine offers little or no clinical benefit it should not be used, this isn’t about free prescriptions it’s about good clinical practice.

 

Prescription charges and the system of exemptions which persist across the border in England are poorly conceived, illogical and manifestly unfair to some groups. 

 

The re-introduction of charges would require the development of a new, fairer system.  To maintain such a system would require a costly framework for determining who should not be charged, who may be exempt from charges and who may be entitled to full or part remission of charges

 

The costs associated with administering this fairer system and then safeguarding that system against misuse would reduce significantly any potential income derived from the re-introduction of a charging regime. 

 

It would also negate the very real health benefits we believe Welsh citizens gain by removing ability to pay as a key consideration when an individual takes their prescription for dispensing.

 

So let’s be clear, the Welsh Government has no intention of reintroducing prescription charges.

 

Ensuring patients have the medication they need not only improves their own health and wellbeing, it also benefits the health service as a whole by reducing hospital attendance and placing fewer demands on general practitioners.

 

Free prescriptions are progressive and an integral part of our health services in Wales. I believe it is socially irresponsible to charge people with serious chronic conditions for the medication they need.

 

Health Secretary Vaughan Gething

 

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The Welsh Health Cabinet Secretary (Minister) Vaughan Gething AM has identified three major priorities for primary care in Wales
* maintaining the sustainability of the sector,
* improving access to services and
* delivering more care in a community setting.

Central to delivering these are objectives are the emerging GP Clusters / Primary Care Networks. There are 64 networks or clusters in Wales with a population base of 30- 60,000 patients. It is based on promoting partnership and collaborative working.

The networks allow general practices and a range of other primary and community care practitioners to get together with their local health boards to shape community based services for their populations. However, unlike CCGs model in England, they are not involved in the commissioning of secondary care.

The Health, Social Care and Sport Committee of the National Assembly for Wales is undertaking an enquiry to obtain a better understanding of how the cluster model is working in Wales. The evidence submitted to the enquiry provides an interesting barometer of the progress that is being made.

Where things are going well, a wide range of new services are bring provided, often using new models of care. Many of these more advanced areas areas want to move towards more formal structures. In the Bridgend area of the ABMU Health Board a social enterprise has been established to look a providing services. Elsewhere a number of networks see the formation of “federations” as the next obvious step.

There is not a single operational model for the networks with varying levels of professional engagement and breath of wider organisational involvement. Some networks are more active than others in their efforts to involve social care organisations, third sector bodies and the wider patient / user / public voice.

Clinical representative bodies (e.g. GPC Wales, RCN, RCSLT, Royal College of Physicians, Royal Pharmaceutical Society, Care Council ) highlight that involvement in the networks is time intensive with some concern about an over-focus on GPs and the lack of parity of esteem for other professional health and social care groups. But management evidence ( e.g various health boards, NHS Confederation, Directors of Primary, Community and Mental Health) suggests an awareness of these problems and that they are working to address them.

An important factor in improving the status of the networks and facilitating their work has been the Welsh Government’s decision to directly allocate funds to them. While most primary care funding still goes through health boards, £16 million of recent allocations have been directly earmarked for the clinical networks. This has been welcomed though some concern has been expressed that some health boards might dip into these resources in areas where the networks are making less progress.

The fragility of primary care overall and general practice in particular is a consistent feature of much of the evidence. This is in line with recent BMA survey evidence that 80% of GP respondents had concerns about the sustainability of their practices. The efforts of the Welsh Government to promote recruitment and the status of general practice were widely supported. But the factors under-pinning this fragility – patient need and expectation, system pressures and supply side issues such as resourcing and staffing levels must all be acknowledged and addressed ( Bevan Foundation).

While some individual submissions suggest that independent contractor status of general practice needs to be enhanced, overall most submissions acknowledge that this traditional model is no longer adequate on its own. Some sort of salaried GP service is required to supplement struggling practices, to staff directly managed practices and to provide out of hours care. As well the Bridgend social enterprise is looking at the option of directly employing GPs as a form of new service delivery. This is a welcome development as up to now, most Welsh health boards only saw salaried GPs being employed by independent contractors and regarded their own reluctant involvement in directly managed practices some sort of transitional safety net.

The need to relocate services to a community setting and to improve access is widely acknowledged across many submissions. Many illustrative examples are given. Some such as the use of pharmacists, better home physio and OT services and community re-ablement for respiratory and cardiac conditions builds on well established practice. But other initiatives such as Predictive Risk Stratification Model (PRISM) are being developed to support anticipatory care models while the Inverse Care Law Health checks (which was developed in the Aneurin Bevan and Cwm Taf University Health Boards) are being promoted for national roll-out in Wales.

Social prescribing is also gaining attention as a means for primary care to engage with primary prevention, health promotion and other activities to reduce the chance of becoming ill though the better use of non-medical community assets and to influence social determinants of health locally. Public Health Wales is working to create an evidence base to support this work.

While there is wide-spread support for the development of primary care networks, there are obvious issues that need to be addressed. There is uneven development and engagement both within networks and across networks and health boards. Hard pressed clinicians in areas of high need are most likely to find it most difficult to be fully engaged in these additional areas of work. Local Medical Committees, health boards and Public Health Wales need to carefully monitor the situation to ensure than this does not lead to an inadvertent widening of the health inequalities by ensuring that the areas with the greatest need are not left behind.

With some exceptions (e.g. ABMU HB, Care Council, College of Occupational Therapists) it is of concern that social care has not figured more prominently in the submissions. Social care is crucial to promoting and maintaining the independence and dignity of the most vulnerable in our community. However there are few submissions from the social care sector and there seems little awareness of the need to include social care as a key player in the management of people with multiple and complex problems.

But while there is little specific reference to social care, many of the submissions acknowledge the key role that multi-disciplinary teams (MDTs) will play in the evolution of primary care networks… both in terms of policy formation and delivery. These teams must not only embrace a wide range of primary care clinicians but also include social care. They should also explore ways to have a much more fluid interface with secondary care – as the RCP describes it, we need “hospitals without walls”. By implication, though it has not emerged in the submitted evidence, this would involve some primary care network participation in the wider planning of secondary health care services for their localities.

The absence of a rigid model for networks has many advantages as it allows clusters to develop at their own pace and in line with their own priorities. However the lack of an overall governance framework must create risks that will inevitably emerge as networks evolve and become more directly involved in care delivery.

The submissions to the Health, Social Care and Sports Committee shows there is widespread support and good will for the emerging primary care networks. The evidence suggests that they are evolving in a positive way. However there a are differing levels of maturity with differing levels of impact at a local level. The Committee will publish its own conclusions in time and hopefully its report will provide a further opportunity to consider how things should develop.

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On November 1st 2016 the Welsh Government’s Cabinet Secretary (Minister) for Health, Well-being and Sport, Vaughan Gething, announced the establishment of a Parliamentary Review which will look at the key challenges facing the health and social care services in Wales.

He said  “ … (it) will review the best available evidence to identify key issues facing our health and social care services and draw out the challenges that these will present over coming years. For example, there are challenges with NHS finances within a reducing Welsh Government budget, workforce planning, recruitment and retention, and meeting the rising demands of healthcare and rising public expectations. The review will examine options for the way forward and will then make recommendations about what the health and care service of the future could look like.”

The review was initiated as part of the “Moving Wales Forward” agreement between Welsh Labour and Plaid Cymru underpinned by wider cross party consultation and discussion.

The current Welsh health strategy, “Together for Health “ is due for revision and the Cabinet Secretary hopes that the Parliamentary Review will be completed in time to inform its replacement. This seems sensible and should give the Review a sharp operational focus.

However such a relatively short time window may not provide sufficient opportunity for the Review to engage in the innovative thinking needed to come up with the radical proposals that an under-resourced health and social care service is likely to need just to sustain itself and survive.

The Review will be led by the former Chief Medical Officer for Wales, Dr Ruth Hussey, supported by an an independent panel drawn for a wide range  of experienced backgrounds predominantly from outside Wales. It will be supported by a stakeholder reference group made up of representatives of professional bodies and social service organisations within Wales. Faced with such an strong resource, which has attracted cross party political support, the Welsh Government might wish to consider asking the Review for a relatively early report to help with the revision of its overall strategy and then requesting it to give additional thought as to what Welsh health and social care is likely to need for the medium and longer term.

 

http://gov.wales/topics/health/nhswales/review/?lang=en

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Wales is the only part of the UK where “deemed consent” to organ donation applies. The means that any deceased who is over 18 years, is mentally competent and who had lived in Wales for  12 months is deemed to have given consent to organ donation unless they have formally registered their objection.

About a decade ago, the UK had a low organ donation rates (13 / million population) compared to countries such countries as Spain, USA and France. As well it had a much lower rate of next of kin refusal. In Wales around three people per month died while waiting for an organ donation with about 300 people on a transplantation list.

The issue was considered by the National Assembly for Wales Health and Well-being Committee in 2008. Though its report did not recommend  “presumed consent”, the Welsh Government felt there was sufficient public support for the proposal and indicated its intention to legislate on the matter. A commitment to do so was included in the Welsh Labour, Plaid Cymru and Liberal Democrat’s manifestos for the 2011 National Assembly election.

The Bill was introduced into the National Assembly in December 2012. Over the next year an extensive debate and consultation took place. There was broad support for its purposes though concern was expressed, by Christian and Islamic faith groups in particular, that “deemed consent” was not real consent and that it undermined the altruistic virtue of the gift of donation.

A key feature of the legislation was its “soft opt-out” option whereby close relatives are involved in the donation decision with particular attention being paid to any evidence that the deceased may not have wished to have their organs donated.

In the run up to the beginning of the legislation in December 2015 there was an major campaign to both explain the new legislation and to raise awareness on the wider organ donation need in Wales. The legislation will require the Welsh Government to maintain a programme of promoting public awareness and to report on progress.

At the end of the first year of the legislation the Welsh Government reported “… the latest figures show that 39 organs from patients whose consent was deemed have been transplanted into people who are in need of replacement organs.

In the two years prior to the introduction of the new system of deemed consent, .. (we) made significant efforts to inform the public of the exact nature of the upcoming changes in respect of transplantation activities. During this period the number of organs transplanted increased each year, from 120 between the 1 December 2013 and 31 October 2014, to 160 between 1 December 2015 and 2016.

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