Category Archives: Devolution

Introduction

 

The  SHA Council agreed to pull together some of the existing policies on prevention and public health, introduce new proposals that have been identified and put them into a policy framework to influence socialist thinking, Labour Party (LP) manifestoes and future policy commitments. The SHA is not funded by the industry, charitable foundations or by governments. We are a socialist society which is affiliated to the Labour Party (LP) and we participate in the LP policy process and promote policies which will help build a healthier and fairer society within the UK and globally. An SHA working group was established to draft papers for the Central Council to consider (Annex 1).

 

The group were asked to provide short statements on the rationale for specific policies (the Why?), reference the evidence base and prioritise specific policies (the What?). Prevention and Public Health are wide areas for cross government policy development so we have tried to selectively choose policies that would build a healthier population with greater equity between social groups especially by social class, ethnicity, gender and geographical localities. We have taken health and wellbeing to be a broad concept with acknowledgement that this must include mental wellbeing, reduce health inequalities as well as being in line with the principles of sustainable health for future generations locally and globally.

 

The sections

 

These documents are divided into five sections to allow focus on specific policy areas as follows:

 

  1. Planetary health, global inequalities and sustainable development
  2. Social and the wider determinants of health
  3. Promoting people’s health and wellbeing
  4. Protecting people’s health
  5. Prevention in health and social care

 

The working group have been succinct and not reiterated what is a given in public health policies and current LP policy. So for example we accept that smoking kills and what we will propose are specific policies that we should advocate to further tackle Big Tobacco globally, prevent the recruitment of children to become new young smokers, protect people from environmental smoke and enable smokers to quit. We look to a tobacco free society in the relatively near future. Whether tobacco, the food and drink industry, car manufacturers or the gambling sector we will emphasise the need to regulate advertising, protecting children and young people especially and make healthy choices easier and cheaper through regulations and taxation policies.

 

Wherever appropriate we take a lifecourse approach looking at planned parenthood, maternity and early years all the way through to ageing well. We recognise the importance of place such as the home environment, schools, communities and workplaces and include occupational health and spatial planning in our deliberations.

 

We discuss the NHS and social care sector and draw out specific priorities for prevention and public health delivery within these services. The vast number and repeated contact that people have with these servces provides opportunities to work with populations across the age groups, deliver specific prevention programmes and use the opportunities for contacts by users as well as carers and friends and relatives to cascade health messages and actions.

 

The priorities and next steps

 

In each section we have identified up to ten priorities in that policy area. In order to provide a holistic selection of the overall top ten priorities we have created  a summary box of ten priorities which identify the goals, the means of achieving them and some success measures.

 

This work takes a broad view of prevention and public health. It starts with considering Planetary Health and the climate emergency, global inequalities and the fact that we and future generations live in One World. A central concern for socialists is building a fairer world and societies with greater equity between different social classes, ethnic groups, gender and locality. We appreciate that the determnants of such inequalities lie principally in social conditions, cultural and economic influences. These so called ‘wider determinants and social influences’ need to be addressed if we are to make progress. The sections on the different domains of public health policy and practice sets out a holistic, ecological and socialist approach to promoting health, preventing disease and injury and providing evidence based quality health and social care services for the population.

 

The work focuses on the Why and What but we recognise the need for further work to support the implementation of these priorities once agreed by the SHA Council. Some will be relatively straightforward but others will be innovative and we need to test them for ease of implementation. A new Public Health Act, as has been established in Wales, but for UK wide policies would make future public health legislation and regulation easier.

 

The SHA now needs to advocate for the strategic approach set out here and the specific priorities identified by us within the LP policy process so they become part of the LP manifesto commitments.

 

Dr Tony Jewell (Convener/Editor)

Central Council

July 2019

The complete policy document is available below for downloading.

Public health and Prevention in Health and Social carefinaljuly2019

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The Welsh Government has announced its intention to increase Welsh GP training positions by  a further 18%. This follows a significant increase in the fill rate for training posts, which this year has already seen 155 places already filled against the target of 136.g

The Health Minister, Vaughan Gething, has now asked Health Education and Improvement Wales (HEIW) to review the number of places in Wales to ensure a skilled workforce is in place to meet the aims of A Healthier Wales to provide care closer to home and reduce pressure on hospitals.

The target fill rate for GP training places is set to increase from 136 to 160, starting this autumn. This figure will be kept under review with a view to increasing it further in the coming years.

Mr Gething said:

We have made excellent progress since launching our Train, Work, Live campaign in 2016 to attract GP trainees to Wales. In 2 of the last 3 years we have over-filled our target number of training places so now is good time to look at increasing the target.

I have asked HEIW to review our GP training places to ensure we have the skilled workforce we need to meet our long term ambitions for the NHS, set out in A Healthier Wales. I want to increase the number of places to 160 in time for the next round of recruitment in 2019 and I hope we can move towards an even higher target in the near future. I have also agreed where there are further opportunities to take on more GP trainees than the 160, HEIW can proceed if there is capacity to do so.

The Train, Work, Live GP trainee campaign includes 2 financial incentives schemes: a targeted scheme offering a £20,000 incentive to GP trainees taking up posts in specified areas with a trend of low fill rates, and a universal scheme offering a one off payment for all GP trainees to cover the cost of one sitting of their final examinations.

HEIW Medical Director Professor Push Mangat, said:

We are absolutely delighted the Welsh Government have agreed to fund our plan to increase GP training numbers in Wales. This will have a positive impact on local healthcare services and the health and wellbeing of residents. Wales has a lot to offer and we look forward to welcoming more doctors to train as GPs in Wales.

 

SHA Cymru has also welcomed the increase in line with its vision to see a significant increase in front line primary health care staff as outlined in its recent submission the Welsh Labour Policy Forum.

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Further investment in Welsh general practice  has been promised  following negotiations for the 2019-20 General Medical Services (GMS) contract – which is worth over £536.6m. Additional funding will also be made available this year to cover the rising costs of pensions, following changes made by the UK government according to the press released from the Welsh Government.

The funding will mean an increase per patient in Wales from the current contract, from £86.75 to £90. The new value per patient is also more than offered in England.

The contract reforms the way in which services operate with a much stronger emphasis placed on clusters working together to plan and deliver services locally to enable patients to access care at or close to home – one of the key aims of A Healthier Wales.

As part of the additional £25m the GMS contract for 2019-20 will deliver:

An uplift of 3% to the general expenses element of the contract for general expenses.

Investment of £9.2 million for the implementation of the Access to In-hours GP Services Standards published on 20 March 2019.

A further £3.765 million going into Global Sum this year, to fund the infrastructure needs of practices in working towards achievement of the in hours access standards.

An investment of up to £5 million will be made available to incentivise partnership working as the preferred model for GMS and to encourage new GPs to take up partner roles though the introduction of a new Partnership Premium available to all GP partners regardless of length of service.
Health Minister Vaughan Gething, said:

Over the last 18 months we have continued with our ambitious programme of reform to the GMS contract. I acknowledge that negotiations have taken longer than preferred, but this reinforces our commitment to fully engage with the Health Service and General Practitioners Committee on contract reform – with Wales being the only nation in the UK to fully engage the Health Service in this way.

This agreement provides an additional boost to GMS services and once again represents a better deal than that being offered in England. The new contract delivers the much needed investment into services to improve sustainability and to meet the aims set out in a Healthier Wales, including an increased focus on cluster working and seamless provision of services.”

Dr Charlotte Jones, chair of the BMA’s Welsh GPs committee said:

I am pleased that GPC Wales and the Welsh Government have been able to reach an agreement for hardworking GPs across Wales.

The introduction of the partnership premium, an increase in the Global Sum and the additional funding to address the rising costs of employer pension contributions, are a clear commitment by the Welsh Government that they intend to secure the independent contractor model for GPs into the future.

The move to addressing last person standing issues will also ensure that those who have dedicated their careers to improving the health and wellbeing of the communities of Wales do not face the risk of bankruptcy.

This contract will provide reassurance for GPs and ensure that patients continue to receive services in the community and as close to home as possible.

Judith Paget, Chief Executive of Aneurin Bevan University Health Board, said:

I welcome this agreement which has been reached between the General Practice Committee, Welsh Government and the Health Boards in Wales.

The changes to the GP contract and the additional investment will underpin the sustainability of local GP services, which we know patients value so much. We look forward to supporting the local implementation of this agreement so that patients, GPs and the wider community will benefit from the improvement in both the quality of services and the access to services that this agreement supports.

Alongside the financial changes, a number of other commitments have been agreed as part of the reformed contract. Including:

A stronger emphasis on cluster working to plan and deliver local services with improved cluster planning, engagement and activity indicators and a shift of some activity to delivery at cluster level

A streamlined Quality Assurance and Improvement Framework (QAIF) with a focus on Quality Improvement activity.

An agreed scope of the approach LHBs will take in providing support to our most vulnerable GPs who find themselves at risk due to Last Person Standing issues.

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In the two decades since the publication of the Sutherland Royal Commission report on long-term care the issues around the cost of caring for an ageing population remains one of the major issues in public policy. And we remain no nearer to its resolution.

While varying elements of catering for long-term care remain the responsibility of the UK Government, devolution has allowed a fair level innovation and diversity in approach including the introduction of free personal care in Scotland which was one of the main recommendations of the Sutherland Commission.

In Wales the National Assembly’s Finance Committee has recently published a useful report on the matter from a Welsh perspective.

In very broad terms the report looked at two inter-related issues i) delivering quality care and ii) how that care will be accessed and paid for.

The report highlighted that while social care in under considerable financial pressure in Wales the level of spend has remained broadly flat in real terms between 2009-10 and 2015-16 compared to a 6.4% decline in England. None the less with an increasingly older population the per capita spending has reduced by 12%.

In responding to this pressure, and despite the increase in numbers, there was evidence that fewer older adults were receiving care. It was suggested that this was in part a reflection of the Welsh Government’s policy to promote more self-reliance and a better matching of service to need but concerns was also expressed that eligibility criteria were being tightened which means that it is more difficult to access care.

There is a greater proportion of unpaid carers in Wales compared to other parts of the UK and Europe representing 12% of the population. They are responsible for 96% of the care that is given in the community even though 65% of older carers have health problems of their own. The Social Services and Well-being Act (2014) in Wales was intended to increase support for carers but of the 370,000 carers only about 6,200 / year had an assessment with less than 20% receiving an offer of care. In response the Welsh Government has said that it is preparing a major publicity drive to make the carers more aware of their rights and to better equip social workers in their assessment of carers’ needs.

In Wales the means testing for care services is more generous that in England with the Welsh Government committed to increasing the capital eligibility thresholds for residential care to £50,000 by the end of it present term. In addition there is a cap on the level of payments for domiciliary packages. There were concerns that these thresholds could deprive social services departments of vital resources but the Welsh Government grant support has prevented that from happening.

The social care sector remains in a fragile state.. There are many instances in which private domiciliary care companies have handed back contracts to local authorities who have, in some instances, been obliged to in-source the service. The residential care sector is also under pressure particularly smaller more community based care homes. In part this is down to the fees that it is able to agree with social services departments. The rates vary across Wales, often inexplicably, and the Welsh Government has committed itself to introducing a new assessment methodology to bring greater transparency and consistency in the fee structure. In addition it is hoped that this new process will address the concerns where self-funding care home residents are paying fee levels which are, in effect, cross subsidising the public sector.

These problems are compounded by the difficulties in the recruitment and retention of staff with some providers reporting turnover levels of 25-33% every year. There are real issues of pay, status and training that need to be addressed. The Welsh Government has been promoting the voluntary registration of domiciliary care workers from 2018 with the target of compulsory registration by 2020. As well it is committed to reducing the use of zero hours contracts and to requiring a delineation between travel and work time in the working day. However it is still difficult to keep care staff when faced with better pay and conditions in other parts of the public and private sector. And all of this is likely to be exacerbated by the UK’s departure from the EU.

The report also looked at future funding models. The Welsh Government believes that a UK wide solution would be preferable but the continuing postponement of the UK Government’s green paper on social care means that other options will have to be looked at including the use of Welsh income tax powers which will be available from April 2019.

In addition a lot of consideration was given to the social care levy which has been advanced by Prof Gerry Holtham and Tegid Roberts.. Their proposal involves the HMRC to collect a levy between 1-3% depending on a person’s age. This sum would be lodged in an investment fund and used to pay for an enhanced social care package. However the report strongly believed that there needed to be a wider public debate on what the public could expect to receive in return for their contributions. The Welsh Government has established an Inter-Ministerial Group on Paying for Social Care with five separate work streams to consider the the full range of the implications of such a social care levy.

The Welsh Government’s policy statement A Healthier Wales (2018) confirmed its intent to support closer collaboration between health and social care in Wales using regional partnership boards as their main instrument to achieve this. Concerns were expressed that Wales lacked a sufficiently robust evidence base to inform social care planning thought the Welsh Government was not convinced about this. There was also a recognition of the very useful role that the Intermediate Care Fund has played in facilitating joint working between health and local government bodies.

Overall this is a useful report which highlights many of the key challenges facing social care in Wales. However there is little evidence that the Welsh Government is in a position to move toward an fully integrated “health and care service” free at the point of use or that it is likely to seek the devolution of the administration welfare benefits service which could allow for a more innovative proposals for the paying for the care of older people in Wales.

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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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