Blog

  • Categories
  • Category Archives: Devolution

    At this stage a debate about the post-Brexit UK Internal / Single Market is unlikely to generate much heat or light – expect for possibly amongst a select band of constitutional lawyers and academics and the most committed of political anoraks. And yet the UK government’s July white paper on the subject has the potential to radically re-fashion how public services are delivered across the UK and to finally precipitate the disintegration of the United Kingdom. The implications of the Northern Ireland Backstop will be small beer compared to the possible fallout from these UK Internal / Single Market proposals.

    Already the UK devolved administrations have expressed their alarm and concern at what the white paper proposes and have demanded a total review of the UK Government’s approach. They see it as a naked power grab by Westminster which will put the UK’s devolution settlement into a rapid reverse gear.

    Until the end of the present Brexit Transitional Period the EU Single Market rules will still prevail. They guarantee the free movement of goods, capital, services, and labour, known collectively as the “four freedoms” and a level regulatory playing field in areas such as  agriculture, fisheries, food standards and environmental policy. This is policed by the EU Commission and the EU Court of Justice. While this external regulation was an unacceptable pill to swallow for hardline Brexiteers, in the main it was judged as fairly objective, detached and objective legal process. But with the end of the Transition Period this framework will disappear.

    The four UK Governments up to now have agreed the need to for a collaborative approach to provide UK citizens and business with high and consistent standards in key areas such as the employment law, movement of good and people, environment and animal welfare. And there seemed to an acceptance to respect the devolution arrangements that have evolved within the UK over the last two decades along with a shared view on the need to develop “Common Frameworks” and dispute resolution procedures which provided for a parity of esteem and safeguards for all parties.

    But the white paper on The UK Internal / Single Market is a very much a “made in Westminster” document reflecting the ideological and policy preferences of the present Tory Government. And this lack of common and shared ground with the devolved administrations  has generated the hostile reception that it has received.

    At its heart the white paper proposals is a Westminster legislative route with the use of the courts as a means of dispute resolution. The lack of a clear process for the participation devolved administrations creates the risk that many areas of devolved policy could find themselves subject to the demands of the UK Internal Market. There is a lack of clarity about which matters should be left to market competition and which matters might be subject to regulation on social, public health or environmental grounds. These are essentially as much political issues as they are technical implementation processes. But where will the judgements lie?

    The risks are even greater as the UK Government itself will remain the final arbiter in international trade and treaties. As these treaties will be binding on all of the UK, the lack of a means to involve the devolved administrations could means – “Westminster rules, like it or lump it”. The track record of the Westminster Government of involving the devolved administrations in the Brexit process or even the response to Covid-19 does not bode well for any set of arrangements that are not copper-fastened by firm commitments to respect the devolution settlement in the UK and which work with the devolved administrations as equal partners.

    Seeking to address these concerns will overlap with the UK’s final departure from the EU regulation at the end of this year and will in turn run into next spring’s elections for the Scottish Parliament and Welsh Senedd. There they are bound to take on additional significance as voters will also be having an opportunity to also cast a judgement on the performance of Boris Johnson’s Tory administration to date.

    3 Comments

    The contact tracing programme in Wales is called “Test, Trace and Protect” (TTP) which emphasises the purpose of the exercise i.e to protect individuals, families and communities. This provides a better focus that “Test, Track and Trace” in England which seems to focus on the process rather than its purpose. The Welsh programme is firmly based on a partnership / public service model.

    The population of Wales is about 3.1 million people ( approx. 55.5 million in England ). The internal market have been abolished in the Welsh NHS over a decade ago. Health care is delivered through seven unitary health boards ( and specialist health trusts for cancer and ambulance service). The health boards are responsible for the planning and delivery of primary and secondary services within their population footprint. There is no “payment by results”.

    The health board geographical footprint is co-terminus with about 2-5 local councils. Partnership working between health boards and local authorities is delivered by Regional Partnership Boards – with improving, but variable, success.

    Public Health Wales covers all of the country. There are public health practitioners attached to each health board though there is some criticism that the service is over-centralised. Local authorities are responsible for Environmental Health.

    The care sector operates on a similar basis as England though means testing for services is more generous in Wales

    With the outbreak of Covid-19, the Welsh Government supported a four nations UK response. Along with all the administrations across the UK it went into “lockdown” at the same time. But has time has gone on it has taken a more cautious and distinctive approach compared to the Westminster. This approach has fairly substantial support in Wales.

    From the start the Welsh Government sought to mobilise a co-ordinated public sector response to the pandemic along with the voluntary sector. Support from the private sector was sought in the supply chain in areas such as PPE but otherwise scarcely involved in direct clinical or health roles.

    Public Health Wales, along with some health board and university capacity, was responsible for the initial testing regime. At first the Welsh Government chose not to avail of the private sector led Lighthouse Testing programme that was being launched in England until it could guarantee the results of the testing was made available.

    Like the rest of the UK, Wales had a hesitant start to the TTP process but things have now settled down. The service delivered on a three tier basis – national, regional and local.

    The Welsh Government and Public Health Wales are main players at a national level. They set out the broad framework, set standards and provide professional advice. There is a single national IT platform which felicitates the TTP programme. This allows a national overview and more coherent understanding of what is happening.

    Public Health Wales also provides the main testing facilities with some use being made of health board capacity and the Lighthouse laboratories. The present testing capacity is about 20,000 tests per day with about 5k being sourced via the Lighthouse capacity. However this capacity has never come close to being called upon with 3-5,000 tests typically done daily. About 50% of test results are available in 24 hours and 85% in 48 hours. The delays mainly arise in tests being undertaken in north Wales but this should be addressed as new capacity is being put in place to locally serve north Wales.

    The regional tier is co-terminus with health board boundaries and involves the health board and its partner local authorities along with input from Public Health Wales. The region supports and co-ordinates the local delivery of the programme. It also provides step-up and advice and support for front line workers.

    The health boards are now responsible for the setting up the testing services across their patch. These samples are taken and transferred on to Public Health Wales ( or the other involved laboratories) to undertake the tests. The test results are usually texted to patients. There in on-line access to the test service.

    The local tier provides the front-line contact tracing service through local government Environmental Health officers and local government employees who have been transferred from other duties due to the pandemic. Some teams will also have some health authority staff. The tracing teams operate roughly at a Upper Super Output Area level (about 30-50,000 population). There are about 600 workers involved at the moment but is possible that 1,600 may be required depending on the level of demand.

    In Wales, during the period from 1st June to 21 June, 1,905 positive cases were referred to local and regional contact tracing teams. This is now down to about 100 referrals per week.

    At the moment over 85% of index cases have been contacted by these local contact teams with over 90% of contacts have been reached and advised. The local knowledge of the contact tracers is felt to be an important advantage in delivering the programme. As well, local government’s involvement allows for the provision a range of local support services where needed.

    Prior to the launch of the main contact tracing programme the Welsh Government undertook a pilot exercise to across different parts of the Wales to identify potential problems. This has allowed the main programme be launched fairly smoothly.

    To the middle of July the number of fatalities in Wales is in lower single figures with no deaths on some days – down from a daily peak of 43 in early April. There are less than 30 new cases daily a reduction from a peak of 391.

    Plans are also being developed to boost the Welsh GP viral surveillance programme with the target of covering 20% of the population. This should provide improved sero-surveillance across Wales to provide an early alert system as we face the risk of a second wave of Covid-19.

    Compared to some other parts of the UK, the Welsh Test, Trace and Protect scheme has attracted public confidence and support. The Welsh Government aspires to eradicating the virus as far as is possible but it recognises that its long, much used border with England means that not all the necessary levers are at its disposal. It also acknowledges that the lack of adequate welfare benefit support from Westminster for those who have to isolate due to Covid-19 infection or through being contacts is an avoidable vulnerability in the campaign to contain and eradicate the virus.

    2 Comments


    Today the Welsh Government updated its approach to easing of public health measures against the Covid-19 pandemic.

    The framework will help to determine when the strict stay-at-home restrictions can begin to be relaxed in Wales and will help to find a way for people in Wales to live and work alongside coronavirus.

    A Wales-wide programme of surveillance, case identification, and contact tracing is being developed through the office of the Chief Medical Officer, Dr Frank Atherton. This will highlight the importance of community testing and support the containment of emerging coronavirus infections as and when restrictions are eased.

    Launching the framework, the First Minister, Mark Drakeford, said:

    Our approach to date has been one of lockdown. We have taken unprecedented steps to protect everyone, but particularly those most at risk from serious illness.

    This has helped the NHS prepare and cope with coronavirus and, even though we have sadly seen more than 640 people die, it has helped to save many more lives. But this strategy comes with its own costs to people’s wider health and wellbeing and long-term costs to our economy.

    We are keeping these regulations under constant review. We know coronavirus will be with us for a long time yet but we want to see whether there are things we can do while we continue to tackle the virus and while the search for better treatments and a vaccine continue.

    The framework – and the seven questions – will help determine when the time is right to relax some of the stay-at home regulations.

    The seven questions are:

    Would easing a restriction have a negative effect on containing the virus?
    Does a particular measure pose a low risk of further infection?
    How can it be monitored and enforced?
    Can it be reversed quickly if it creates unintended consequences?
    Does it have a positive economic benefit?
    Does it have a positive impact on people’s wellbeing?
    Does it have a positive impact on equality?
    The Chief Medical Officer for Wales’ office has developed the Wales-wide programme of surveillance, case identification, and contact tracing.

    It will have four main strands – improved surveillance of cases of coronavirus; effective identification of cases and contact tracing; learning from international experience and engaging with the public.

    Dr Atherton said:

    Action to ease the lockdown restrictions will need to be supported by a comprehensive public health response, which will need to developed quickly and at scale.

    Across the UK, we have worked and put in place unprecedented measures to contain and delay the spread of coronavirus. We have also worked to reduce the overall impact of the virus by strengthening essential services, including healthcare.

    We are now working towards a new recovery phase to lead us out of the pandemic but only when the conditions are right.

    The First Minister added:

    Coronavirus is not going to disappear – it is likely it will be with us for a long time. We will need to have some sort of restrictions in place for some time yet to continue to control the spread of the virus and reduce community transmission. This framework will help us determine what is right for Wales.

    There is a long road ahead of us towards recovery to pre-pandemic levels, but if we continue to work together, I hope we will be able to make changes to the restrictions and see a gradual return to something resembling normal life.

    The Welsh Government has worked closely with the rest of the UK throughout the pandemic and has shared the development of the framework with the Scottish, Northern Irish and the UK governments.

    Comments Off on WELSH STEPS TO EASE COVID-19 PUBLIC HEALTH MEASURES – UPDATE

    A Healthier Wales (June 2018) is the Welsh Government’s response to the  Parliamentary Review of the future of Health and Social Care in Wales. It promises a programme of transformative whole system change with a move to a service that focused on health, well-being and prevention – a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality.

    A key part of the this transformation will be delivered through local primary and community care clusters working with both Local Health and Regional Partnership Boards. There will be a shift in services from general hospitals to regional and local centres with primary and community care delivering a expanded range of professionally led services. In October 2019 the Wales Audit Office (WAO) published Primary Care Services in Wales which evaluated progress with a particular focus. on strategic planning, investment, workforce, oversight and leadership, and performance.

    The WAO report acknowledges the work that the Welsh Government and NHS Cymru is doing to achieve the level of transformation that is needed. A National Primary Care Board and a National Director has been appointed to provide a focus and impetus to drive this agenda forward. A Primary and Community Care Development and Innovation Hub has been formed with the support of Public Health Wales which is also providing guidance to improve clinical network governance. And at health board level designated directors or senior operating officers provide a lead for primary care with work being undertaken to develop a national evaluation framework which can be used to measure progress at a local level.

    These initiatives have been supported by a number of funding streams that operate at all levels in Wales from the National Transformation Fund and the Integrated Care Fund to a National Primary Care Fund. These resources are allocated in a variety of ways including to clinical networks and practices to promote change and innovation including “pathfinder” and “pacesetter” projects operating at a grass roots level.
    But despite all of this the WAO concludes that change has not happened as quickly or as widely as intended and has outlined a number of reasons why this has not happened. This is acknowledged in the Welsh Government’s own National Integrated Medium Term Plan (2020-23)

    A key component of the Healthier Wales approach is The Strategic Programme for Primary Care was launched in November 2018. It is based on the new “Primary Care Model for Wales”. This outlines what it  regards as the main components of a good primary care system. These key components include informed and empowered citizens, self-care, stronger community services, new first points of contact for patients including triage to ensure they are seen by the appropriate healthcare professional, better urgent care arrangements and stronger multi-disciplinary working.

    There is much to commend in this New Model but the WAO points out that it has emerged with little public consultation. This lack of debate and discussion means that in many respects there is a lack of clarity as to the purpose and direction of the New Model.

    In the “old model” GPs were the initial point of contact and gatekeepers for virtually all other health services. In the New Model the GP will continue to provide the first port of call for some patients but many patients will also be able to directly access many alternative community based professionals, thus freeing up GP time to see the sickest patients and those with complex chronic conditions. These alternative practitioners will include pharmacists, physiotherapists, opticians, dentists and members of mental health teams.

    The emergence of this New Model seems to be driven by necessity and is a pragmatic response to the sustainability challenges facing general practice rather than an evidence based evaluation of the key elements that a holistic general practice and primary care service would require . This sustainability challenge is caused by the combination of the growing workload in general practice, changing work and contractual patterns as well as signficant recruitment difficulties.

    This New Model is intended to provide improved access “to services”. This is bound to be seen as preferable to having no access at all but of itself it may not be the most optimal configuration or care pathway. This range of “front doors” into the health service will inevitably lead to discontinuity of care, fragmentation and a lack of co-ordination.

    Continuity of care is a key characteristic of quality primary care. It has two mail elements, horizontal continuity as a patient / service user utilises a range of services as part of a holistic response to their needs and longitudinal continuity based on ongoing personal care is delivered over time. Both are important but the former seems to have primacy in the current articulation of the New Model.

    Delivering horizontal continuity depends on having good team work supported by an infrastructure that goes with the grain of seamless care across professional and organisational boundaries. This will require health and regional partnership boards as well as local clinical networks working more effectively together supported by shared personal care records and a robust IT system.

    Longitudinal continuity and quality care is built on long term personal relationships. But these relationships will struggle to develop and mature if patients and service users face a variety of diverse professionals whenever they attempt to use the service. “Time” is at the heart of these relationships both in terms of having the time to listen and work with patients in line with their needs and also it is only over time that a continuing personal,professional relationships can be built.

    General practice is under continuing and unsustainable pressure but despite this the workforce is not increasing in line with need and list sizes are static. This, in part, explains the pressure to promote the New Model of primary care but that will never be an adequate solution without a substantial increase in crucial front line workers particularly GPs. The Welsh Government has launched a number of initiatives to increase GP numbers including a welcome increase in training posts  but neither it or the WAO seem to be willing to move much beyond the traditional parameters of the solutions being offered by the medical “establishment” such as GPC Wales or the RCGP.

    There are between two to three dozen health board managed practices in Wales as well as 778 sessional / “locum” GPs working alongside 1,964 GPs principles. But despite this large salaried GP workforce there is no overall strategic policy in place to promote their professional development or retain them in clinical practice. Initiatives such as the establishment of a GP Locum Register are a step forward but much more needs to be done in the face of the evidence that the independent contractor option is no longer the preferred model of work by very many GPs.

    Already the Auditor General for Wales pointed out that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years has not being achieved. If the changes that the Welsh Government and NHS Cymru have put in place do not achieve a  rebalance in resource allocation then little new will happen. In addition the WAO also expressed concern at the lack of transparency in the way that primary and community care is funded. This makes it very difficult to monitor any real shifts in resources is taking place with is a precondition to achieving transformational change.

    Apart from the reasons outlined in the WAO report there are additional problems in monitoring where NHS resources are actually allocated. The creation of larger health boards in Wales in 2009 has meant that a certain level of sensitivity has been lost allocating resources. The Welsh Government’s commitment to clinical networks, which cover about 50,000 people, is an opportunity to address this loss of sensitivity as well as providing a more meaningful population size to monitor health inputs and outcomes.

    Over recent recent years health and social care spending has has increased between 4.5 – 6% which is generous compared to the pressures on the overall Welsh Government budgets. These increases must be used to provide the headroom for a meaningful transfer of resources towards primary and community care. As the WAO suggests a transparent framework is needed to monitor this transfer.

    This framework should include a rapid move towards a 10% allocation of NHS resources to primary care services. This should be linked to the creation of at least an additional 200 GPs in post in Wales as a matter of urgency so that average list sizes will be reduced to Scottish levels with more easily accessible time being available for patients.

    Health boards and clinical networks, working with Public Health Wales, must monitor where these resources go locally to ensure that there is a clear focus on addressing health inequalities and the Inverse Care Law.

    Primary health and community care teams must be strengthened both address current health and care needs both at the individual and wider community level. And where traditional models of delivery, such as the independent GP contract, are failing to deliver, health boards must take direct responsibility. Progress cannot be held back by the speed of the slowest.

    The latest NHS Planning Framework (2019-22) specifically asks that health boards should place a particular emphasis on prevention, reducing health inequalities, the new Primary Care Model for Wales, timely access to care and mental health. However it does so at a fairly high level and only give very broad indications as to what it expects it health boards to deliver. In this context, the WAO report’s recommendation of a more explicit accountability framework should provide for greater focus and accountability.

    In a Healthier Wales the Welsh Government expected to demonstrate early impacts over three years. We are already half way though this time frame and, as the WAO report shows, much more now needs to be done to deliver against that ambition.

    5 Comments

    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.

    Comments Off on WELSH GOVERNMENT ANNOUNCES INCREASED GP TRAINING PLACES

    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.

    Comments Off on WELSH GOVERNMENT INVESTMENT IN GENERAL PRACTICE

    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.

    3 Comments

    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.

     

    1 Comment

    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.

    Comments Off on PLANNING IN THE WELSH NHS

    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

    2 Comments

    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.

    Comments Off on Will Parliamentary Review Deliver Major Change in Wales?

    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

    2 Comments