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    The Welsh Government is proposing to use its legislative powers to require local authorities and Local Health Boards to  produce a market stability assessment report on the social care sector  in their Regional Partnership Board (RPB) area.

    The legislation will be supplemented by a code of practice on the exercise of relevant functions in relation to market stability reports and statutory guidance on taking a partnership approach to preparing and publishing market stability reports.

    This innovative piece of legislation is welcomed by the Social Health Association Cymru – Wales which has responded to the Welsh Government consultation document.

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    Response to Welsh Government Consultation by Socialist Health Association – Cymru / Wales


    What do we want to know? Welsh Government would welcome comments on the draft regulations, code of practice and statutory guidance from local authorities, local health boards, and other organisations or sectors which are represented on RPBs or have an interest in the provision of care and support to the local population.
    It would also welcome comments from members of the public, including especially individuals who need care and support, and carers who need support. In particular, we would welcome responses to the following questions:


    Question 1 Do you agree that market stability reports should be prepared on a regional basis, by local authorities and local health boards through the regional partnership boards? If not, please give your reasons.

    A.    The Socialist Health Association Cymru believes that the business model underpinning our social care service in Wales is no longer sustainable and we need to be planning for a National Care Service.

    The independent sector continues to express concern about its marginal viability with residential care providers requiring levels of bed occupancy that go against the Welsh Government’s policy of more care in a domestic and homely community environment.

    There is a recruitment and retention crisis which is worse in the independent sector due to poorer pay and conditions, less training and fewer opportunities for career progression.

    Within this context we believe there is an urgent need to undertake regular assessments of the continuing viability of the current model of provision.

    While the consultation document proposes reports on a regional basis, it important that the geographical spread of provision in mapped at a more local level.


    Question 2 Do you agree that market stability reports should be produced on a five yearly cycle alongside the population needs assessments? If not, what alternative arrangements would you propose, and why?

    We note that the proposals recommend that a five year assessment cycle with at least a mid-cycle interim review.

    A.   We believe that the overall fragility of the sector requires a three yearly overall assessment with a yearly review.


    Question 3 Have we specified all the key matters that need to be included in market stability reports? If there are other matters you think should be included, please specify.


    A.   While we are fully aware of the sector’s legacy of being heavily dependent on for-profit providers, we are surprised at the failure of the consultation document to consider what role public bodies might play in service provision. This is only briefly mentioned in the context of a sudden closure of an established private sector provider.

    The omission is all the more surprising as it recommended that the assessments should be linked the to Regional Partnership Board needs assessment.

    The implicit assumption is that local authorities will have no role in the management or shaping of the market beyond its present contract compliance assessments. This means that it will be for others to address gaps in service provision.

    The variation in local authority fees across is Wales in considerable. It is far from clear why this is the case though these fees are at the heart of any assessment of the viability of the sector.

    Question 4 Do you agree that market stability reports should be kept under regular review and revised as necessary, but at least at the mid-way point of the five year cycle? If not, what other monitoring and review arrangements would you propose, and why?

    A.  See reply to Q2


    Question 5 In your opinion, does the draft code of practice strike the right balance between what is required of local authorities and what is left to their discretion? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    A.    The document urges “reasonable” efforts for community engagement. This is a rather elastic requirement which could result in a minimum level of engagement. It would be useful to be more specific that efforts should be made to engage with organisations such as the CarersUK, Stroke Association, Alzheimer’s Society, Mind as well as any successor organisation to Community Health Councils.

    There should be a specific reference made to any community councils in the Regional Partnership Board area.

    There only the most fleeting reference to engagement with care staff and other support / partnership professional groups. There should be a clear requirement to engage with local trade unions involved in the Education, Health & Care Sectors e.g. Unison, GMB Unite the Union, RCN, NEU and Local Medical Committee. In some areas, where there may be low levels of trade union membership, the local trades union council ( if it exists) should be consulted.

    Local groups of faith should also be specifically included in any engagement. They provide comfort and support to many of our citizens in times of difficulty and they can have important insights into the needs for particular communities.

    Question 6 In your opinion, does the draft statutory guidance set out clearly the partnership approach that local authorities and local health boards should take in preparing their market stability reports? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    A.  See replies already given.
    The document mentions the need to anticipate trends but is rather limited in the scope of the horizon scanning it envisages. This is a vulnerable sector underpinned by a fragile business model. It follows that more vision is required in looking at delivery models of care e.g. more in-house provision by public bodies, the NHS or the Third Sector.

    Question 7 What impacts do you think our proposals will have on the duties of public bodies under the Equality Act 2010, or upon a local authority’s duty under the 2014 Act to have due regard to the United Nations Convention on the Rights of the Child, the United Nations Convention on the Rights of People with Disabilities, or the United Nations Principles for Older People?

    A.   This is a timely document and Welsh Government is to be commended in initiating this legislation. Not withstanding the attitude of the Westminster Government to international agreements the Welsh Government has always used best international standards to drive policy.

    A citizen focused, responsive, stable and caring service needs to be in place to meet international standards. This must include provision that is based on the needs and wishes of its users. The workforce must be well trained and valued.

    None of this will be possible if overall business model of care is not longer fit for purpose for the challenges of the 21 Century.

    Question 8 We would like to know your views on the effects that our proposals with regard to market stability reports would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    A.   This is particularly important. Bigger, footloose corporate bodies have a smaller footprint in Wales which is generally a good thing. Smaller, local providers with a local workforce are more likely to be culturally sensitive to their needs of citizens.

    In many parts of Wales the local population will include people who have spent most of their lives in an area and others who have moved in at various stages of their life cycle. Our providers must respond to this diversity.

    Many vulnerable users would wish to engage with services in their first language. The planning and service delivery process must be responsive to this need.

    The Welsh language is an important part of Welsh life. As well, individual communities have other cultural attributes which can provide support and comfort to local service users which should also be factored into a citizen centred service.

    Question 9 Please also explain how you believe the proposed policy around market stability reports could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    A.   See Q8.

    Market stability reports should include a specific section demonstrating how the needs of Welsh speakers and other sensitive cultural dimensions are taken into account.


    Question 10 Under the Well-being of Future Generations (Wales) Act 2015, public bodies have a duty to consider the long-term impact of their decisions. We would like to know to what extent you think our proposals will support the principle of sustainable development set out in that Act. Further information on the Well-being of Future Generations (Wales) Act 2015 may be found here: https://www.futuregenerations.wales/about-us/futuregenerations-act/

    A.   Our health and care service is still too illness and crisis orientated. It needs to be more pro-active and enabling for all our citizens.

    Beyond the immediate pressures of Covid-19 and the longer term legacy we have inherited, the Welsh Government needs actively to promote a policy of prevention and early intervention to create a more equal and socially just society that is at ease with itself.

    This includes providing our young people with the best start in life, providing all citizens with the opportunity to live full and enjoyable lives and providing a healthy ageing strategy including tacking loneliness and social isolation for citizens as they progress through life.

    Question 11 We have asked a number of specific questions. If you have any related issues which we have not specifically addressed, please use this space to report them. Please enter here.

    A.   SHA Cymru welcomes this proposal to assess the inputs into service provision other than in crude quantitative ways. This approach could be extended to other field of policy e.g. to assess the scope and scale of service provision in different communities and localities.

    Our Chief Medical Officer has often pointed out that “one size does not fit all”. Different communities have different needs. If we are to address these varying needs at a community level we need to develop processes which could be informed by the lessons learned from implementing this legislation.

    Comments Off on ASSESSING THE VIABILITY OF THE SOCIAL CARE SECTOR — Response to Welsh Government Proposals


    The current business model for social care in Wales, like the rest of the UK, is under extreme pressure. This vulnerability has predated the present Covid-19 pandemic. Care Forum Wales, the main representative body for the private care sector, has claimed that Wales could lose half its care homes within a year unless urgent action is taken. A Care Forum Wales survey also reported that 84% of respondents said low pay made it difficult for the recruitment of staff. Responding to these long standing concerns the Welsh Government commissioned the Welsh Institute for Health and Social Care to study the variation in terms of employment in the social care sector in Wales.

    The study looked at the comparative experience of various social care sectors in Wales including local authorities, independent sector and the NHS. There were (2017) approximately 1350 providers in the independent sector with a workforce of 52,500 and 130 local authority services with a workforce of 11,000. While the study showed variation within sectors there were also important overall differences between the sectors which could account the differing sectoral work experiences.

    The median minimum basic pay for front line independent sector care workers was 18% less that for local authorities (£9.74/hr) and 9% for NHS. The differences for maximum basic pay were 32% less for independent sector workers compared to local authority staff (£11.88) and 18% less for NHS health care support workers. Independent sector care supervisors received 32% less in their median minimum basic pay compared to local authority supervisors (£13.37/hr) and 78% in their median maximum basic pay ( LA supervisors £18.03/hr) . In addition the public sector workers were much more likely to receive pay enhancements for pensions and activities such as weekend shifts, holiday cover and over-time.

    Compared to 55% of independent sector front-line workers about 25% of local authority staff were in permanent full-time employment while 23% in independent sector were permanent part-time posts compared to 51% in public sector. However there were less differences in more senior posts across the sectors. About 20% of front-line care workers across the independent, local authority and NHS had the equivalent of zero hours contracts. There was some evidence that not all staff were unhappy with the relative flexibility these contracts provided.

    The report confirmed that recruitment, retention and staff turnover is a problem for the sector as a whole. While all had concerns about the recruitment and retention of staff this was greatest in the independent sector. These problems were less in more senior staff positions and overall there was a greater problem in recruiting staff compared to retention. While the independent sector felt it was in competition with local authorities for staff, both felt under pressure from the NHS and outside sectors such as retail. As well there were geographical variations with rural areas having less problems that more urban ones.

    While pay was an important factor other issues such as the status of social care, work pressures and responsibilities were felt to barriers to recruitment and retention. On the other hand the caring and pastoral aspects of the work were valued by the staff and contributed to them staying in post in despite the poor levels of pay.

    The Welsh Government has responded to some of the problems in the sector with others more difficult to address due to ongoing austerity policies and the continuing failure of the Westminster Government to live up to its promised on producing a comprehensive set of proposals to deliver a quality, affordable social care service.
    In order to improve the skills and status all all staff care staff will be expected to be registered with Social Care Wales by 2022. Once they have been in employment for more than three months care staff will have the right to choose between a defined hours or “zero hours” contact. And last year (2019) the Welsh Government supported “We Care” a campaign and on-line portal to support social care recruitment.

    In the Covid-19 pandemic care staff were provided with a £500 grant in recognition of their work by the Welsh Government. However despite declaring its commitment to the workers in the sector, the Westminster Government refused to exempt the bonus from stoppages such as taxation and NI contributions.

    It is clear that most of those who work in the sector are committed to their job and value its humanitarian values even above pay. An unemployment fall-out from Covid-19 might provide some easing of recruitment and retention difficulties but this cannot be seen as a sustainable solution. More comprehensive measures are needed.

    For decades social care has been provided on the cheap with the cost, in the first instance, being borne by staff in terms of their pay, work conditions and their opportunities for career progression. This downward pressure was driven by the policies of out-sourcing and tendering and an under-valuing of the public sector. But this policy has more or less come to the end of the road.

    The Welsh Government realises this and has commenced a consultation process on legislation that will require local authorities and health boards to regularly assess the financial sustainability of the care sector in their catchment areas. This should provide important information to inform the future shaping of local social care services.

    But we need to do more. We must start looking for more radical solutions within the overall context of a National Care Service. As a first step domiciliary care services should be brought back into the public service as their contracts lapse. And we then need to see how this option can be extended to all other workers in the sector.

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    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.

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    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.

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    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.

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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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