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    Through the decade of austerity, the Welsh Government is to be commended for its efforts to maintain the sustainability of our social services, in contrast to other parts of the UK. Socialist Health Association – Cymru (SHAC-C) welcomes the initiatives to promote greater joint working with other key agencies such as the NHS, housing, and education. The cap on the costs of domiciliary care and the increased thresholds for residential care provides Welsh residents with a more generous provision than elsewhere.

    We also welcome the proposals to improve the status of the social care workforce through its increased professionalisation and to seek remuneration solutions through the Social Care Forum. The initiatives to reduce the prevalence of zero hours contracts and to enhance the choice of the care workforce should help to bring some stability to the sector.

    Innovative initiatives such as the Children’s Commissioning Consortium Cymru has provided a strategic response of humanely addressing some of the most difficult challenges in Children’s Services provision.

    During the Covid-19 pandemic the Welsh Government recognised the vital role of its public sector partners as being pivotal in its response rather that embark on a wasteful and incompetent embracing of the private sector. It acted quickly to learn important early lessons by intervening to provide care home providers with personal protective equipment and to institute a regular programme of staff testing.

    In this period of crisis, partnership working across organisational boundaries happened to an unprecedented extent. It showed what is possible – with proper leadership and the political will to make things happen. These achievements were on a par with those inspired by the “Spirit of 45” which followed WW 2.

    SHA Cymru fully supports the Welsh Government’s £500 bonus payment to our frontline social care staff. It is a pity that the UK Government did not have the generosity of spirit to reciprocate.

    Despite these commendable policy initiatives, SHA Cymru feels the consultation underestimates the scale of the challenges that the social care sector faces. The present substantially privatised provider model is in crisis at all levels from children’s services to services for older people. It is not at all clear what are the continuing advantages of this model. There is an underlying premise that it is possible to achieve the necessary improvements in quality through commissioners purchasing and procuring services from non-public services bodies.

    Social care should not be a market. The approach of ‘switching suppliers’ may work for consumers of electricity, but it doesn’t work for social care. It does not matter who provides your electricity, the product is the same and it is just a matter of price. It does matter who provides your social care. Who delivers the care can determine what care is given.

    The NHS was conceived as a national service, designed to meet the health needs of both individuals and communities. Provision was rationally planned and provided. Individuals accessed it when needed. Their needs were not assessed and then the market searched for the product. This is very much the “for profit” and insurance model where you justify your claim in line with means testing and eligibility criteria.

    In the past a combination of pro-market ideology and determination to drive down costs was the rationale for the current model. As time has gone on it is becoming increasingly obvious that there is a price to be paid for this dogma – in terms of quality of care, workforce retention and training as well overall sector stability. SHA Cymru welcomes the view arising from the two-year review of A Healthier Wales that further work will be done to…” rebalance social care and address the barriers which have made it difficult for the public sector and not-for-profit organisations to be major providers of care.”

    We accept that there will be an element of disruption if there was a precipitate switch to a public service model of care. However, we believe that this can be done in stages e.g., i) establishing national terms of service for care staff ii) national fee structures iii) taking domiciliary care services in-house and remodelling others into mutual/social enterprises iv) provision of new all-life housing as an alternative to residential care in advance of any wholescale transfer of residential care provision.

    This consultation document recognises that the market is not working. Its responses are substantially proposals to re-shape the market. SHA Cymru asks if it is time to consider alternatives to the market itself. We believe this, in line with a substantial investment, is the only way to address all key problems that this consultation is trying to address. The inherent tension between the use of the for-profit sector to deliver public services is threatening the quality of care for service users and is undermining the attainment of the employment environment which the consultation wishes to achieve. In the event of market failure, it is the public sector that must pick up the pieces.

    SHA Cymru supports the establishment of a National Care Service. This is the first step in addressing many of the consequences of the present fragmented provision model. This national model would have many of the features of the NHS which are so valued by people in Wales, but we do not support the “take over” of social care by NHS.

    Social care is a service which not only interfaces with health care, but it also interfaces with many other sectors including education, housing, the world of work and training, the welfare system as well as culture and recreation. Social care and its workforce have a different range of values and professional standards which do not readily fit with the mainstream medical model.

    A National Care Service must promote a more uniform set of standards of across Wales while recognising the diversity of our population and the diversity of its needs. These standards would include what citizens can expect from social care as well promoting a working environment that values the staff which will deliver the service.

    Such a service must be free at the point of use. The present means testing system is long out of date as it catches more and more people on relatively modest means into its clutches following the growth in home ownership since the 1980s. There is a strong view that those who pay for care also contribute a premium to make up for the inadequate levels of public funding and the consequences of a decade of brutal austerity.

    A reformed social care sector must be about more than structures and organisational boundaries. This is where the consultation document is weakest. The present market model of provision, linked to a decade of austerity, shapes what type of care is provided. Fewer people are being deemed eligible for more complex packages of care. Those who do not reach the threshold are obliged to fall back on their own resources and the resilience of their families, friends, and their communities where the root of the problem often lies in the first place. This is often falsely described as reducing unnecessary dependency and promoting the resilience of the care seeker.

    As social care is only fully accessed by people with increased complexities of care this place greater demands on service providers who are invariably operating on stand-still levels of resources.

    The service needs to be more citizen and user directed where co-production of provision is the heart of the assessment and delivery process. However, SHA Cymru has serious concerns about initiatives such as “direct payments” which have their own add-on costs, and which often operate on the fringes of poorly or self-regulated market.

    SHA Cymru strongly believes that obtaining any advantages and benefits of user directed care are entirely consistent with a public sector or mutual/social enterprise model of care. However, it will require resources and a culture in which the service user is the key architect of the service provided. In this new approach the work of social workers and other Allied Health Care professionals will be to facilitate and empower citizens rather than being constrained by eligibility and financial barriers on what can be provided. We need to move beyond a service in which the citizen receives what is defined by a range of eligibility criteria and means testing to one that is based on a holistic assessment of their needs.




    SOCIALIST HEALTH ASSOCIATION CYMRU
    Response to individual Questions.

    Summary of the consultation questions The Welsh Government welcome comments on all aspects of the proposals. We are particularly interested in responses to the questions. A summary of the questions is provided below.

    Question 1: Do you agree that complexity in the social care sector inhibits service improvement?

    Yes.
    The complexity and inefficiencies of the market exists at many levels.

    Service users.
    1. Services users are subject to a needs assessment which is often predicated on seeking ways to delegate caring duties to the applicant, their family, or friends.
    2. Financial constraints may curtail the delivery of a fully holistic care package.
    3. Applicants are subject to a financial assessment which can be difficult and obtrusive.
    4. The lack of staff continuity means that service users must deal with a series of different carers.

    Commissioning Process.
    1. There is a multiplicity of providers of social care, usually in the for-profit sector. This involves additional and unnecessary transactional costs. This is further complicated by additional costs when a “self-funder” must be reassessed having dropped below the various capital thresholds.
    2. There is continuing confusion between paying for “social care” and “continuing NHS care (which is free).

    Cross Organisation Boundaries.
    1. We welcome efforts to promote integrated joint working via Regional Partnership Boards and through funding streams such the Integrated Care and Transformation Funds. However, all these arrangements are not without their problems though they have made an important contribution to joint working.

    The lack of clear mechanisms to identify, allocate and share budgets is a significant obstacle to joint working.

    Joint working on the front line is facilitated by putting a “face to a name” and building trust. The relationships built during the present Covid-19 crisis bears this out. In “normal times” it unusual for front line workers in social care, housing, education, and the NHS to build up a relationship based on joint working – they do not know each other, they work for different organisations with different priorities, and they do not share a common workspace.

    Question 2: Do you agree that commissioning practices are disproportionately focussed on procurement?

    Yes. Except that the extremes, price will always trump quality.

    SHA Cymru strongly believes that the number of people who obtain services and what services are provided are curtailed by financial constraints rather than by full needs assessments. This also applies to unpaid carers.

    We accept that austerity is a major obstacle to commissioning for quality when resources are extremely limited, and need is increasing.

    Also, it is difficult to measure quality as opposed to measuring a failure of compliance which is set out in rules, standards, and regulations. There needs to be better ways of capturing the lived experience of the service-user, their carers, their parents, and their advocates.

    Question 3: Do you agree that the ability of RPBs to deliver on their responsibilities is limited by their design and structure?

    Regional Partnership Boards are a step in the right direction. The Welsh Government must do more to promote their importance and profile.

    However, most of the organisations that are involved still have a limited commitment and retain a strong territorial loyalty to their parent bodies. Competition for funding and resources is a major obstacle to joint working.

    The governance arrangements for the RPBs are totally opaque and SHA Cymru suspects that their existence is only known to a small number of people in the NHS, local government, Third Sector, and public bodies such as NRW.

    The RPB needs assessments and the strategic responses that they generate are not major priorities for most of the constituent bodies. They are more exercises in compliance that an engine for change and delivery.

    We believe that RPBs could enhance their role and effectiveness by being a catalyst and conduit of best practice within their region and elsewhere.

    Question 4: Do you agree a national framework that includes fee methodologies and standardised commissioning practices will reduce complexity and enable a greater focus on service quality?

    Question 4a: – What parts of the commissioning cycle should be reflected in the national framework?

    SHA Cymru supports a National Care Service in Wales in which citizens have a reasonable understanding of what they can expect from their social care service. However, this national service must reflect the diversity of need and culture in the various parts of the country.

    We support the creation of a national social care workforce for Wales rather than the infinite variety of current employment practices and standards. This will ensure a uniformly trained workforce with national terms of service. As staff pay is the single biggest cost in the sector this will remove a lot of the fog that surrounds fee setting now. This will simplify the commissioning process and reduce its inefficiencies.

    We also welcome the Welsh Government’s proposals for regular sector viability assessments. This will be an important mechanism to align capacity with need. However, we are disappointed that these proposals are not linked with policies to promote direct public sector provision where local needs are not being met.

    The commissioning process must seek to identify unmet and unfunded need. This will provide important information for future planning cycles.

    Question 5: Do you agree that all commissioned services provided or arranged through a care and support plan, or support plan for carers, should be based on the national framework?

    Yes. However, this does not mean a one size fits all provision delivered in any colour providing it is a bland white!

    In health and education people have a reasonable understanding of what to expect across Wales. There is no reason why the same should not apply in social care. Indeed, the co-payment element in social care makes this more important. We welcome the Welsh Government cap on the cost of domiciliary care and the increased thresholds for residential care.

    Care plans must be co-produced with the service user and their carers rather than provided within constraints and obfuscations of means testing and eligibility barriers.

    Question 5a- Proposals include NHS provision of funded nursing care, but do not include continuing health care; do you agree with this?

    Without understanding the historical context, the present system is totally incomprehensible to the average citizen. There is no sense that one person gets a “free NHS bath” while someone else has to pay for a “social care bath”. Equally there is no logic that a person with a chronic illness such as cancer gets a free service on the NHS while those with dementia must pay for most of their care via social services.

    These arrangements fly in the face of the Welsh Government’s commitment to user centred and integrated care.

    Question 5b- Are there other services which should be included in the national framework?

    As mentioned in our introduction we believe that in a National Care Service there should be national standards of care, national eligibility criteria for services, national means to promote co-production and citizen led services and national terms of service for staff.
    Question 6: Do you agree that the activities of some existing national groups should be consolidated through a national office?

    A National Care Service needs a strong sense of national purpose for social care. The concept of a “national office” fails to capture this vision. SHA Cymru believes that we need a national executive or directorate to drive forward many of the objectives outlined in the consultation document. The executive / directorate should have a clear mission to develop a quality, coherent service across all of Wales.

    In a National Care Service in Wales many of the present “bolt-ons” should be integrated into a single cohesive organisation. However, the specific specialisms of the individual services need to be recognised and provided for.

    Question 6a- If so, which ones?

    While we support an overall National Care Service, the regulatory and inspection roles should be independent and seen to be independent. We welcome the integration of NHS and Social Care complaints processes on an independent basis from the NHS and local government.

    Question 7: Do you agree that establishing RPBs as corporate legal entities capable of directly employing staff and holding budgets would strengthen their ability to fulfil their responsibilities?

    Yes. SHA Cymru would welcome the establishment of the RPBs as corporate legal entities. Now they exist as a gift provision by their component bodies. This deprives them of the status or capacity to plan the delivery of integrated services across organisation boundaries.

    There must be mechanisms to allocate resources to the RPBs for both their own administrative / management purposes and to have the means to fund integrated cross boundary services. We note the references in the consultation document to experiences in the other parts of the UK in relation to integrated working.

    We believe that there are valuable positive lessons from the Scottish experiences. On the other hand, we would advise caution about replicating the main English direction of travel – which is deeply contaminated by serious under-funding and commercialisation of services.

    Question 8: Do you agree that real-time population, outcome measures and market information should be used more frequently to analyse needs and service provision?

    Question 8a- Within the 5-year cycle, how can this best be achieved?

    The Financial Crisis of 2008, Brexit and the Covid Pandemic of 2020 show how vulnerable long-term planning is to unforeseen events. Any planning cycle must be flexible enough to adjust to such shocks.

    However, we also realise that strategic change cannot be delivered on short time scales. The NHS process of in-built short- and medium-term reviews within a long planning cycle has a lot to commend it.


    Question 9: Do you consider that further change is needed to address the challenges highlighted in the case for change?
    Question 9a- what should these be?

    The consultation document has presented itself with a range of almost irreconcilable ambitions.

    For the immediate future we are likely to face continuing austerity. We welcome the Welsh Government’s commitment to continue to lobby and use its good offices to urge the UK Government to deliver on its decade old, and much delayed, pledge of addressing the challenges of social care. If these efforts are not successful, many of the consultation paper’s objectives will not be achievable.

    A shift toward “commissioning for quality” is highly commendable, but the road to achieving this is littered with obstacles and potholes. The sector itself is in a highly fragile state bordering on unsustainably. At a very minimum, a quality service requires a valued, stable, and well-trained workforce. All these requisites are at the mercy of the variability that is inherent in a multi-provider for-profit model for care delivery.

    Unless there is a way of addressing current financial pressures then the present trend of ever higher eligibility criteria will mean fewer and fewer people will be in receipt of care. As need is inevitably going to increase it will mean that more and more of people will be left to live deal with their problems by whatever means they can muster.

    Question 10: What do you consider are the costs, and cost savings, of the proposals to introduce a national office and establish RPBs as corporate entities?

    See the answers to Q6 and Q7 above.

    Question 10a- Are there any particular or additional costs associated with the proposals you wish to raise?

    We accept that a quality social care service will cost money.

    We note the work that is being done on a social care levy and we wait to see its outcome. However, any market-based funding system will be subject to major shocks – we have seen three since 2008 – and we wonder how resilient they will be in the long run. Very few insurance based public services have been sufficiently resilient to survive without state interventions and guarantees.

    Welsh language

    Question 11: We would like to know your views on the effects that a national framework for commissioning social care with regionally organised services, delivered locally 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?

    It is essential that social care services should be delivered bi-lingually. This is crucial across all age groups from children’s services to services for vulnerable older adults. Equally the right for people with learning and physical disability to live their lives thought either Welsh or English must be fully recognised.

    The local needs assessments must take full account of the cultural values and diversity of the population it is assessing. Service providers must not regard responding to this diversity as an optional extra.
    Welsh and English have a particular standing in Wales. However, many other vulnerable people e.g., asylum seekers, refugees, migrant workers, and minority ethnic groups will have needs which a holistic service must strive to address.

    Question 12: Please also explain how you believe the proposed policy to develop a national framework for commissioning social care with regionally organised services, delivered locally 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.

    If “quality” is to be the key barometer of performance, then a citizen focused service that is planned and delivered in line with local needs can only promote Wales as a bi-lingual country. Most social care providers are heavily dependent on local people for service provision. This workforce will be familiar with local cultural values and norms. A secure, valued, and well-trained workforce can only enhance the quality of life of the citizens under their care.


    https://gov.wales/improving-social-care-arrangements-and-partnership-working

    Comments Off on REBALANCING SOCIAL CARE IN WALES — Response to Welsh Government White Paper on Social Care.

    Joint Authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.

    With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.

    Cultural change must precede structural change.

    The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.

    Facing up to the resource consequences

    It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.

    The review makes the following three recommendations;

    1. ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    1. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    1. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

     The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.

    The transformation process – from what to what?

    The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.

    These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.

    If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible.  Patients are aware, however, they may subsequently have a wait depending on availability of resources.

    Managing the resource consequence

    For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.

    The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.

    The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.

    The political consequence

    The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.

    That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.

    Implications for England

    We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.

    The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.

    The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.

    Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.

    Comments Off on Realistic hope for a Social Care system driven by Human Rights from Scotland

    In September 2020 the Welsh Government invited 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 Regional Partnership Boards (RPBs) or have an interest in the provision of care and support to the local population. RPBs are the main Welsh platforms of collaboration between health, social care, the Third Sector and a range of other key stakeholders.

    The Socialist Health Association – Cymru agreed its repose to the consultation questions as follows:-


    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.

    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.

    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.
    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?

    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?

    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?

    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?

    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?

    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.

    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/

    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.

    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.

    October 2020

    Comments Off on Social Market Stability in Wales — Consultation Response SHA-Cymru

    A recent study by the Bevan Foundation has called for the establishment of a “ Welsh Benefits System”. It found that over £400 million in welfare type payments are distributed by devolved bodies but that the system  lacks coherence and does not operate in a strategically focused way.

    Just over half of all public expenditure in Wales is undertaken by devolved bodies e.g. Welsh Government, NHS, housing, and local government. The bulk of the remainder is through welfare payments which constitute over one third of all Welsh public expenditure. While the overwhelming bulk of these these payments are administered and delivered by the Westminster government a relatively small element is delivered by via devolved Welsh public bodies. However in terms of Welsh social protection payments, the sum is not insignificant and it operates to complement the main welfare benefit system.

    These payments cover twelve different schemes which were included in the study. They include Council Tax Reduction Scheme, Free School Meals, Disabled Facilities Grants, Education Maintenance Allowance and Discretionary Assistance Fund. They all operate under their own rules with varying eligible criteria and administered through a range of separate organisations who have their own way doing business.

    In view of this the Bevan Foundation calls on the Welsh Government to review all of these payments with purpose of establishing a new “Welsh Benefits System” which would have a clearer strategic focus, be less complex, easier to access and be more consistent in its operation across Wales.

    It sets out five principles on how the system should operate:-
    • It should focus on households on low incomes, defined as being eligible for Universal Credit, and use the same criterion across all schemes.
    • It should provide cash or in-kind help that is sufficient to make a real difference to household incomes
    • It has a single point of access for several benefits, using online, phone or postal methods.
    • It is based on eligibility for and an entitlement to assistance, not discretion.
    • Applicants are treated with dignity and respect.

    At a time when we are facing into a period of increased unemployment and financial hardship these proposals need serious consideration. In addition they provide an important stimulus to a wider debate on whether other social protection payments should be devolved to allow the Welsh Government and other devolved bodies to develop a more coherent anti-poverty strategy in Wales.


    https://www.bevanfoundation.org/publications/a-welsh-benefits-system/


    Comments Off on A WELSH BENEFITS SYSTEM MAKES SENSE

    Attached is the advice / guidance just published by Public Health Wales’ TAC advisory group.

    It reports that infection and transmission rates are higher than previously thought, though the mechanism for this is not well understood.

    Preventive measures such as social distancing, hygiene, face masks for older pupils ( and encouraged in younger pupils) and ventilation must be instituted. Health education should promote good practice outside the classroom and school. The potential of asymptomatic testing should be considered.

    It argues that teaching is a low risk occupation and that school closures are a relatively weak anti-spread measure.

    In view of the negative impacts of school closures, it should be a very last resort.

    https://gov.wales/sites/default/files/publications/2020-11/technical-advisory-group-evidence-review-on-children-and-young-people-under-18-in-preschool-school-or-college-following-the-firebreak.pdf

    Comments Off on EDUCATION AND COVID ADVICE == WALES

    SHA Cymru fully supports the actions of the First Minister and the Welsh Government in their management of the current crisis resulting from COVID 19. During this time SHA officers have had opportunities to meet with a number of Welsh Ministers. We have been impressed with the sheer amount of work they are undertaking and by the collegiate and thoughtful style they have adopted.
    The decision-making process has been clear, evidenced based, and methodical. It stands in sharp contrast to the vacillation of the Prime Minister and his Cabinet. We take some confidence from this that Wales and its people will emerge from the pandemic knowing that the Welsh Government, using scientific evidence available to them at the time, aimed to reduce further significant loss of lives and huge damage to the Welsh economy.

    Any questions or comments to Tony Beddow, tonesue@aol.com

    2 Comments

    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.

    ================================================================

    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.

    2 Comments

    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

     

    1.   Background

     

    1. SHA Cymru Wales is pleased to take the opportunity to help shape Welsh Labour’s policies in regard to health and social care in Wales. Our submission is the product of discussions among SHA members in Wales facilitated via several Zoom sessions and exchanges between members of drafts of the emerging response. The contents reflect the views of our membership. Our membership consists of past and current NHS and care staff from a wide variety of health and care backgrounds and also others who have interests as both citizens and users of different parts of the health and care system in Wales, or who are interested in the politics of health and care, and in political discussion.
    2. The Party explained that the consultation document was finalised before Covid-19 arrived. It is clear that the pandemic has altered significantly the context in which Labour’s policy process now sits. Even though Covid-19 is still a major challenge at the time of writing this submission, SHA Cymru Wales believes that many of the issues arising from it are already clear (and are described in the “Independent Sage Report”). These are addressed in section B below which deliberately adopts a broader “emerging futures” perspective.
    3. Not only has the pandemic impacted on the way the care system now works and is likely to work in the future, it has also impacted more widely on society in terms of altered work patterns, the wider use of technology both inside and outside the care system, and of course upon the ability of the economy to resource public services to the level needed.
    4. Adding further to this new uncertainty is a pre-existing one of the consequences of the U.K withdrawal from the E.U. with probable changes to trade terms. Further the extent to which migrant labour will be available to support the health and care sector in Wales is already being adversely affected by the Immigration and Social Security Co-ordination (EU Withdrawal) Bill. The withdrawal – in particular its impact on food security, medicines safety and existing supply chains – must be fully assessed.
    5. Section C deals with the content of the Policy Document itself. Here members sense a persisting lack of momentum and capacity to deliver the key objectives outlined in “A Healthier Wales”. SHA Cymru Wales accept that a decade of austerity has been a major brake on improvements. Some progress has been made in terms of improved co-operation between health and social care at a local level with the establishment of the Transformation and Integrated Care Funds and increased training posts for a number of professions.
    6. Transformational change however is not taking place in terms of promoting public health and rebalancing the care system towards prevention, anticipatory care and a community/primary care based service.
    7. There have been a number of concerns expressed by the public about the quality, resilience, or consistency, of some clinical services in some parts of Wales. For example, hospital emergency services cherished by local populations are under threat and the reasons advanced for changes have not proved persuasive with the public. NHS in-house elective services struggled to treat patients within the target times set by Welsh Government before Covid-19. One Health Board depends heavily on the private hospital sector to undertake its elective work and is responsible for about 70% of all those referred by the Welsh NHS to private hospitals. Response times of emergency ambulances – often for reasons outside the control of the ambulance service itself -are sometimes longer than the service or ill patients would like. More widely there are some concerns about the resilience of the wider primary care services (including dentistry and pharmacy) in some parts of Wales. Finally there have also been a number of concerns about the quality, resilience or consistency of some clinical services in different parts of Wales.
    8. These concerns suggest an enduring problem either with the way that NHS Wales is resourced to meet the requirements laid upon it, or with the managerial linkages between the Senedd and the different care settings in which: i) the maintenance of good health is pursued; ii) early diagnoses of likely ill health are made; iii) treatment is given to restore people to a state of good health and iv) ongoing care and support is provided.
    9. In particular, SHA Cymru Wales feels that the care system in Wales is unbalanced in that anticipatory care and preventive work – in primary care and through public health measures -remains under-resourced despite the recent initiatives cited in the policy document.
    10. Added to public unease about patient services, are worries about financial control in the Welsh NHS. The abolition of the internal market and it’s replacement with a model based on partnership and co-operation ought to provide Wales with a unique advantage compared with an England system driven by competition, outsourcing of work to the private sector, and debts caused by P.F.I. schemes still needing to be serviced. The strengths of the Welsh NHS need to be more effectively exploited. There are worries too about the effectiveness of the special measures regime that is intended to improve both the immediate management of the Welsh NHS, and the way that changes to services that cross Board boundaries are planned and implemented.
    11. Underlying these concerns is an unease that there is no shared and unifying vision of what the Welsh NHS -with its local government and other partners- is being tasked to achieve for the Welsh public. “Healthier Wales” was intended to be the policy statement providing that radical vision. In our view it has been largely ignored and we return to this later in section C where SHA Cymru Wales suggest that NHS Wales builds upon past Welsh achievements in this regard, puts in place the political and managerial mechanisms to agree evidence-driven national policy objectives to be attained locally, and devises the mechanisms by which improved service delivery on the ground is assured.
    12. There is little detail about true co-production of health by both citizens and care professionals and how this can be moved from rhetoric to reality. This too would be a powerful engine for transformation.

     

    1. Covid 19 and its legacy

     

      1. At the time of writing, members believe that Covid-19 will shape the context in which the management and development of the health and care system in Wales sits. The pandemic vindicates many of the policies and approaches of the Welsh Government. The Welsh public service model stands in stark contrast to the fragmented cocktail of private sector provision and procurement which characterises much of the response in England. The time and effort that has been spent over many years in Wales to build better working relationships between the NHS, local government and the third sector has facilitated a more coherent and coordinated response to the pandemic than appears to have been the case in England.
      1. This public service approach allowed for partnerships at a local level which both responded to the leadership provided by the Welsh Government and to the local challenges faced by front line services. These partnerships should be maintained and refined as important community assets to promote local well -being.

    Proposal 1: SHA Cymru Wales propose that Wales considers creating a permanent “Wales Health and Care Reserve” (WHACR) comprising ex-health and social care staff and other volunteers with a wide variety of skills that can be refreshed through updating training on a regular basis, and who can be called upon in an emergency to assist full- time staff. This reserve should be organised on a neighbourhood or Cluster basis to support community clinical and care networks. It should be supported by schemes such as the Duke of Edinburgh award and the Welsh Baccalaureate. Established voluntary bodies with a relevant skill base should be encouraged to become involved.

      1. Welsh Government was correct to seek and encourage a “four nation response” to the pandemic even if it has not always come to the correct conclusion. It is regrettable that this was not always reciprocated by the U.K Government. The devolution settlement came under great strain as the four parts of the U.K. felt it necessary to respond to events as they saw fit. Different approaches to “lock down”, to testing, tracking and protecting across the U.K., and confusion about the purchasing of protective equipment and testing materials, exposed inadequacies in any U.K. wide arrangements meant to deliver a coordinated management to the effects of the virus.

    Proposal 2: SHA Cymru Wales requests that Welsh Labour commit to seek to join with its Scottish and Northern Ireland partners, to pursue revisions to the arrangements that govern these matters with the U.K. Government so that a “four nation” response to any  surge in this pandemic or in future pandemics is maintained. However, we do acknowledge that there will be times when it is necessary for the Welsh Government to take a Wales specific approach and we fully support its right to do so.

      1. SHA Cymru Wales welcomes the Senedd’s early work to review the Welsh experience to date. This is important work in the event of a failure to fully eradicate the Covid-19 virus and if further waves of mass infection have to be faced.

    Proposal 3: SHA Cymru Wales welcomes the First Minister’s support for a public enquiry  to review these events. Its terms of reference should be agreed by all four nations. Further we believe that all advice given to Welsh Government in relation to the options for managing this crisis should be made available to the public.

      1. SHA Cymru Wales recognises the pressure the Welsh Government faced in creating extra health provision as the Covid-19 pandemic began. This meant that the distinction between the health and social care systems became blurred as hospital patients were moved from acute beds to care homes in order to deal with an expected influx of patients with Covid-19. The result was that care homes were put at risk from viral transmission from hospital to care home settings. Further, people receiving domiciliary care services were also exposed to risks from itinerant care staff. Quickly the care system– comprising a range of privately run businesses of different sizes and types– required a degree of state support and guidance to sustain its operations. These took time to put in place. In this context SHA Cymru Wales congratulate the Welsh Government for ensuring a consistent supply of PPE to the care sector, for its extension of the testing regime in line with professional advice, and for the financial support provided to front line social care workers and others.

    Proposal 4: The Covid-19 pandemic highlights the integrated nature of health and social care and the need for quarantine facilities, equity of equipment, training, pay and quality facilities for the social care sector as well as for the NHS.These arrangements should be put in place as soon as possible.

      1. This scale of public service support needed for the social care sector must raise fundamental questions as to the long-term resilience of the current private sector business model.

    Proposal 5: As part of a process of major reform SHA Cymru Wales urge that the social care workforce in Wales is immediately transferred to the public service and that the Welsh Government brings the management of the care sector back under public control and leadership.

      1. Covid-19 has made it clear that the care system is fragmented – relying on multiple contracts with private sector providers especially those driven by commercial aims. Covid-19 exposed the inherent vulnerabilities in the present social care business model.

    Proposal 6: SHA Cymru Wales believes that the time has come for the main components of adult social care in Wales to be brought under public control, stewardship, or ownership and funded broadly on the same basis as the NHS. Domiciliary care services should be brought under the purview of local authorities first.

      1. “Personal care”, whether given at home or in a residential care setting, should be accepted as requiring oversight from the nursing profession and be delivered free under the NHS by staff trained to support individuals needing such care.

    Proposal 7: SHA Cymru Wales recommend that work commences as soon as possible on assessing at what speed, and in what way, the transfer of selected services from the private sector in Wales to the public sector can best be achieved to forge a new and equal partnership of health and social care services in Wales. SHA Cymru Wales asks that work be done to assess the costs, benefits, and problems that would arise from such a change.

      1. Room should be left for selected services to be operated by bona fide charities, co-operatives, and other voluntary groups where they have the skills and / or a reputation that resonates with the public. For example, Marie Curie Cancer Care, services supporting people affected by substance misuse, and charities supporting people through physical disabilities and mental ill health would meet this criteria. Here grants should be considered as an alternative to the formal contracts of a commercial relationship.
      1. While the present pandemic is unprecedented in its extent it does highlight the problems that the NHS and social care face when placed under excess demand, as frequently happens with the regular “winter bed crises”.
      1. The current DGH model combining elective and urgent surgery with emergency medical admissions alongside obstetric and paediatric services may need to be re-thought so that acute hospitals no longer operate consistently at very high levels of bed occupancy providing little head room for seasonal variations in demand. Elective capacity should be maintained in a protected environment by “built in” physical and engineering design and by so managing the protection and deployment of care staff so that transmission of any contagious infection is minimised. Similar considerations need to apply to ambulance services, primary care, community nursing, mental health and other health services, and indeed adult and children’s social care.
      1. 12. In England changes made to the public health function by transferring it to local government and then subjecting it (and other services) to reduced financial allocations have impaired its ability to react quickly and decisively to effect the necessary public health shut down testing and tracking arrangements long associated with controlling such diseases. The use of private sector contractors adds to fragmentation of the service. SHA Cymru Wales supports the current  arrangements in Wales whereby a strong public health tradition set within a public service model has been preserved and is able to serve both Welsh Government, Welsh local government, the Welsh NHS, and the wider public interest. However, SHA Cymru Wales share the concerns of those who feel that the Welsh Public Health function has become too concentrated at its centre and has insufficient presence in or influence within local authorities, health boards, and their partners at a community and neighbourhood level.

    Proposal 8: SHA Cymru Wales propose that Directors of Public Health should simultaneously hold statutory posts both in their local Health Board and in their local authority. This draws on past practice where medical officers of public health had a “proper officer“ function in local government with appropriate links with Environmental Health, Education, Community Development, and social care colleagues. Post holders should provide for both bodies an annual report describing local health status and how challenges of health inequalities should be, or are being met. The report should be taken in the public part of the agenda and drawn to the attention of community councils.This topic must feature highly in the performance regime linking Welsh Government, Local Government, and health Boards.

      1. The pandemic has facilitated, or required, new ways of delivering patient services, managing organisations, and connecting communities. Many people have now experienced remote consultations with their GP or hospital services via video conferencing. Diagnostic results have been shared via the internet between clinicians. Engagement of staff and the wider public in remote discussions have brought into question the traditional ways of linking patients and their relatives. New ways of managing organisations have also emerged as “working from home” has expanded.

    Proposal 9: Welsh Government should ensure that all citizens have reliable access to easy- to- use internet technology so that new forms of “ digital inequality” do not arise. Part of the work of WHACR cited above (Proposal 1) could be to assist people whose abilities or technical skills are not commensurate with relying on complicated technology.    

      1. SHA Cymru Wales believes, along with the Independent Sage Report, that these experiences have increased the desire and ability of communities and people to take an active part in debates about how their care services and indeed other facets of life – need to be re-fashioned “from the bottom up”. This sits alongside the ongoing development of GP clusters with a stronger community or neighbourhood focus.
      1. Covid-19 will leave a harsh legacy and a massive workload in terms of both physical and mental health rehabilitation for patients. This will be in addition to the NHS and social care catching up with deferred elective care delayed due to the pandemic. There is clear evidence that the excess death rate experienced over recent months is not solely due to Covid-19. While it is not fully understood why this is the case, it is probable that a significant proportion is due to the failure to seek, or obtain, health care in a timely way. Also, Welsh Government must prepare for what has been described as a tsunami of rehabilitation care as patients recover from severe episodes of Covid-19 infections and the impact upon their mental health. It must also anticipate – and plan to deal with – a legacy of stress experienced by care staff in Wales.

    Proposal 10: The Welsh Government should establish an urgent working group to plan how health and social care in Wales can recover from the longer-term consequences of Covid-19 on our country to both address the backlog in deferred need and the increased demand for physical and mental health rehabilitation. This should include consideration of making best use of recently commissioned health and care capacity.

     

    1. A critique of the Stage 2 document

     

      1. The Parliamentary Review on Health and Social Care in Wales concluded that there was an urgent need for rapid transformational change in Welsh health and social care services. This has been acknowledged by the Welsh Government. Welsh Labour’s consultation document however neither develops nor furthers this vision, nor does it convey an appropriate sense of urgency about the timing and nature of such change. It is a “steady as she goes” approach with “more of the same”. There is no clear set of priorities, sense of direction, or a picture of what the future of health and social care service in Wales ought to look like for service users, their families and carers.
      1. The stand-still in life expectancy in Wales over the last decade with the persisting health inequalities scarcely merits a mention – again with no policy proposals as to how to respond. The Covid-19 pandemic highlights these inequalities where the most socially disadvantaged communities carried the heaviest illness burden.
      1. Concerns remain about the failure to transform service delivery in line with both the Parliamentary Review and A Healthier Wales. This is exemplified by the tolerance of low levels of investment in primary care and a failure to recruit sufficient clinical staff.

    Proposal 11: GP numbers should be increased to produce an average list size of 1,400 patients per GP. Starting in those clinical network areas with the poorest health profile and least health and social care inputs. Where the traditional GP contractor model is failing to deliver these numbers, health boards need to take the lead in directly employing multi- professional primary care team members, including well supported salaried GPs.

      1. By reducing list sizes, patients will have easier access to, and more time with, their health care professionals so that a long-term caring relationship can be built biased towards prevention and anticipatory care. These communities, and other at-risk groups such as vulnerable children, care home residents, people with chronic illness and multiple morbidity etc. must be clearly identified and the outcomes from the care they receive be continually monitored with a view to continuing improvement. Clinical networks need to become a stronger focus for service innovation through a vision of health and well-being stretching far beyond a narrow medical horizon. The tools of public health and community development need to be harnessed to create stronger, healthier, resilient, and more engaged communities.
      1. These networks must be further enabled to lead the shift away from over-dependence on secondary care and towards localised anticipatory and preventive services aimed at maintaining independence. This shift of resource must enable the GP:patient ratio to improve. It must respond to the challenge of “the inverse care law” and must underpin an increase in primary care resources and effort aimed at reversing the unexpectedly stalled improvements in mortality indicators.
      1. General practice must no longer be viewed as a set of tasks carried out in isolation. It must regain its role as family practice committed to understanding local communities and the families that live in them and supporting them in pursuing their own good health. Practitioners in community development, social prescribing, and advocacy on community issues, must sit alongside continuity of care as part of a team of professionals serving the community.

    Proposal 12: Each neighbourhood should have public health input and advice and should be integrated into the work of primary care clusters. This should be marked with a change of name; clusters should become “neighbourhood networks.”

      1. Public health, primary care (including community pharmacies) and its estate should increasingly combine with other community assets such as post offices, food banks and community volunteers to create hubs which mix primary care provision with schools and community and leisure centres. In this way healthy living can be promoted and communities empowered to change the local culture and environment.
      1. SHA Cymru Wales sees neighbourhoods as the basic democratic unit of the NHS where the local community, comprising both professionals and local people, work to bring about beneficial changes and fashion the NHS as a people’s endeavour. As an example, indicators of any local “food poverty” should be devised as a health measure – for Covid-19 has both highlighted the frailties in how people access food and also brought about beneficial changes locally to support vulnerable people and build new partnerships. Nutrition is recognised as a determinant of health. Food poverty drives health inequalities whether caused by low income levels, unavailability or inadequate skills and accommodation. One suggestion that should be explored is the development of a national food service in Wales tasked with removing food poverty in Wales.
      1. SHA Cymru Wales is pleased to note that part of our submission last year urging the development of housing that supports the independence of older people and others with care needs was welcomed by the Party. SHA Cymru Wales looks forward to further work on developing emerging community models of engagement such as the Local Area Co-ordination arrangements operating in Swansea and similar initiatives elsewhere.

    Proposal 13: SHA Cymru Wales request that the consolidation and expansion of initiatives cited above be included in the manifesto along with a prototype “ Resilient Communities fund” to be deployed in a number of challenged localities to underpin and build on existing volunteer / community efforts such as those operating food box schemes and medicine / prescription deliveries.

      1. Further steps should now be taken to utilise technology so that patient medical and social care records can be “jointly owned” by care practitioners and citizens.

    Proposal 14: SHA Cymru Wales supports pilot projects currently exploring how patients can access and “co-own” their medical records as part of the co-production of good health.

      1. Primary care investment must not be at the expense of clearing the backlog that has built up in the mainstream service provision for cancer, stroke, heart disease and re-ablement surgery (e.g. hip and knee replacement). Nor should a current lack of capacity in services for children and young people with learning needs and mental health issues be allowed to continue.
      1. As noted earlier, for years it has become acceptable to attempt to run the hospital sector on a 90%+ occupancy rate. We have seen the problems this creates with perennial winter bed pressure crises but the onset of Covid-19 has shown the other inherent risks from constantly running the service at maximum capacity most of the time.

    Proposal 15: Staff and patient safety requirements must require the acute hospital system always to run with headroom for the predictable, cyclic variation in annual demand.

      1. Another concern of members was an uncertainty about what the 21st century purpose of the Welsh health and care system ought to be. Twenty years ago Wales had a well-deserved reputation for the quality of its strategic planning processes – aimed at achieving a level of health in Wales on a par with the best in Europe – and its ability to make progress. Evidence was gathered about the best preventive programmes, diagnostic techniques, treatment options, and after-care services across Europe and used to counter the main causes of premature death in Wales and the main causes of significant but avoidable morbidity in Wales. Health Boards (then known as health authorities) – with their partners – used the evidence to craft “local protocols for health” that were resource effective, people-centred, and aimed at increasing the length and quality of life in all parts of Wales. Despite, or perhaps because of, the success of this approach, John Redwood’s arrival in Wales saw the end of this work, no doubt in the belief that market forces would do the planning for Wales. In the view of some, since then NHS Wales has struggled to design a clinical and managerial process that systematically tackles health inequalities and improves health status in Wales.
      1. SHA Cymru Wales believes that Wales should draw heavily on that earlier strategic approach. For while SHA Cymru Wales accepts that Welsh Labour has had a strategic vision since the Wanless report in 2003, and “ A Healthier Wales” that has merit, it has not been accompanied by processes that translate strategy into deliverable Health Board and Trust 3 Year Integrated Medium Term Plans (IMTPs) able to be fully implemented by Health Boards, NHS trusts, and their key partners. The chain of accountability is opaque. Boards are, or appear to be, still dominated by secondary care voices

    Proposal 16: Welsh Labour should provide a clear statement of what the Welsh care system is meant to do (and by derivation what it isn’t) using a National Planning framework within which Health Boards and Trusts have to develop and deliver their plans. SHA Cymru Wales suggest that the Health Boards give a stronger voice for primary and community care and citizens in this process. A clear set of evidence- driven political and managerial processes are needed by which the aims of the Welsh NHS, and the resources needed to achieve those aims, are directly linked. Exhortations to “ do something”, on their own, are unlikely to achieve much.

      1. Setting a national direction and strategic intent must be underpinned by effective local delivery mechanisms to deliver the objectives of A Healthier Wales. The abolition of the internal market in Wales provided a unique opportunity to develop an integrated planning and delivery system at a local level to give effect to the national strategic purpose and direction. However, this has proved more than problematic. Some health boards are subject to Welsh Government intervention of varying extent, and varying success. Repeated reviews have expressed concerns at the capacity and governance of local health and social care planning and delivery. SHA Cymru Wales welcomes the partnership working that is taking place at regional partnership boards, but this process has got to mature, be more transparent and be accountable.
      1. In the light of the foregoing, SHA Cymru Wales welcomes the proposal for a “national executive” as outlined in the Final Report of the Parliamentary Review. The Parliamentary Review recommended that this “national executive” should be about strengthening executive functions to help align national strategic priorities with local service changes and innovations. The present slow pace of change suggests that this is urgently needed. It specifically suggested that the “national executive” should be aligned with national social care policy. SHA Cymru Wales recommends that the “national executive” should be the key national agency for integrating and driving forward both a National Health and a National Care service in Wales.
      1. SHA Cymru Wales is concerned that the consultation document chooses to specifically mention “specialist and hospital-based services” when considering the roles of the “national executive”. This is at odds with the core message of both the Parliamentary Review and A Healthier Wales. Both speak of transforming our care services away from an over-reliance on the hospital sector. We also regret that the policy consultation document makes no reference to the Parliamentary Review’s proposal that the work of the “national executive” should be underpinned by an explicit and transparent performance framework by which progress can be measured with particular reference to measuring progress in improving public health and tackling health inequalities.

    Proposal 17: SHA Cymru Wales believes that a National Health and Social Care Executive, tasked with delivering national health and social care in a clear, evidence based, and coherent way could deliver the transformational change needed. However, it must have clear terms of reference and its performance should be underpinned by a clear and transparent performance framework. The terms of reference, and the performance framework should both be subject to consultation with key stakeholders.

      1. There is also a view that the wider public, and local communities, feel excluded from some of the decision making in the care system. Local Government services in principle have a direct line of accountability to their populations through elected councillors and scrutiny committees. If the proposals in 16 and 17 above are implemented, local government should have an increased oversight of the care system as a whole.

    Proposal 18: SHA Cymru Wales recommends that Welsh Government place a legal requirement on Welsh local authorities to institute rigorous oversight and scrutiny arrangements in regard to the work of both Health Boards and the performance of the local care system as a whole. SHA Cymru Wales suggests that these scrutiny committees should have a minimum of three independent (non councillor) members nominated by local interest groups that can provide an informed view of how local service delivery is experienced by citizens and service users and what changes users desire.

      1. The policy document understandably makes little mention of the resources likely to be available the Welsh NHS and its local government partners over the course of the next four years. The damage done to the U.K. and Welsh economy by the pandemic is still to be assessed, as are the uncertainties of leaving the E.U. However, the NHS and social care in Wales already consumes over half of the block grant. Even with these spending levels, the Welsh NHS is under- powered both in primary care and acute secondary care.
      1. SHA Cymru Wales has long held the view that not only is the Barnett formula in need of refinement, but successive Conservative governments have not operated it fairly across the devolved polities. Further, there is limited scope to deploy the (limited) tax-raising powers now available to Wales in a way that can significantly increase the money available to Welsh Government. It is suggested that Welsh Government should adopt a four pronged strategy to address the issue of spending constraints. The first is to seek to increase – by a fair application of the Barnett formula –the funding available to Welsh Government from U.K. Government. The second is via Welsh taxation and growing the Welsh economy. The third is to examine in an ongoing way the operating costs of the Welsh NHS and social care, applying legitimate cost-saving measures where possible. One example is to examine critically the way in which newly licensed medicines are introduced in Wales. The current system requires only that the new product is not inferior to an existing (often cheaper) product rather than requiring either a superior treatment or lower spending. The fourth is to introduce a long term cost avoidance program that is driven by a primary care and public health preventive and anticipatory care approaches outlined in paragraphs C 14-17.
      1. The Welsh Government seeks to allocate its resources to health boards and local authorities on a needs-based formula. However, a thick fog hangs over how these allocations are used once these local organisations receive them. The First Minister correctly said that there are more inequalities within the populations served by health boards and local authorities than there are between the individual organisations Currently there is no obvious way to assess and compare how these inequalities within health boards and local authorities are addressed.

    Proposal 19: Public Health Wales and Stats Wales should develop a methodology by which it will be possible to measure inputs and outcomes in terms of resource allocation to the most vulnerable communities and groups within health boards and local authorities.

     

      1. Finally, it is suggested that the efforts of the NHS (and its local government partners) to contribute to the “green agenda” be welcomed. This aspect of its work should be highlighted and reported publicly as part of the overall performance regime.

     

    1. Conclusion

     

    1. The unexpected arrival of the pandemic, and the havoc and loss of life it has wrought has altered the perspective from which future health and care policy can be assessed. It threw into sharp relief those individuals and communities that are our most vulnerable.
    2. For this reason our response has been crafted in two parts – one to anticipate needed changes in order to make the Welsh care system more resilient to any future virus, and another to address challenges that were obvious prior to the arrival of Covid-19, but have proved resistant to change. SHA Cymru Wales believes that the 19 proposals described above will make a positive contribution to the health status of the people of Wales and it commends these to the Party.

    Labour Stage 2 SHA Cymru Wales final response Health and Social Care

    2 Comments

                      DOCTORS IN UNITE

    The rising death rate from COVID-19 and the pressure of the pandemic on a weakened NHS have caused warranted anxiety. There were reports from Italy of rationing, when life saving equipment was simply unavailable for some sick patients, and difficult triage decisions had to be made by doctors. Many deaths in the UK are occurring among elderly residents of care homes, and unlike deaths in hospital, these have not been given prominence in daily reports.

    Press coverage has indicated that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) agreements have been misused. Rather than an agreement on a one to one basis after full discussion and as part of advance care planning, marginalised groups such as the elderly and disabled have been asked for consent by letter. In some cases decisions have been made on their behalf.

    Such agreements should only apply to what happens in the event of the heart stopping during an illness, but they have been wrongly interpreted as consent to not having treatment for illness, or not being admitted to hospital.

    Professional bodies such as the British Medical Association are attempting to provide an ethical framework for health care staff faced with impossible decisions regarding rationing and who should take precedence. Not only has the government failed to provide guidance on this matter, perhaps because it undermines their narrative that the NHS is coping with the onslaught and will continue to do so. Their grotesque incompetence in failing to follow World Health Organisation advice has put front line workers in an unprecedented position: having to make decisions about who should and who should not receive care.

    The government, policymakers, managers and clinicians have a responsibility to patients. They must ensure that any system used to assess the escalation or de-escalation of care does not disadvantage any one group disproportionately. Treatment should be considered irrespective of a person’s background when it can help them survive, balanced against the risk of that treatment causing harm.

    A GP surgery in Wales sent letters to patients asking them to complete a DNACPR form, reportedly stating “several benefits” to its completion. The form explained that “your GP and more importantly your friends and family will know not to call 999” and that “scarce ambulance resources can be targeted to the young and fit who have a greater chance.”

    In an “ideal situation”, it continued, doctors would have had this conversation in person with vulnerable patients, but had written instead due to fears the doctors may be asymptomatic carriers of coronavirus. The practice later apologised to recipients of the letter.

    A GP surgery in Somerset also wrote letters to a support group for adults with autism, requesting they make plans to prevent their clients being resuscitated if they become critically ill. The letter was later withdrawn after criticism.

    The Guardian has reported that “elderly care home residents have been categorised ‘en masse’ as not requiring resuscitation”, and that “people in care homes in Hove, East Sussex and south Wales are among those who have had ‘do not attempt resuscitation’ notices applied to their care plans during the coronavirus outbreak without proper consultation with them or their families”.

    The Mirror also reported that adult patients and parents of children with chronic conditions were sent letters asking if they wanted to have DNACPR statements agreed in case of admission to hospital with coronavirus.

    A learning disability care provider described an unprecedented increase in the number of DNACPR letters it had received. In the Health Service Journal their spokesperson said “making an advance decision not to administer CPR if a person’s heart stops, solely because they have a learning disability, is not only illegal, it is an outrage.

    “We are seeing DNR orders that have not been discussed with the person themselves, the staff who support and care for them, or their families. This is very concerning as it may potentially lead to people being denied life-saving treatment that other patients would be granted”.

    NHS Trusts, GPs and clinical commissioning groups have been told by NHS England they must not send out blanket DNACPR forms.

    The British Medical Association, Royal College of Nursing and Resuscitation Council UK provide detailed guidance on decisions relating to cardiopulmonary resuscitation. CPR was introduced in the 1960s following recognition that some hearts could be restarted when they had stopped beating, often after a heart attack.

    The probability of CPR being successful in other situations is generally low. It involves compressing the chest, delivering high voltage electric shocks to the heart, attempts to ventilate the lungs and giving intravenous drugs. Injury to ribs and internal organs may occur and some patients survive only to spend long periods in intensive care without full recovery. This is why people talk about the risks and benefits of CPR.

    The heart and lungs stopping is a natural part of dying from any cause. When CPR is used in people who have been gravely ill it is very unlikely to work. Rather than a peaceful death, their lives could end in the context of aggressive but futile attempts to change an irreversible process.

    To prevent this happening patients can be asked well in advance about their wishes, with a full exploration of the issues involved. In normal circumstances, the decision to not attempt CPR is made after a discussion between patient and doctor. An understanding can be reached that because of frailty, and because the heart stopping is the final stage of an irreversible process of multiple organ failure, the potential benefits to the patients are outweighed by the risks of pain and indignity.

    Standardised DNACPR forms were introduced to attempt to ensure patients’ wishes were recorded and would be easily available to healthcare staff. They do not have to be signed by patients. The member of the healthcare team who has discussed CPR with the patient signs the form, as does the responsible senior clinician (this may well be the same person).

    Doctors are told by their professional organisations that “considering explicitly, and whenever possible making specific anticipatory decisions about, whether or not to attempt CPR is an important part of good-quality care for any person who is approaching the end of life and/or is at risk of cardiorespiratory arrest.

    “If cardiorespiratory arrest is not predicted or reasonably foreseeable in the current circumstances or treatment episode, it is not necessary to initiate discussion about CPR with patients.

    “For many people, anticipatory decisions about CPR are best made in the wider context of advance care planning, before a crisis necessitates a hurried decision in an emergency setting.”

    The purpose of advance care planning is to allow each individual to choose in advance what interventions, including CPR, they wish to receive in the event of deterioration in their health. For people with multiple conditions, or those who are severely unwell, the optimal time to undertake advance care planning is when they are relatively stable. Discussions are best had in their home or usual care environment where planning can be supported by the healthcare professionals who know them well. These may include doctors and nurses based in general practice, in the community, in hospices or in hospitals. Making a decision in advance ensures that there is time for all the appropriate people to be involved in a decision. It allows time for reflection and scrutiny.

    Decisions made may be written down, and described variously as a living will, personal directive, advance directive, medical directive, or advance decision. This is a legally enforceable document in which a person specifies what treatments or interventions they would not wish to undertake in the future if they are unable, due to illness, to give their opinion at that time.

    Nearly one in five people over 80 may need hospitalisation with COVID-19. An estimated 1.28% of people diagnosed with COVID-19 will die. Around half of patients ill enough to be admitted to ICU in the UK for ventilation have died. 95% of UK COVID-19 deaths have occurred in patients with underlying medical conditions.

    Consequently asking people most at risk to decide what they would like to happen in the event of them becoming unwell is sensible, and good medical practice.

    It is however important to distinguish this from a blanket application of DNACPR orders to particular groups. This is discriminatory and illegal. There must be full consultation with the individual concerned. A thorough face-to-face discussion with staff who know the patient well is required. This has clearly not happened in the examples cited in the press.

    Care workers may worry about breaking social isolation rules and potentially infecting patients at home visits. There are ways around this, including video consultations. Poor communication over such sensitive issues breeds mistrust.

    The risks and benefits of CPR may change in the context of coronavirus. In patients with COVID-19 pneumonia who then have a cardiac arrest, not only is there little likelihood of CPR restarting the heart, there is the potential for health personnel to become infected as a consequence of attempted resuscitation.

    Professional guidelines are however quite clear. “A decision not to attempt CPR applies only to CPR. All other appropriate treatment and care for that person should continue. It is important that this is widely understood by healthcare professionals and that it is made clear to patients and those close to them.

    This is essential as it is a common fear amongst members of the public that a ‘DNACPR’ decision will lead to withholding of other elements of treatment.”

    For example, if someone in a care home agrees to a DNACPR, it does not mean they cannot be admitted to hospital if appropriate, or that they cannot be considered for intensive care. It only means that if their heart stops, resuscitation would not be attempted.

    There is an anxiety about the availability of resources if the number of patients overwhelms the amount of life saving equipment available. The COVID-19 pandemic is a major challenge for a weakened NHS. The elderly, care home residents and those with disabilities are being marginalised. The government mantra of “stay at home, protect the NHS, save lives” led people with acute medical conditions to avoid medical attention when they needed it, and encouraged some ill with COVID-19 to stay out of hospital, dying at home when they may have survived.

    The idea of rationing life saving care is anathema to healthcare staff, but it may be on the horizon. In Italy, which has twice as many ventilators per 100,000 population as the UK, there were age cut-offs applied for admission to intensive care. Ventilator treatment was withdrawn from some patients expected to do badly in favour of younger patients with a better prognosis.

    If rationing does become a reality, front line teams will try and work in accordance with accepted ethical principles. This will unfortunately not provide perfect answers.

    Ethicist and barrister Daniel Sokol described the dilemma on April 7th. “It is no secret that intensive care unit (ICU) capacity may be overwhelmed if the pandemic worsens. Why then is there so little published guidance on ICU triage from the UK government and NHS Trusts? The Royal College of Physicians’ ethical guidance on covid-19, published on 2nd April 2020, stated that ‘any guidance should be accountable, inclusive, transparent, reasonable and responsive.’ The British Medical Association’s ethical guidance, published the next day, emphasised the need for decisions to be made ‘openly, transparently, by appropriate bodies and with full public participation’.”

    Sokol asked, “Where are the protocols setting out the triage criteria?” He suggested that senior officials in the government and NHS England may be reluctant to publish anything that might clash with the current messaging that the NHS is managing present demand and is likely to continue to cope. “The official message is that with continued communal efforts the NHS can be protected, ICU need not be overwhelmed, and tragic choices will be avoided. Publishing a document that contemplates an NHS in chaos and tragic choices aplenty sits awkwardly with that message”.

    He also wondered if fear of legal challenge was a factor. The National Institute for Health and Care Excellence was threatened with judicial review on publishing its COVID-19 guideline for clinical care. This advice was subsequently amended due to concerns about unlawful discrimination against people with long-term conditions including autism and learning disabilities.

    The 2019 National Security Risk Assessment also highlighted the potential for public outrage if health and care systems were seen to struggle, especially if provision of the remaining services was unevenly distributed.

    There are no ethical guidelines from the Department of Health or NHS England for front line staff and senior managers relating specifically to COVID-19, but the British Medical Association (BMA), Royal Colleges and specialist medical bodies have produced their own.

    The BMA suggests, “All patients should be given compassionate and dedicated medical care including symptom management and, where patients are dying, the best available end-of-life care. Nevertheless, it is legal and ethical to prioritise treatment among patients. This applies where there are more patients with needs than available resources can meet.”

    To help decide which patients to treat, they ask doctors to “follow your organisation’s guidelines and protocols, including relevant procedures for making complex ethical decisions. The speed of patient’s anticipated benefit will be critical. Other relevant factors include: severity of acute illness; presence and severity of co-morbidity; frailty or, where clinically relevant, age.

    “Managers and senior clinicians will set thresholds for admission to intensive care or the use of highly limited treatments such as mechanical ventilation or extracorporeal membrane oxygenation based on the above factors. Patients whose probability of dying, or requiring prolonged intensive support, exceeds this set threshold would not be considered for intensive treatment. They should still receive other forms of medical care. Prioritisation decisions must be based on the best available clinical evidence, including clinical triage advice from clinical bodies. These criteria must be applied to all presenting patients, not only those with COVID-19.”

    The Royal College of Physicians says, “Any decisions made to begin, withdraw or withhold care must also comply with the shared decision-making policies of the NHS. This means that these decisions should include the patient and their wishes (as much as is feasible for the given situation) and, if appropriate, the patient’s carers. This is true regardless of whether the patient has COVID-19.

    “Front-line staff, policymakers, management and government have a responsibility to patients to ensure that any system used to assess patients for escalation or de-escalation of care does not disadvantage any one group disproportionately. Treatment should be provided, irrespective of the individual’s background (e.g. disability) where it is considered that it will help the patient survive and not harm their long-term health and wellbeing.

    “Many front-line staff will already be caring for patients for whom any escalation of care, regardless of the current pandemic, would be inappropriate, and must be properly managed. We strongly encourage that all front-line staff have discussions with those relevant patients for whom an advance care plan is appropriate, so as to be clear in advance the wishes of their patients should their condition deteriorate during the pandemic.”

    There is an urgent need for national guidance from the Department of Health and NHS England on how to manage if resources run out. In the absence of such guidance, individual clinicians will be using the available evidence to assist in making extremely challenging decisions.

    This will not be an easy task, as illustrated by one Italian doctor speaking to the New York Times. “If you admit an 82-year-old with hypertension, in a situation where you have two or three patients waiting outside your I.C.U. who have many more chances of survival that you cannot admit because your I.C.U. is full, then it becomes really inappropriate, or I would say, immoral”.

    It is outrageous that UK medical staff may be put in this position due to the government’s incompetence.

    Dr John Puntis is the co-chair of Keep Our NHS Public

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