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‘LEGISLATION WATCH WALES’ – October 2018

Health and Social Care Briefing

Acts

Additional Learning Needs and Education Tribunal (Wales) Act 2018

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=16496

The Act makes provision for a new statutory framework for supporting children and young people with additional learning needs. This is to replace existing legislation surrounding special educational needs and the assessment of children and young people with learning difficulties and / or disabilities in post-16 education and training.

The Act also continues the existence of the Special Educational Needs Tribunal for Wales and provides for children, their parents and young people to appeal to it against decisions made in relation to their or their child’s additional learning needs, but renames it the Education Tribunal for Wales

The Bill was introduced on 12 December 2016. Royal Assent was given on 24 January 2018.

Abolition of the Right to Buy and Associated Rights (Wales) Act

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=17260

According to the Explanatory Memorandum accompanying the Act, the purpose and intended effect of the Act is to end all variations of the Right to Buy and the Right to Acquire.

The key purposes of the Act are to:

  • abolish the right of eligible secure tenants to buy their home at a discount under Part 5 of the Housing Act 1985 (Right to Buy);
  • abolish the preserved right of eligible former secure tenants to buy their home at a discount under section 171A of the Housing Act 1985 (Preserved Right to Buy);
  • abolish the right of eligible assured or secure tenants of a registered social landlord or private registered provider to acquire their home at a discount under section 16 of the Housing Act 1996 (Right to Acquire);
  • encourage social landlords to build or acquire new homes for rent, the Right to Buy, Preserved Right to Buy and Right to Acquire will not be exercisable by tenants who move into new social housing stock more than two months after the Bill receives Royal Assent, subject to certain exceptions;
  • provide for at least one year after the Bill receives Royal Assent before the abolition of the Right to Buy, Preserved Right to Buy and Right to Acquire for existing social housing stock comes into force.

Further detail about the Act can be found in its accompanying Explanatory Memorandum.

The Bill was introduced on 13 March 2017. Royal Assent was given on 24 January 2018.

Public Health (Minimum Price for Alcohol) Wales Act

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=20029

The Act provides for a minimum price for the sale and supply of alcohol in Wales by certain persons and makes it an offence for alcohol to be sold or supplied below that price.

The Act includes provision for:

  • the formula for calculating the applicable minimum price for alcohol by multiplying the percentage strength of the alcohol, its volume and the minimum unit price (MUP);
  • powers for Welsh Ministers to make subordinate legislation to specify the MUP;
  • the establishment of a local authority-led enforcement regime with powers to bring prosecutions;
  • powers of entry for authorised officers of a local authority, an offence of obstructing an authorised officer and the power to issue fixed penalty notices (FPNs)

The Act proposes the MUP would be specified in regulations. However, for the purpose of assessing impacts and the associated costs and benefits, the Explanatory Memorandum uses a 50p MUP as an example.

The Public Health (Minimum Price for Alcohol) (Wales) Act became law in Wales on the 9th of August 2018.

Regulation of Registered Social Landlords (Wales) Act

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=19962

The purpose of the Act is to amend or remove those powers which are deemed by the Office for National Statistics (“ONS”) to demonstrate central and local government control over Registered Social Landlords (RSLs).

These changes will enable the ONS to consider reclassifying RSLs as private sector organisations for the purpose of national accounts and other ONS economic statistics.

Further detail about the Act can be found in its accompanying Explanatory Memorandum.

The Regulation of Registered Social Landlords (Wales) Act 2018 became law in Wales on the 13th of June 2018.

Law Derived from the European Union (Wales) Act 2018

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=21280

A Government Emergency Bill, introduced by Mark Drakeford AM, Cabinet Secretary for Finance. An Emergency Bill is a Government Bill that needs to be enacted more quickly than the Assembly’s usual four stage legislative process allows. A definition of an Emergency Bill is not provided in the Government of Wales Act 2006 (“the 2006 Act”) or in the Assembly’s Standing Orders however Standing Order 26.95 states that:

“If it appears to a member of the government that an Emergency Bill is required, he or she may by motion propose that a government Bill, to be introduced in the Assembly, be treated as a government Emergency Bill.”

As with all Assembly Bills, Emergency Bills must relate to one or more of the 21 Subjects contained in Schedule 7 to the 2006 Act in order for it to be within the scope of the Assembly’s legislative powers.

The Act is intended to preserve EU law covering subjects devolved to Wales on withdrawal of the UK from the EU. Further, it will enable the Welsh Ministers to ensure that legislation covering these subjects works effectively after the UK leaves the EU and the European Communities Act 1972 is repealed by the European Union (Withdrawal) Bill.

The Act enables the Welsh Ministers to legislate to maintain regulatory alignment with the EU in order to facilitate continued access to the EU market for Welsh Businesses. It also creates a default position in law whereby the consent of the Welsh Ministers will be required before any changes are made by UK Ministers to devolved legislation within the scope of EU law.

Further detail about the Bill can be found in its accompanying Explanatory Memorandum.

The Law Derived from the European Union (Wales) Act 2018 became law in Wales on 6 June 2018.

Legislation in Progress – current Bills

Public Services Ombudsman (Wales) Bill

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=20012

This is a Committee Bill, introduced by Simon Thomas AM, Chair of the Finance Committee. The Business Committee has remitted the Bill to the Equality, Local Government and Communities Committee. The Bill includes provision which set out the new powers for the Ombudsman to:

  • accept oral complaints
  • undertake own initiative investigations
  • investigate private medical treatment including nursing care in a public/private health pathway
  • undertake a role in relation to complaints handling standards and procedures

 

Further detail about the Bill can be found in its accompanying Explanatory Memorandum. The Bill is currently at stage 2.

Autism (Wales) Bill

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=19233

An Assembly Member Bill, introduced by Paul Davies AM was successful in a legislative ballot in March 2017, and given leave to proceed with his Bill by the Assembly in June 2017.

The Business Committee has remitted the Bill to the Health, Social Care and Sport Committee.

The overall purpose of the Bill is to ensure the needs of children and adults with Autism Spectrum Disorder in Wales are met, and to protect and promote their rights.  The Bill delivers this purpose by seeking to:

  • Introduce a strategy for meeting the needs of children and adults in Wales with ASD conditions which will:
    • Promote best practice in diagnosing ASD, and assessing and planning for meeting care needs;
    • Ensure a clear and consistent pathway to diagnosis of ASD in local areas;
    • Ensure that local authorities and NHS bodies take necessary action so that children and adults with ASD receive the timely diagnosis and support they need across a range of services;
    • Strengthen support for families and carers and ensure their wishes, and those of people with ASD, are taken into account;
    • Promote research, innovation and improvement in ASD Services;
    • Establish practices to enable the collection of reliable and relevant data on the numbers and needs of children and adults with ASD, so that the Welsh Ministers, and local and NHS bodies can plan accordingly;
    • Ensure key staff working with people with ASD are provided with appropriate ASD training; and
    • Regularly review the strategy and guidance to ensure progress.
  • Require the Welsh Ministers to issue guidance to the relevant bodies on implementing the strategy.
  • Require the Welsh Ministers to collect suitable data to facilitate the implementation of the Bill.
  • Require the Welsh Ministers to undertake a campaign to raise awareness and understanding of ASD.

Further detail about the Bill can be found in its accompanying Explanatory Memorandum.

The Bill is currently at stage 1 (consideration of the general principles of the Bill and the agreement of the Assembly to those principles).

Childcare Funding (Wales) Bill

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=21394

A Welsh Government Bill, introduced by Huw Irranca-Davies AM, Minister for Children, Older People and Social Care. The Business Committee has remitted the Bill to the Children, Young People and Education Committee.

The Childcare Funding (Wales) Bill (“the Bill”) gives the Welsh Ministers the power to provide funding for childcare for qualifying children of working parents and to make regulations about the arrangements for administering and operating such funding.

The Bill is intended to facilitate the delivery of a key commitment in the Welsh Labour manifesto ‘Together for Wales 2016’. This is to provide 30 hours per week of government funded early education and childcare to the working parents of three and four year olds in Wales for up to 48 weeks per year (this is referred to in the Explanatory Memorandum accompanying the Bill as ‘the Offer’).

All eligible 3 and 4-year-old children (from the term after their third birthday) are entitled to a minimum of 10 hours early education per week during term time over 39 weeks of the year. The Offer builds on this universal entitlement and provides up to a total of 30 hours early education and care per week over 48 weeks of the year for the 3 and 4 year olds of working parents.

The Bill relates to the childcare element of the Offer and is therefore concerned with the funding that will be provided in respect of the eligible children of working parents.

Further detail about the Bill can be found in its accompanying Explanatory Memorandum.

The Bill is currently at stage 1 (consideration of the general principles of the Bill and the agreement of the Assembly to those principles).

Renting Homes (Fees etc…) Wales Bill

http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=22120

A Welsh Government Bill, introduced by Rebecca Evans AM, Minister for Housing and Regeneration. The Business Committee has remitted the Bill to the Equality, Local Government and Communities Committee.

The Bill includes provision for:

  • prohibiting certain payments made in connection with the granting, renewal or continuance of standard occupation contracts;
  • the treatment of holding deposits.

Further detail about the Bill can be found in its accompanying Explanatory Memorandum.

The Bill is currently at stage 1 (consideration of the general principles of the Bill and the agreement of the Assembly to those principles).

Future and possible Bills (of interest)

Assembly members have voted to introduce a Welsh Parliament and Elections Bill due to be brought forward in early 2019. The Bill will be designed to change the name of the Assembly to Senedd Cymru/Welsh Parliament; lower the voting age for Assembly elections to 16; amend the law relating to disqualification from being an Assembly Member and make other changes to the Assembly’s electoral and internal arrangements.

http://www.assembly.wales/en/newhome/pages/newsitem.aspx?itemid=1910&assembly=5

In the statement on forthcoming legislation 2018/19, the First Minister highlighted:

  • A Bill to remove the defence of reasonable punishment
  • A Bill to improve accessibility of Welsh Law and how it is interpreted
  • A Local Government Bill (lowering the age for elections and a range of other proposals – not ‘wholescale merger’)
  • A Bill to establish an Duty of Quality for the NHS and a Duty of Candour for Health and Social Care, introduce and establish a new independent body to represent the citizen’s voice in health and social care services and will require LHBs to appoint a Vice Chair
  • Ban the use of wild animals in travelling circuses

Updated October 2018

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A Healthier Wales?
Cymru Iachach?
Monday October 1st 7pm to 9pm
The new Welsh Government Plan for Health and Social Care What does this mean for us in North Wales?

Come and hear the debate from our expert Panel

Huw Irranca-Davies,
Minister for Children, Older People and Social Care
Donna Hutton
UNISON Cymru Wales Head of Health
Professor Rhiannon Tudor-Edwards
Professor of Health Economics, Bangor University
Dr Matthew Davies
General practitioner, BCUHB Cluster Lead
Chair: Tony Beddow
Secretary, SHA Cymru Wales

Register at
https://www.eventbrite.com/e/a-healthier-wales-cymru-iachach-tickets-49012698300?aff=es2
www.shacymruwales.cymru

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

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

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

 

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We were interested in the BBC’s news topic “More children having teeth out in hospital” on Saturday 13.1.18. The president of the British Society for Paediatric Dentistry, Claire Stephens, was interviewed and correctly identified that dental caries (decay) is an entirely preventable disease. This is demonstrated in England, in 2014/15, 75.2% of five year old children had no visible decay. In Wales, at the same time, only 64.6% of five year olds had no visible decay.

Jonathan Ashworth, the shadow Secretary of State for health, was also interviewed and correctly pointed out that dental disease was associated with deprivation. Indeed Professor Jimmy Steele’s 135th anniversary lecture at the British Dental Association in July 2015 sent a clear message that dental caries is no longer a significant disease in higher socio-economic groups.

With this in mind we investigated the problem of caries in young primary school children using a qualitative methodology, interviewing parents, in order to identify issues and highlight possible solutions. Our results showed that parents felt responsible for their children but were poorly informed and not supported to act responsibly. The parents were not aware of the need for toothpaste to be of an adequate strength and for the need to avoid rinsing following brushing.

With regard to those parents who had experienced their children having multiple extractions under general anaesthesia, they felt blamed. Attempts from professional personnel delivering the service were unhelpful to nurturing future positive behaviours. Furthermore, instructions to find a dentist for future care were followed by the parents but it was impossible to find an NHS dentist to facilitate this instruction.

However the campaign Design to Smile in Wales, a school supervised toothbrushing scheme, has been of value in supporting responsible behaviours in two ways. Firstly, parental consent was obtained following pestering from the child to be involved in the activity. Secondly, home tooth brushing was promoted by the child, when prior to involvement in the scheme the parent was unsuccessful in directing home tooth brushing.

It seems to us that in order for improvements in oral health to be facilitated and thus impact on the need for hospitalised extractions it is necessary to:

  1. Improve access to services for deprived populations through primary care policy and implementation. The access should include long term continuing care and not only pain relief.
  2. Target supervised tooth brushing to schools servicing high need populations.
  3. Improve the clarity of oral health education to include the need to attend the dentist, use fluorides of adequate strength and avoid rinsing following tooth brushing.

This begs the question “Has the power given to primary care organisations through the legislation enabling the new contracts of 2006 and beyond been effective?” Claire Stephens holds the government to account for the increase in hospitalised extractions even though the mechanisms for developing services are localised and have a dental professional input.

It is possible that improvements in oral health could be achieved through implementing the above. These could be facilitated within the current structures provided by government since 2006, if managers and dental care providers choose to administer and deliver services appropriately.

(Three authors Wayne Richards, Anne-Marie Coll, Teresa Filipponi)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Solving Social Care. And more besides

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The interim Parliamentary Review, published in July 2017, observed the the Welsh NHS and social care has been subject to many well-considered reviews since devolution. They all shared the common fate of not to achieving transformational change as they never successfully made the transition from the page to the front line. In an attempt to address this it recommended that Welsh health and care services should concentrate on a limited number of significant innovations, evaluate the outcomes and implement the most successful ones with a sense of urgency.

Despite this the Final Report (January 2018) itself produces ten “high level”recommendation (with many supplementary “supporting actions”) over-ridden by what the Review calls “The Quadruple Aim” of improving population health, improving the quality and experience of care, better engagement with the workforce and increase value for investment through innovation, elimination of waste and implementation of best practice. This represents a massive “whole system” challenge and one wonders if this Final Report will itself become a victim to the fate as its predecessors and for the same reasons.

At the heart of the final report is the challenge of delivering a health and care service that will meet the growing pressures it faces despite the continuing under-resourcing of public services in a era of never ending austerity. The unstated conclusion is that the high level recommendations linked to the Quaduple Aims will achieve the type of efficiencies that are needed to deliver a sustainable service.

Everything suggests that this is a heroic assumption. Health care funding has historically grown at an annual rate of over 3.5%. Annual efficiency gains in excess of 1.5% are exceptional despite desktop exercises which claim that a vastly greater efficiency improvement potential. Despite the very many useful insights and recommendations that the Final Report provides there is nothing in it that would indicate that it will deliver where others have failed.

But even if this report is not capable of delivering everything there are many key recommendations that the Welsh Government needs to take on board to improve health and social care performance in Wales.

The Final Report strongly reiterates the views of SHA Cymru and the Nuffield Trust that the Welsh Government needs to be more actively involved in the executive delivery of policy as well as the setting of the strategic direction for health and social care in Wales. While it is crucially important that Welsh Health Boards deliver locally sensitive services their relatively small size make them captive to many “localist” vested interests which makes it almost impossible for them to implement the strategic decisions which are required in Wales.

Local health boards seem to be have an disproportionate focus on acute services. SHA Cymru has pointed out that following the abolition of the internal market in Wales most of the health board senior management came from acute NHS trust backgrounds which very much flavoured the direction that policy would flow and that non-executive health board members were failing to provide sufficient challenge to this approach. This was not helped by the failure of the Welsh Government itself to emphasise importance of a holistic approach. And as budgets became ever tighter it has become even more difficult to move the agenda beyond the immediate priorities of firefighting the latest high profile crisis.

In response the Final Report makes a number of recommendations including that the Welsh Government should use a range of initiatives and financial incentives to mould the activities of health boards. This intention is laudable but it is arguable if the recommendations will be sufficient to achieve the required outcomes.

Considerable emphasis is placed on the importance of delivering more cohesive health and social care. The introduction of Integrated Medium Term Plans are welcomed but are seen as been being excessively verbose and mistaking policy quantity for quality. Many obstacles remain to greater integration with the report not acknowledging the fundamental problems that exist between a free or means-tested service and the substantial cultural differences that now exist between sectors that are delivered though the NHS and local government. The progress that Local Service Boards and Regional Partnership Boards are achieving is recognised and the Social Services and Well-being Act (2012) has provided an important legislative catalyst for change. But the Review does not ask if the Welsh Government needs to consider whether a more prescriptive legislative approach is what is needed to achieve the more accelerated progress that is needed.

Wales needs a shared infrastructure to start to make this happen. IT systems have to reach across all health and social care. Common, shared pathways with national standards are needed while still capturing both local and individual sensitivities. This will require Welsh Government investment to achieve the qualitative change and staff skilling to make it happen.

Compared to the Interim Report more attention is given to health inequalities though it still remains a fairly peripheral issue in the overall scheme of things. The wider importance of public health measures are emphasised in passing through this is outside the Review’s terms of reference. Health boards are urged to make greater use of epidemiological data to inform and to recognise the importance of very early years in their planning but there are no practical recommendations on how “to follow the money” or to identify and evaluate the processes and outcomes that will diminish the effect of the continuing “inverse care law”.

There is a very strong emphasis on the need to use the patient experience to measure service quality and inform the planning process. Linked to this is the need to involve clinical and other front line staff. It is vital to empower individuals and communities to achieve a good health and well-being and it recognised that those with the greatest need and who are most disadvantaged are often most likely to find this difficult to achieve. This is a task where health boards and local authorities could usefully work together to achieve the best results.

Most of what is in this Final Report is highly commendable though it is much broader in scope than the streamlined, targeted and readily implementable actions that the Interim Report felt was needed. Equally it is totally unrealistic to believe that it will achieve the step change in Welsh and social care performance that obviate the need for substantial public service investment in both services.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Land Transaction Tax and Anti-avoidance of Devolved Taxes (Wales) Act 2017

The Act includes provision for introducing a “Land Transaction Tax” (LTT) to replace the UK Stamp Duty Land Tax in Wales from April 2018 and measures to tackle the avoidance of devolved taxes. The Bill sets out:

  • the key principles of LTT, such as the types of transactions that will incur a charge to LTT and the person liable to pay LTT;

  • the procedure for setting tax rates and bands;

  • how the tax will be calculated and what reliefs may apply;

  • specific measures to tackle devolved tax avoidance;

  • the application of the Act in relation to leases;

  • the specific provisions applicable to a variety of persons and bodies in respect of LTT;

  • the provision for making a land transaction return and for the payment of the tax; and

  • duties on taxpayers to make payments and pay penalties and interest in certain circumstances.

Further detail about the Act can be found in its accompanying Explanatory Memorandum.

The Land Transaction Tax and Anti-avoidance of Devolved Taxes (Wales) Act 2017 became law in Wales on 24 May 2017.

Legislation in Progress – current Bills

Public Health (Wales) Bill

The Public Health (Wales) Bill utilises legislation as a mechanism for improving and protecting the health and wellbeing of the population of Wales. It comprises a set of provisions in discrete areas of public health policy:

The Bill proposes to introduce changes that:

  • Re-state restrictions on smoking in enclosed and substantially enclosed public and work places, and give Welsh Ministers a regulation-making power to extend the restrictions on smoking to additional premises or vehicles;
  • Place restrictions on smoking in school grounds, hospital grounds and public playgrounds;
  • Provide for the creation of a national register of retailers of tobacco and nicotine products;
  • Provide Welsh Ministers with a regulation-making power to add to the offences which contribute to a Restricted Premises Order (RPO) in Wales;
  • Prohibit the handing over of tobacco and/or nicotine products to a person under the age of 18;
  • Provide for the creation of a mandatory licensing scheme for practitioners and businesses carrying out ’special procedures’, namely acupuncture, body piercing, electrolysis and tattooing;
  • Introduce a prohibition on the intimate piercing of persons under the age of 16 years;
  • Require Welsh Ministers to make regulations to require public bodies to carry out health impact assessments in specified circumstances;
  • Change the arrangements for determining applications for entry onto the pharmaceutical list of health boards (LHBs), to a system based on the pharmaceutical needs of local communities;
  • Require local authorities to prepare a local strategy to plan how they will meet the needs of their communities for accessing toilet facilities for public use; and
  • Enable a ‘food authority’ under the Food Hygiene Rating (Wales) Act 2013 to retain fixed penalty receipts resulting from offences under that Act, for the purpose of enforcing the food hygiene rating scheme

The Bill was introduced on the 12th of September 2016.

The Bill is currently at stage Post-stage 4.

The Solicitor General on behalf of the Attorney General, Counsel General and the Secretary of State for Wales wrote to the Chief Executive and Clerk of the Assembly to advise that they would not be referring the Public Health (Wales) Bill to the Supreme Court under sections 112 or 114 of the Government of Wales Act 2006.

Additional Learning Needs and Education Tribunal (Wales) Bill

The Bill makes provision for a new statutory framework for supporting children and young people with additional learning needs. This is to replace existing legislation surrounding special educational needs and the assessment of children and young people with learning difficulties and / or disabilities in post-16 education and training.

The Bill also continues the existence of the Special Educational Needs Tribunal for Wales and provides for children, their parents and young people to appeal to it against decisions made in relation to their or their child’s additional learning needs, but renames it the Education Tribunal for Wales

The Bill was introduced on the 12th of December 2016. It is currently at Stage 2.

Stage 2 began on the 7th of June. Dates for Stage 2 consideration are yet to be agreed. No proceedings may be taken at Stage 2 until the financial resolution has been passed by the Assembly. The financial resolution for this Bill is expected to be moved following the summer recess.

Trade Union Wales Bill

According to the Explanatory Memorandum accompanying the Bill, the purpose and intended effect of the Bill is “to ensure the continued and effective delivery of public services”. It seeks “to support the social partnership agenda, through which the continuous improvement of key public services in Wales can be delivered”.

The Bill proposes to introduce changes that dis-apply certain provisions of the UK Government’s Trade Union Act 2016 as they apply to devolved Welsh authorities. The provisions to be dis-applied are as follows:

  • the 40% ballot threshold for industrial action affecting important public services;
  • powers to require the publication of information on facility time and to impose requirements on public sector employers in relation to paid facility time;

  • restrictions on deduction of union subscriptions from wages by employers

The Bill was introduced on 18th of January 2017. It is currently at Stage 3.

Stage 2 began on the 10th of May 2017. Stage 2 consideration took place in the Equality, Local Government and Communities Committee on the 15th of June.

Abolitions of the Right to Buy and Associated Rights (Wales) Bill

According to the Explanatory Memorandum accompanying the Bill, the purpose and intended effect of the Bill is to end all variations of the Right to Buy and the Right to Acquire.

The key purposes of the Bill are to:

  • abolish the right of eligible secure tenants to buy their home at a discount under Part 5 of the Housing Act 1985 (Right to Buy);
  • abolish the preserved right of eligible former secure tenants to buy their home at a discount under section 171A of the Housing Act 1985 (Preserved Right to Buy);
  • abolish the right of eligible assured or secure tenants of a registered social landlord or private registered provider to acquire their home at a discount under section 16 of the Housing Act 1996 (Right to Acquire);
  • encourage social landlords to build or acquire new homes for rent, the Right to Buy, Preserved Right to Buy and Right to Acquire will not be exercisable by tenants who move into new social housing stock more than two months after the Bill receives Royal Assent, subject to certain exceptions;
  • provide for at least one year after the Bill receives Royal Assent before the abolition of the Right to Buy, Preserved Right to Buy and Right to Acquire for existing social housing stock comes into force.

Further detail about the Bill can be found in its accompanying Explanatory Memorandum.

The Bill was introduced on the 13th of March 2017.

The Bill is currently at Stage 1.

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SHA deplores the weekend actions of computer hackers that caused the paralysis of large parts of the NHS in England and Scotland, placed patients at risk, and in some cases brought to a halt some ongoing operative and diagnostic procedures. SHA pays tribute to the NHS staff that coped so magnificently with such interference and those who toiled over the week end to restore services.

SHA notes that the Welsh NHS was not especially affected and believes that this is due in no small measure to the integrated way in which  primary and secondary care services are planned, delivered and supported in Wales which removed the internal market and its damaging effects over a decade ago. SHA also understands that the technical resilience of NHS Wales was in no small measure due to the priority given, over a number of years, to investment in NHS Wales IT systems and to the role of its central NHS IT support team.

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

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

 

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Health Secretary Vaughan Gething

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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