SOME IMPLICATIONS FOR WELSH NHS
In April 2013 the First Minister, Carwyn Jones, established a commission chaired by Sir Paul Williams to independently review all aspects of Wales’ public services to see how they are currently working and how they can be improved in the future. On Monday, January 20th Sir Paul, who was formerly the Chief Executive of NHS Cymru, published his Commission’s report.
It is a very important document which plans to fashion public services in Wales for the next generation. Due to its recent 2009 structural reform which ended the “internal market in Wales the Commission was asked to exempt the NHS from direct recommendations. Nonetheless there are implications for the NHS in a number of its key recommendations.
The Commission’s overall view is that public services in Wales have islands of good performance. There is therefore an urgent need for these to be extended to become the norm.
Welsh public services need greater ambition and greatly improved performance across the whole sector. We need to raise the bar to higher than being “best in Wales”. These problems run much deeper than what arises from the complexities and difficulties created by the myriad of existing structures and organisational boundaries. Transformative improvement is needed, not least because projections anticipate that Welsh public services’ resource will decline by up to £4-5bn for the next decade or so.
This reduction will have a major effect on the role of the state and public services in delivering “the common good” both in terms of practical service delivery and in being an important dividing line in policy terms.
The Report accepts that public services in Wales will not be subject to the invisible hand of commercial and competition challenge. Consequently the visible hand of public accountability and scrutiny must fill this gap as a means of driving performance. However this is done very inadequately in Wales at the moment.
Public engagement is often seen as a bureaucratic necessity which, as the Report agrees, almost invariably changes nothing. This perception is particularly true of the NHS. Scrutiny is seen as threatening and usually evokes a negative and defensive response.
The Report recommends a move to a total integration of health and local government services in Powys on the basis that this large rural area has only community based health care with hospital services being delivered from outside its border. While earlier moves in this direction did not reach fruition, this integration should be welcomed as an important innovation which could provide wider lessons for NHS areas that do have a hospital network.
Community Health Councils (CHCs) are recommended to continue with an enhanced advocacy role but probably with a diminished inspection role. CHCs spend a lot of time and effort on their inspection programme but it is not clear that it adds anything to the inspection programmes carried out by other regulators. However the Commission does not acknowledge that while CHCs have been an important part of the NHS landscape in Wales for decades, they have seriously underperformed in terms of being an effective patients’ voice.
They do come to the fore when major service re-configuration is taking place but their day to day work is very low key and is almost unnoticed by the public. The purpose and role of CHCs is valuable but we need a better way of giving effect to it. One option is that this might be achieved by CHC functions being linked to more organically to mainstream democratic structures and processes.
This might be a role for an enhanced CHC but also it could also be a role of a democratic body such as the local authority perhaps enhanced with third sector and other public interest groups. We could also consider an enhanced role for CHCs in social services scrutiny though there could be an overlap with local government scrutiny which would be an unwelcome duplication. Again this is an argument for an integrated public scrutiny system incorporating local government.
A fundamental weakness in proposing democratic scrutiny of the NHS by local government is that its current scrutiny of its own services is not an exemplar of good practice. The Williams Commission makes clear that local government scrutiny must see massive improvement and the proposal to extend local government’s scrutiny role in the NHS should be seen in this context.
The Report correctly is critical of the adequacy of the current performance of Local Health Board non-exec board members. They are appointed for their technocratic expertise but this creates a major gap in local democratic accountability. A balance has to be drawn between local accountability and professional expertise in carrying out board duties but the Report suggests that the current balance is not right. This seems to be correct.
The present LHB structure ,which is the outcome of the abolition of the internal market in Wales, is correct but it needs to improve its governance performance. Too often LHB boards have the mind-set and behave like a former acute hospital trust board ( with all their weaknesses). They have not been able to incorporate the good community links that the earlier LHB boards had created, accepting that the former LHB boards were too big and unwieldy. As well they are still struggling to give effective priority to primary and community health care.
Interestingly the Report highlighted the apparent paradox that Board members are corporately responsible for their own decision making and still have, potentially, a self-scrutiny role. It seems to suggest that the scrutiny role is not compatible with the corporate decision role. The unstated but obvious implication of that is that there is a need for external scrutiny and challenge. If this external scrutiny was to have some democratic basis it might help to fill the accountability deficit that the Commission identified.
The Report did flirt with the idea of democratically elected LHB non-executives but it did not explore the idea in any depth. Is this something that the SHA might wish to consider though it is likely that LHB elections would resemble the Police Commissioner elections which have provided a somewhat limited popular mandate?
The Report was very clear in rejecting the transfer of adult social services to the NHS. On balance their conclusions are correct even if the decision is fairly finely balanced. The Report says, as an alternative, that there are sufficient mechanisms in place to allow joint, integrated social services commissioning and delivery. This is the case as there has been an insufficient use of these mechanisms — a symptom of the overall sluggish public service performance in Wales.
The Report recommends closer links between the Ambulance and Fire Service. Again this is something that should be welcomed. The Fire and Ambulance service is a joint service in many countries like France and in parts of the USA. There are obvious synergies between the services though there are massive operational and cultural differences at the moment.
Interestingly the Report is very positive about many aspects of the performance of the Fire & Rescue Service. This stands in contrast the on-going challenges facing the ambulance service. An immediate priority must be to improve the performance of the ambulance service. Nonetheless a clear signal as to the direction of travel should be given to both emergency response organisations with a medium objective of much closer integration of the two services. A key early issue in this context is the station network of both services. The Welsh Government should require that no decision on station network of either service is taken in isolation and should consider the implications for its partner blue light organisation.
The Welsh ambulance service has been to the fore in enhancing the skills of its paramedic staff to cover conditions that are not immediate life threatening conditions. These enhanced skills do overlap with some GP out of hours work. At the moment the ambulance service is seen as part of hospital out-reach services. Consequently they are obliged to transfer their patients to Accident & Emergency Departments if they are not being brought to the hospital for admission. Some flexibility in these arrangements could allow the ambulance service to also interface with primary care and bring patients to that service if clinically appropriate rather than mechanically bringing them to A & E Departments.