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