This commentary is from the officers of SHA Cymru. It does not necessarily reflect the views of the SHA as a whole or other SHA members.
During earlier phases of the Covid 19 pandemic it was expected that the “new normal” for health and social care would be be triggered once the pandemic had come to an end. But this was an unduly optimist view. We now have to look at a resetting of health and social care while the pandemic lingers on. This will add to the complexity of the challenge.
The Welsh Government recognises this in its plans to modernise planned care and reduce waiting lists in Wales. Though it has allocated £170 million to the task it envisages that it could take up to 2026 to get our service back to an acceptable normal. In the interim there will be a series of phased targets to monitor progress. There are almost 700,000 people waiting in the system and that there were as many 500,000 referrals deferred over the last two years. This reduction seems to be particularly high in the cancer field where referrals and investigation are significantly lower than expected.
This massive backlog will require critical changes to the way health and social care is delivered. The focus will be on prioritising children, those with the most urgent need and who have waited the longest. There is a very welcome acknowledgement that service capacity will have to increase in many key areas. Sixty per cent of the patients who are waiting have to receive their first appointment so diagnosis needs to be made more quickly through the development of new more streamlined diagnostic pathways.
How outpatients departments operate is crucial to this. The efficiency of this gateway must be improved through fewer visits delivering more optimal outcomes. Over 100,000 people are currently waiting for diagnostic tests. Diagnostics and assessments must dovetail more smoothly and where appropriate alternate pathways to diagnostics and care will be provided, including beyond conventional office hours and in new “Community Diagnostic Hubs”.
And while patients wait more support will be provided both in terms of managing clinical care and keeping patient informed about what is happening. This should help to prevent patients being unable to avail of treatment because of a preventable deterioration in their health while they wait.
There will be fewer routine, knee-jerk outpatient follow-ups. Instead more patients will be managed in a home setting with more ready access to advice and support through community and primary care services. Patients however will be empowered to self-initiate review or follow-up in line with protocols that are suited to their needs. The innovative use of IT means that these reviews will not always be at a physical out-patient clinic. However there will need to be greatly improved communication interfaces that work when needed if this is to be a real innovative asset rather than just another obstacle to care. In developing these new ways of working, priority will be given to the to the ten highest demand conditions.
Steps will be taken to protect elective and planned capacity. This is a particular issue with the ongoing pandemic due to the risks of infection spread in clinical setting affecting both patients who become unfit for their treatment and staff who are unable to work. Wherever possible there will be dedicated and segregated care pathways to protect elective capacity. There will be more regional elective centres with regional waiting lists to increase throughput, streamlined bespoke treatments and to provide segregated care.
But there will also have to be greater flexible capacity in responding to varying levels of emergency pressures. The present practice of running all in-patient services at close to maximum capacity must change. There should be headroom to allow for unexpected demand. The NHS needs to move more towards EU norms for hospital bed and medical staff numbers. There is a welcome recognition that it will no longer be acceptable to routinely curtail elective capacity in the face of predictable variability in “winter” bed pressures.
The Welsh Government says that the private sector will have to be mobilised to help clear the backlog. The Socialist Health Association Cymru supports the requestion of all private sector capacity for the common good .This needs to be done in a way that does not interfere with the re- building of NHS capacity so that service will be in a position to again be able to meet its own needs in a timely way. Wales had more or less achieved this position prior to start of the austerity cuts in 2010. But over the last decade annual spending increased by about 1.5% while out-patient demand alone increased by 4% so it clear that there is is a serious mismatch between capacity and need.
Much of what the Welsh Government is planning makes sense and can be achieved with proper investment to tackle capacity bottlenecks and through re-designed care pathways. These pathways need to be regularly monitored and remedial action taken where problems are identified. As the NHS internal market has been abolished in Wales, proper planning and leadership is needed at all stages to make it happen. And while programme has a particular focus on modernising planned care and reducing waiting lists in Wales it will not happen without strong joint working between primary and secondary health care and social services. And this is where the plan is weakest.
The plan is dependent patients achieving a smooth transition from home to hospital and back again. This will also require increased capacity and innovation within primary and social care. Investment in social care in Wales has continued to outstrip the position in England but the service remain very fragile. Services that prevent unnecessary admission or facilitate early discharge need to be enhanced. The decision of the Welsh Government to explore the creation of a National Care Service in Wales is therefore very welcome and well overdue.
In launching the Plan in the Welsh Senedd the Health Minister, Eluned Morgan MS, highlighted that though staff numbers in the Welsh NHS increased by over 50% in the last two decades more needed to be done. This is especially true in primary care where the numbers of GPs principals have remained static throughout all of this time at just under 2,000. Considering the role that being assigned to primary care in the plan, this continuing failure to recruit more GP and reduce list sizes over such a long period of time is simply unsustainable.
This failure to recruit GPs not only places this overall Plan in jeopardy but it also places the Welsh Government’s commitment to tackling growing health inequalities and the Inverse Care Law at risk. While the programme acknowledges that Covid has exacerbated growing health inequalities, there is little in it to indicate how the declared priorities of tacking health inequalities are to be addressed. There is the usual exhortation to people to live healthier life-styles and for a greater involvement in the self-management of their care. Achieving any of this is however highly problematic in the face of the cost of living crisis, the loss of health promoting public facilities in our poorest areas and the lack of an effective allocation of capacity in line with need.
A key part of the Plan is greater engagement in providing quality assurance on the service that is being provided. The public will be involved in service design and change so that they the more match user needs. In addition more work will be done to embed patient outcomes and patient’s experience in the pathway. Effectively using this information is crucial to providing reassurance about care quality or to indicate where service improvement is needed.