SHA Cymru welcomes this Stage 2 consultation exercise. There are a number of positive proposals but in the Iechyd Da – A Healthier Wales section there is little that will have a “transformative effect which will make a real difference”. It is a continuation of the present range of policies. These policies are having some welcome impact but at a slow pace. They are not “the bold ideas” that the consultation document calls for.
Labour has a proud record but this legacy is more or less exhausted. We must show the electorate that we are a party with a new range of fresh and radical ideas that reflects the needs of Welsh people. We cannot be the party of the status quo and “more of the same”.
Health and social care will be massive Senedd election issues and it is essential that the extra £600m investment is used to make a real difference. The level of performance will need to continue to improve to make a sufficient impact by the election day.
The present state of health and social care is clearly not in balance. Our ambulance services, A/E Departments, acute wards and waiting lists are under intense pressure. There are a number of reasons for this:-
- Primary care is not working well enough
- There are too many bottlenecks in our diagnostic pathways
- Secondary tier services are not being used to best effect
- Patient flows are not optimal due to delays in making social care arrangements.
KEY NHS PRINCIPLES
The key founding principles of the NHS are universal care, free at the point of delivery, based on need, publicly funded and publicly provided – though we note that the UK Government does not regard public provision as a core requirement.
The Ministerial Advisory Group on NHS Wales Performance and Productivity took the view that there is a cultural reluctance to use capacity in the independent sector in Wales. The Welsh Government must not be beguiled by this criticism as there is scant evidence that the use of the private sector provides for better patient care.
PRIMARY CARE
General Practitioners are crucial to primary care. However over recent years there has been a constant decline in the number of FTE GPs from 1,611 in 2021 to 1,581 in 2025. This decline in front-line GPs has taken place despite a 14% increase in the numbers of doctors in GP training. So though more GPs are being trained in Wales, they are not taking up Welsh posts in sufficient numbers.
These figures must in part explain the continuing problems patients have in getting GP appointments and the pressure that GPs themselves feel under.
In view of this it is not at all surprising that the number of consultations in General Practice has gone down over recent years (21m in 2022-23 to 19.4m 2024-25). This in turn will mean there will be greater problems for GPs to have the time to deal with the growing number of patients with more complex needs.
At the same time there is increasing use being made of physicians’ assistants and advanced nurse practitioners to fill the gaps. This down-skilling, with its reduction in patient safety and a lack of professional transparency, is not acceptable especially at a time of growing medical unemployment.
Policy implications:-
- appointment of more GPs
- set target of 2,000 FTE GPs by end of next Senedd term.
- set targets to reduce average list sizes to 1,500 patients / GP, starting in most socially disadvantaged areas.
- as fewer GPs are interested in becoming independent contractors, a public service salaried option with national contracts must be made available which will both keep doctors in the profession and make general practice an attractive option for new graduates.
- strict monitoring and workforce planning to ensure that GPs are appointed where needs are greatest.
- curtailment in the use of PAs and ANPs as substitutes for more doctors.
IMPROVED EFFICIENCIES
The Ministerial Advisory Group on NHS Wales Performance and Productivity highlighted the need for NHS Wales to be more efficient in its performance. While some of its recommendations are straight out of the NHS England marketisation play-book and need to be avoided, there are a number of proposals that should be taken on board.
There is unacceptable variation in performance across the NHS in Wales in terms of facilities use such as theatre time and staff. Waiting lists need to be managed in a more orderly and disciplined way with bottlenecks in the diagnostic and investigations pathways addressed with more investment. Elective surgical capacity needs to be protected from the pressures from the acute sector and the establishment of “surgical hubs” is a welcome step in this direction.
About 1 in 7 of acute hospital beds are occupied by patients who do not clinically need to be in hospital but cannot be discharged due to delays in assessments and the provision of community health and social care arrangements. There are innovations such as “Discharge to Recover then Assess” but these schemes will only work where there is a strong network of primary and community health care available linked to fully holistic social care packages. Starting with GPs, this capacity simply is not there.
A/E Departments are under growing pressure. This is partly due to more and more patients using A/E Departments as default because of access issues at a primary care level (often prompted by the 111 service) and as a means to circumvent delays in their elective care pathway. The “Six Goals for Urgent and Emergency Care” has been in place for a number of years but it has had limited impact due to much of it requiring additional work and staffing levels that an over-stretched workforce is struggling to deliver.
It has been estimated that 1 in 5 patients do not need emergency or urgent care and could be safely treated in another setting. In addition a lack of a proper flow through our hospitals means that moving patients’ care on to hospital wards is becoming ever more problematic as is moving patients through their in-patient care pathways.
For much of the year acute wards are working at over 80% capacity. This means there is limited headroom for surges in demand – some of which is predictable over the winter months but which can also occur at other times. This is a dangerous practice for patients, puts unacceptable pressure on staff and should not be tolerated as routine. In part this may be due to a lack of properly staffed hospital beds but clearly other factors are involved as well.
In 2023-24 over 260,500 hours were lost to the ambulance service due to handover delays. This in turn has led to greater problems for emergency patients being seen and transported to an appropriate place of care. Again this reflects an “all-system” problem with part of the solution being an upskilling and enabling of ambulance staff to have more discretion in how and where they move patients to places of care.
NATIONAL CARE SERVICE
The move towards a National Care Service is a top priority. We welcome the steps that the Welsh Government is making in this direction including the removal of “for-profit provision” in children’s services. Over recent years the Welsh Government has done a lot to sustain our social care service through the introduction of the “real living wage” for care staff, implementation of workforce registration, more generous means testing for social care and a cap on domiciliary care costs etc.
The present substantially privatised provider model is clearly not working well with very wide variations in terms of pay, terms of service and training. With the establishment of national social care standards in many of the areas that private providers used to make “savings”, this model is more problematic. The Welsh Government needs to review the role of public sector care provision, starting at domiciliary care level as an immediate priority.
In addition SHAC believes that the Welsh Government should have a designated Minister to champion services for those with a disability with a strong focus on a social model of care to ensure that these people live a full and fulfilled lives. People with a disability not only have a need for more care but they have a reduced life expectancy. They need targeted programmes to address their additional needs.
DEMOCRACY, GOVERNANCE AND ACCOUNTABILITY
While the NHS is, by far, the most valued public organisation in the UK, it operates with little public accountability and has a strong focus on responding to illness rather than promoting health. And too often care is not patient-led with it being delivered in an undignified and unhearing way. It has always been difficult for the patient’s voice to be heard in the NHS and we are not convinced that the Llais reforms have improved the situation.
For many patients physically accessing services is a formidable challenge, incurs unacceptable financial costs and a deterrent to seeking care. Services are provided in unsuitable and difficult to access locations or are logistically too far away from where people live. The presumption must always be that services are delivered as close to their users as possible — consistent with quality standards.
In the early years of the NHS there was much greater public accountability as local government was very involved in the provision of many community and public health services. Every year, for example, local Medical Officers of Health had to provide reports on their catchment populations. While these reports were often formulaic and pro-forma, they nonetheless gave an overview of the state of local public health and helped to inform a range of policies that contributed to improving the well-being of the local population.
There is a big democratic deficit in our NHS. To fill this gap our local councils should have a statutory duty to hold local health organisations to account for their performance and to receive an annual public health report. This will provide added public accountability to our NHS. It will also help the NHS to inform local government of the sorts of policies that will promote a healthier population as well as facilitating a more holistic understanding of what is required to address the needs of vulnerable children & families as well as dealing with social care issues.
In the early 1980s the Welsh NHS led the way in devising a strategic direction for our health services in Wales to address preventive, anticipatory and therapeutic care. This innovative and exciting approach got swallowed up in the Thatcherite drive towards markets and the commercialisation of health care. SHAC believes there is a case for revisiting this approach to see what lessons can usefully be learned.
DETERMINANTS OF ILL HEALTH
Repeated reports over the last decade by the Chief Medical Officer and Public Health Wales have pointed out the deterioration in Welsh public health linked to growing health inequalities. Devolved administrations, like Wales and Scotland, have led the way in addressing many factors that have contributed to this through tackling smoking, alcohol misuse, the consumption of high calorie foods, innovative school meals initiatives and programmes such as the Flying Start.
But the growing levels of obesity and being over-weight, reduced levels of physical activity and the loss of affordable communal spaces (including loss of public toilets) show that we have a growing unhealthy social fabric which is creating an increasingly unhealthy nation. A long-term evidence-based strategy, including the use of strict regulation and fiscal interventions, is needed to reduce the consumption of high fat, salt and sugar (HFSS) food and facilitate the uptake of healthy minimally processed alternatives. Working with the UK Labour Government we need to be doing much more to address the determinants of poor health and health inequalities.
In many parts of Wales there are promising initiatives such as “Marmot” regions, cities and towns being developed, but they need to be rolled out in a much more comprehensive and dynamic way. We also note the excellent work of the Deep End Cymru which demonstrates the persistence of the Inverse Care Law in Wales with resources being still least likely to be allocated to where need is greatest. Again these inequalities must be tackled as a priority.
INNOVATION AND IT
The NHS and social care is making a greater use of IT. The case for much of this makes sense and should be built on to promote more effective, efficient and timely care. The use of a shared record across health and social care is long overdue. This information can be extremely useful for health service planning, education and research.
But there is a need for clear vision in terms of avoiding greater health inequalities, promoting public trust and protecting confidentiality and privacy. There seems to be an unstoppable impetus towards a digital first NHS and social care. But we do need to take stock.
The Public Health Wales survey (2023) on digital health use in Wales as shows, many patients find it a barrier. It reported that only 20% felt that technology provided a better patient experience compared to 50% who disagreed. This was more likely to be the case with older people with poor health. And much less use was likely to made of IT to deal with clinical matters as opposed to getting information or administrative tasks. Though IT use has increased since Covid there does not seem to be any groundswell of enthusiasm to replace face to face care with digital substitutes.
There needs to be reasonable expectations on how fast people wish to engage with new technology and a greater understanding of the problems that users face in doing so. There is a regular rhetoric about designing IT services around users without fully acknowledging the totality of the reasons why users still wish to give primacy to personal human interactions.
November 2025.