Where health and social services should meet

On occasion in Welsh politics important matters slip though the net and get little attention. One of these is the Welsh Government’s Commission on Public Service Governance and Delivery that was announced earlier this year (here). If it sounds as though this is about boring bureaucracy in one sense it is. Nonetheless, the Commission’s deliberations will have profound consequences for the future of both Welsh local government and the health service.

The chairman is Sir Paul Williams, former Chief Executive of Bro Morgannwg NHS Trust, later of Abertawe Bro Morgannwg University Health Board, and then NHS Wales itself, between 2009 and 2011. This may suggest a likely health service bias to what the Commission will decide.

Tomorrow Winners and losers in another Welsh council shake-up Mike Hedges says another reorganisation of local government could cost some Council Tax payers dear.

That would probably be wrong. In it’s terms of reference, lately published on the Welsh Government’s website (here), the Commission has been told explicitly that it must not interfere with the boundaries of the seven NHS Trusts in Wales. On the other hand, it appears to have a free hand to recommend what it will so far as the boundaries of the 22 local authorities are concerned.

But that, too, might be wrong. This is what First Minister Carwyn Jones told the Assembly when he made a statement about the Commission at the end of April:

“When I made my announcement two weeks ago, many leapt to the conclusion that this was just a step towards the inevitable reorganisation of our local authorities. That is premature. Resources are scarce; no responsible government would incur the cost and disruption of any major structural reforms without a clear, coherent and compelling case for doing so. So, while there may well be a case for reorganisation, it has not yet been made clearly. I am not going to pre-empt what the commission might conclude on this issue or anything else, and I urge others not to do so either. However, I am clear that the status quo is not an option. Change is inevitable and essential, whether in terms of the structure, funding, leadership or accountability. All those involved in public service management and delivery should prepare for that—not apprehensively, but by contributing fully to the debate and helping to shape the future.”

Apart from Sir Paul the Commission has six members. Again, their names have been slipped out on the Welsh Government’s website with little fanfare, and little if any notice from the media. They are:

• Nick Bennett, Chief Executive of Community Housing Cymru and one time Liberal Democrat Assembly candidate in Ynys Mon.
• Nick Bourne, former AM for Mid and West Wales and former Leader of the Conservatives in the Assembly, and currently a member of the Silk Commission.
• Nerys Evans, former Plaid Cymru AM for Mid and West Wales, a Welsh Government commissioner in Blaenau Gwent, and part of the Deryn lobbying firm.
• Juliet Luporini, owner of the Kardomah restaurant in Swansea, chair of the Swansea Business Improvement District, and a member of Economic Minister Edwina Hart’s Task and Finish Group that looked at Business Rates.
• Gary Owen, Wales Regional Officer of the Unite Union and former chair of the Wales Labour Party.

Quite why this group has been chosen and what their expertise is in local government, the health service and relations between them is unclear, though plainly they touch base with each of the four parties in the National Assembly. However, they’ll have to get their skates on because their terms of reference (here) say they have to report by the end of the year. The terms of reference list the following factors which the Welsh Government says should inform their findings:

1. The current structure of Local Health Boards within Wales is already supporting the move to integrate services more effectively and to put services on a sustainable footing for the medium to long term. The Welsh Government would not, therefore, expect LHB configuration to require consideration by the Commission.
2. The action already underway in developing the provision of public services including, but not limited to, the work of the Public Service Leadership Group as overseen by the Partnership Council for Wales; the Welsh Government’s footprint for collaboration in public services; and the range of legislative measures such as the Social Services Bill, the Sustainable Development Bill and the Planning Bill.
3. The need for greater simplicity in governance and delivery arrangements for services in order to enable effective integrated planning and delivery for people in Wales, including through the work of Local Service Boards.
4. The recommendations of the Hill Review into education improvement.
5. The proposals put to the Silk Commission by the Welsh Government (and any emerging outcomes from the Silk Commission).

By far the most important of these is the first, since one of the most important issues facing the Commission – indeed, probably the most important – is the relationship between the delivery of health and social services. This is where the wicked issues in the system are to be found, and where most money is lost. The implication, as leading figures in Welsh local government– from Russell Goodway in Cardiff to Dyfed Edwards in Gwynedd – have already acknowledged, is to align the boundaries of local government with the health authorities.

However, that immediately raises a major problem, which is north Wales. There is widespread acknowledgement that the Betsi Cadwaladr Health Board, which covers the whole of north Wales, from the Lleyn to Wrexham, is dysfunctional because it is too large and unwieldy. There are already calls for it to be split into in effect the old Gwynedd and Clwyd. If that were to happen, then a local government reorganisation to fit with NHS delivery could more easily follow.

The answer, surely, is to bite the bullet and make the NHS properly accountable on a local basis, just as education, social services, housing, waste collection and the rest are now. We should put them altogether into one democratic structure. Perhaps we could then have a real democratic debate about the reconfiguration of hospitals and the location of accident and emergency and maternity services. Will Sir Paul’s Commission have the vision and courage to follow this line of thought?