A chance for Welsh health and social services to coalesce

When local government was re-organised in 1996 under the then Secretary of State for Wales, John Redwood, I was working for an organisation of parents and carers of people with learning disabilities. We were concerned about the scale of the new authorities, about the retention of skill and expertise on specific conditions such as autism.

We were concerned, too, about the process of change and the loss of the effective public engagement which had developed.  The involvement of service users and carers in the planning and design of local services had required a greater degree of transparency in decision making than ever before.  Relationships had developed between social services, health, and user and carer organisations.  It was not perfect, but it was a big step forward and something which members of the public valued and wanted to protect.

The issue of democratic accountability for the delivery of health and of social care and the link with really effective, consistent public engagement remains highly relevant. It is a theme which runs through many of the challenges which face us in the delivery of health and social care.

When First Minister Carwyn Jones announced the creation of the Commission on Public Service Governance and Delivery he described any conclusion that this was just a step towards inevitable reorganisation of local authorities as “premature”.  However, he also said that he believed there was hardly anyone “who believes that having 22 local authorities, with their present boundaries, is right for delivering local government services across Wales”.

We have a big opportunity to create a coherent structure, which would give critical mass to local government, better to meet the many challenges which face it, to link health effectively with social care, to have a far more consistency across Wales, and to tackle the many unjustifiable postcode lotteries. Underpinning this would be local democratic accountability working with and supporting public engagement on a range of levels. Change is going to happen, structural reform is a necessary bridge to the future. It is an enabling step for the major work which lies on the other side.

When I did my MSc Dissertation in 2000 as the National Assembly came into being, I looked at the opportunity for the new Assembly to deliver health and social care more effectively than the previous arrangements. Everyone I interviewed spoke of the potential of the Assembly to drive far more effective participation, involvement and partnership as being the great positive. There is much further to go to realise this potential and the Commission, which is due to report before the end of the year, has the chance to enable a significant step forward.

The effectiveness of the links between health and social care matter very much to individuals. Failure to work together well leads to, for example, delays in discharge from hospital, to lack of availability of the timely, low level support which can prevent social isolation and depression, it increases pressure on unpaid carers.

As Wales faces further reductions in public spending, this question of re-configuring services to prevent dependency becomes more pressing. The Wales Audit Office, in its thoughtful report A Picture of Public Services 2011’ looks at the key financial challenges facing Welsh public services. Cuts in one part of the public service can, and often do, have an impact on another. The report says:

“The obvious example is cuts in social care, which potentially just re-direct service users and costs over to the NHS. In our view, there is a real strategic gap in terms of guidance and direction around cuts”.

The strategic gap is linked to structure, to the lack of good alignment between the different parts of public services. We need strong and responsive leadership, locally and nationally if there is to be an effective response to tough financial times.  Responsiveness and really engaging with the public in a dialogue is key.

The Wales Audit Office goes on to say that all public services will need to fundamentally review the way in which they work, “identifying and designing out activity which does not provide real value, and providing high-quality services which people want and need.” This is what lies on the other side of structural change.  In practice achieving change is often difficult, controversial and testing to creativity and relationships. Achieving the widest possible understanding and support will be essential.

The shift in services towards a far more citizen driven approach will need momentum to be both created and, vitally, sustained.  The Llankelly Chase Foundation, an organization which works to transform the quality of life for those who face severe and multiple disadvantage, has produced a useful list of those things which cause decision makers to want to change.  They are also I believe the things which are needed to sustain change. They are: evidence, scrutiny and visibility, voice and power, equality and diversity and rights.  All of these things are linked to the effective engagement of citizens, from better, more systematic means of understanding the experience of people in hospital to equality of access to sports and to the arts.  The point is that citizen involvement is integral to achieving improvement.  Process and the outcomes achieved are essentially linked.

Dan Boucher, in his recent book, The Big Society in a Small Country, published by the IWA, speaks of the value of associations, the mediating structures between the individual and the state. He also quotes cultural historian and commentator Peter Stead, “We need to completely redefine the nature of public life in Wales so that people are doing things other than administering the lives of others.”

Associations, clubs, societies, communities of interest around faith and belief, sport, creativity, campaigns are the way in which society organizes itself, examples of energy, connectedness and places where opinions are shared and evolve. Public policy needs to support and draw on this energy and on the ability of communities and individuals to address their own challenges.

The opportunity now is to put in place a structure for public service delivery which brings closer democratic accountability to health and which gives local authorities sufficient scale. This should underpin the continuing work of making a reality of appropriate, resource-effective engagement. My experience showed me that this requires a clear planning structure to be in place, for aims, objectives and principles of services to be clear and explicit, for there to be open discussion and meetings involving all parties, a timetable for decisions and practical support for non-professional involvement. There is a major opportunity here to develop a public service which has public engagement hard-wired into its design and operation. This really does have transformatory potential.