The eagerly anticipated Hussey report on health and social care in Wales is launched: will anything change this time?
Another year, another review of health and social care in Wales: same old, same old?
Calls for radical reform of health and social care do seem to come along with depressing regularity. Many old hands will recall a similar review by Sir Derek Wanless 15 years ago, which supposedly put the Welsh NHS on notice: change, or die. It didn’t, and it hasn’t. So far. Now Dr Ruth Hussey and her eight distinguished colleagues have come along and delivered a similar ultimatum.
Dr Hussey gave readers of the Welsh Agenda a sneak preview of some of their key findings when I interviewed her for the latest edition (Winter 2017). Now the final report is out, with about 80 recommendations and a clarion call for change: ‘Wales needs a different system of care… Unless faster, more widespread progress can be unlocked, access to and the quality of services will decline in the face of predictable pressures. The next five years will be a crucial test…’
If the case for change is compelling, then why hasn’t it compelled?
This is actually the title of Dr Hussey’s Foreword to the report; it was also the question I put to her in the interview. And here’s the answer: ‘ there has [been] neither sufficient clarity of vision nor sufficient attention on the practical means of achieving [it]’. The report’s recommendations try to plug both those gaps. Its subtitle: ‘A Revolution from Within’
Bold language, but what’s the substance?
The report tries to set out what amounts to a unifying philosophy, in answer to the question: what are health and social care in Wales trying to achieve? The answer is what is (rather inelegantly) termed the Quadruple Aim:
- Better population health and wellbeing through prevention
- Better experience and quality of care
- Better engagement of the workforce
- Better value from the funding
Surely the last thing we need is yet more principles and aspirations?
Most people in health and social care would wholeheartedly agree. But fortunately, all the rest of the report is actually about HOW this is to be realised. Successive sections focus on empowering patients and the workforce, on improvement and innovation, and – crucially – on how the whole system should work – how its accountability, leadership, planning and incentive structures can be lined up to revolutionise care delivery.
So what are the biggest suggestions?
As a start, every part of Wales would be required to carry out a fundamental reform of its model of care in at least two localities, using extra investment from a Transformation Fund. And then in the longer term, the report tries to establish a system which will automatically innovate and change rapidly of its own accord, without the need for constant rows and crises of confidence.
Some of the more nerdy recommendations actually have the greatest potential. For example, the report calls for much stronger and more effective national leadership of the NHS (‘a strengthened executive function’); joint accountability of local authorities and Health Boards; the use of indicators that measure health equity and population health; much better public sector management; a wholesale review of how change is incentivised; and a radical simplification of NHS planning. And in an attempt to hold feet to the fire, the report calls for an annual, public report on performance by the Government to be debated in the Senedd, with ‘transparent benchmarking across Wales, the UK and internationally’.
So is this a blueprint for the future?
Wisely, this report – less than 40 pages in total – is modest in its level of prescription. It tries to set out sufficient game changers, without getting bogged down in detail. It aims to create a platform from which health and social care can then move to a different plane.
Is there anything missing?
There are two huge gaps, neither of which were in their terms of reference. The first is resources. Even if all these changes are made, we can’t be sure that there will be enough money, or enough skilled staff, to make the new system work. This needs a substantial ‘transformation fund’ of new money, and it needs key people in the system to be freed from the relentless grind of keeping the current system going in order to make change happen. Second, will the politics work? At the very end of the report, there is a telling plea: ‘Building a modern health and care system on this scale requires bold and confident political leadership…’
Will it go down in history as a classic of its kind?
It just might, but it makes a big ask of the political, professional and managerial cadres. As the report itself points out: ‘Much of what is needed is not about structures but about culture and behaviour. Changing these aspects requires long term commitment to working in a different way’. As a piece of inspirational policy rhetoric, this doesn’t reach the heights of Beveridge’s five Giant Evils: ‘Wales should aim to get ahead of the curve… seeking assessing and scaling technologies that enhance access to advice and information…’ But its occasionally leaden prose will be forgiven if it manages to catalyse the scale and pace of change, which notably did not follow the Wanless report, or indeed many of the other attempts to foment revolution in Wales’ health and social care.
Here’s hoping!
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I am bitterly disappointed. Yet again lots of lovely philosophical aspirations – but nothing
new and no action.
My particular concern is the interface between health and social care in order to achieve
integrated care for older people – barely mentioned, even though we know that quite apart
from its own internal problems, social care (lack of) is responsible for much of the problems
of the NHS.
Action needed (this list is not comprehensive):
1. Redefine what is meant by “social care” – not a single concept; it consists of three
parts (living costs, support services (eg day centre, meals on wheels, aid and
adaptations, which are “proper” social care, and which are now squeezed out by the
third element – personal care, which is by definition not “social”). Personal care is
basic nursing care, which is the remit of the NHS.
2. Repeal Section 47 of the Social Services and wellbeing (Wales) Act which just at the
time when we need more working together, explicitly forbids local authorities from
“providing or arranging for the provision of a service or facility which is required to be
provided under a health enactment”, “meet a person’s needs for care and support (including
a carer’s needs for support) under sections 35 to 45 by providing or arranging for the
provision of nursing care by a registered nurse” “(5)A local authority may not secure the
provision of nursing care by a registered nurse in discharging its duty under section 15.
3. Remove the distinction between residential and nursing homes (already in Wales
legislation) and ensure that all care homes have appropriate staffing (ie including
nurses) to meet the needs of the increasingly sicker clientele, thus avoiding the need to
remove vulnerable people from on home to another when their needs increase.
4. Ensure that local authorities pay the proper rates to care homes, ending the scandal
that people paying for their own care have to pay for LA funded people as well.
5. Recognise and resolve the conflict between the commitment to prevention (which
requires early intervention) and the local authorities raising the bar for eligibility for
care to people who are already critical.
6. Mandate pooled budgets (mandatory in Wales from April) and use this to abolish the
distinction between “funded nursing care” and “continuing health care”, enabling
funding allocation to be based on a single assessment of nursing needs and abolishing
the huge wastage (and appeals and terrible angst for patients and families) associated
with the current system of continuing health care.
7. However, pooled budgets are only the first step – when you have a single budget, who
has the authority to spend it and on what? We will never get integrated care until (relevant
parts of) health and social care are delivered by a single organisation. Scotland has done
it(integrated care organisations required by legislation, which are responsible for delivering
services delegated by health and local authorities) so has Salford (which has transferred its
450 social care staff to the local NHS Trust) and some other pilot areas.
So why cant Wales?
Sadly the answer is because health and social care organisations cling to their autonomous power, do
not trust each other enough to delegate, and put their own status before the needs of patients.
I agree with June. Action speaks louder than words! My worry is that the Welsh Government will spend the next 18 months focusing on developing a range of ‘principles’, and that health and social care organisations will spend a lot of time working out how these ‘principles’ will be applied for specific groups in specific localities. However, in mental health for example, we already have national standards, we have principles, we have an all Wales all age agreed strategy, we have legislation and we have an abundance of policies. We don’t really need any more! We don’t need a set of ‘specific principles’ – what we need is for the current legislation, the existing strategy and the abundance of policies to actually be implemented and for their delivery to be measured. Instead of developing new principles, and writing new strategies, why don’t we try implement the ones we already have?