A revolution is needed in Wales’ Health and Social Care

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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