SHA Cymru Wales: Response to Welsh Labour’s Stage Two Consultation paper on health and social care.
1. SHA Cymru Wales is pleased to take the opportunity to help shape Welsh Labour’s policies in regard to health and social care in Wales. Our submission is the product of discussions among SHA members in Wales facilitated via several Zoom sessions and exchanges between members of drafts of the emerging response. The contents reflect the views of our membership. Our membership consists of past and current NHS and care staff from a wide variety of health and care backgrounds and also others who have interests as both citizens and users of different parts of the health and care system in Wales, or who are interested in the politics of health and care, and in political discussion.
2. The Party explained that the consultation document was finalised before Covid-19 arrived. It is clear that the pandemic has altered significantly the context in which Labour’s policy process now sits. Even though Covid-19 is still a major challenge at the time of writing this submission, SHA Cymru Wales believes that many of the issues arising from it are already clear (and are described in the “Independent Sage Report”). These are addressed in section B below which deliberately adopts a broader “emerging futures” perspective.
3. Not only has the pandemic impacted on the way the care system now works and is likely to work in the future, it has also impacted more widely on society in terms of altered work patterns, the wider use of technology both inside and outside the care system, and of course upon the ability of the economy to resource public services to the level needed.
4. Adding further to this new uncertainty is a pre-existing one of the consequences of the U.K withdrawal from the E.U. with probable changes to trade terms. Further the extent to which migrant labour will be available to support the health and care sector in Wales is already being adversely affected by the Immigration and Social Security Co-ordination (EU Withdrawal) Bill. The withdrawal – in particular its impact on food security, medicines safety and existing supply chains – must be fully assessed.
5. Section C deals with the content of the Policy Document itself. Here members sense a persisting lack of momentum and capacity to deliver the key objectives outlined in “A Healthier Wales”. SHA Cymru Walesaccept that a decade of austerity has been a major brake on improvements. Some progress has been made in terms of improved co-operation between health and social care at a local level with the establishment of the Transformation and Integrated Care Funds and increased training posts for a number of professions.
6. Transformational change however is not taking place in terms of promoting public health and rebalancing the care system towards prevention, anticipatory care and a community/primary care based service.
7. There have been a number of concerns expressed by the public about the quality, resilience, or consistency, of some clinical services in some parts of Wales. For example, hospital emergency services cherished by local populations are under threat and the reasons advanced for changes have not proved persuasive with the public. NHS in-house elective services struggled to treat patients within the target times set by Welsh Government before Covid-19. One Health Board depends heavily on the private hospital sector to undertake its elective work and is responsible for about 70% of all those referred by the Welsh NHS to private hospitals. Response times of emergency ambulances – often for reasons outside the control of the ambulance service itself -are sometimes longer than the service or ill patients would like. More widely there are some concerns about the resilience of the wider primary care services (including dentistry and pharmacy) in some parts of Wales. Finally there have also been a number of concerns about the quality, resilience or consistency of some clinical services in different parts of Wales.
8. These concerns suggest an enduring problem either with the way that NHS Wales is resourced to meet the requirements laid upon it, or with the managerial linkages between the Senedd and the different care settings in which: i) the maintenance of good health is pursued; ii) early diagnoses of likely ill health are made; iii) treatment is given to restore people to a state of good health and iv) ongoing care and support is provided.
9. In particular, SHA Cymru Wales feels that the care system in Wales is unbalanced in that anticipatory care and preventive work – in primary care and through public health measures -remains under-resourced despite the recent initiatives cited in the policy document.
10. Added to public unease about patient services, are worries about financial control in the Welsh NHS. The abolition of the internal market and it’s replacement with a model based on partnership and co-operation ought to provide Wales with a unique advantage compared with an England system driven by competition, outsourcing of work to the private sector, and debts caused by P.F.I. schemes still needing to be serviced. The strengths of the Welsh NHS need to be more effectively exploited. There are worries too about the effectiveness of the special measures regime that is intended to improve both the immediate management of the Welsh NHS, and the way that changes to services that cross Board boundaries are planned and implemented.
11. Underlying these concerns is an unease that there is no shared and unifying vision of what the Welsh NHS -with its local government and other partners- is being tasked to achieve for the Welsh public. “Healthier Wales” was intended to be the policy statement providing that radical vision. In our view it has been largely ignored and we return to this later in section C where SHA Cymru Wales suggest that NHS Wales builds upon past Welsh achievements in this regard, puts in place the political and managerial mechanisms to agree evidence-driven national policy objectives to be attained locally, and devises the mechanisms by which improved service delivery on the ground is assured.
12. There is little detail about true co-production of health by both citizens and care professionals and how this can be moved from rhetoric to reality. This too would be a powerful engine for transformation.
B. Covid 19 and its legacy
1. At the time of writing, members believe that Covid-19 will shape the context in which the management and development of the health and care system in Wales sits. The pandemic vindicates many of the policies and approaches of the Welsh Government. The Welsh public service model stands in stark contrast to the fragmented cocktail of private sector provision and procurement which characterises much of the response in England. The time and effort that has been spent over many years in Wales to build better working relationships between the NHS, local government and the third sector has facilitated a more coherent and coordinated response to the pandemic than appears to have been the case in England.
2. This public service approach allowed for partnerships at a local level which both responded to the leadership provided by the Welsh Government and to the local challenges faced by front line services. These partnerships should be maintained and refined as important community assets to promote local well -being.
Proposal 1: SHA Cymru Wales propose that Wales considers creating a permanent “Wales Health and Care Reserve” (WHACR) comprising ex-health and social care staff and other volunteers with a wide variety of skills that can be refreshed through updating training on a regular basis, and who can be called upon in an emergency to assist full- time staff. This reserve should be organised on a neighbourhood or Cluster basis to support community clinical and care networks. It should be supported by schemes such as the Duke of Edinburgh award and the Welsh Baccalaureate. Established voluntary bodies with a relevant skill base should be encouraged to become involved.
3. Welsh Government was correct to seek and encourage a “four nation response” to the pandemic even if it has not always come to the correct conclusion. It is regrettable that this was not always reciprocated by the U.K Government. The devolution settlement came under great strain as the four parts of the U.K. felt it necessary to respond to events as they saw fit. Different approaches to “lock down”, to testing, tracking and protecting across the U.K., and confusion about the purchasing of protective equipment and testing materials, exposed inadequacies in any U.K. wide arrangements meant to deliver a coordinated management to the effects of the virus.
Proposal 2: SHA Cymru Wales requests that Welsh Labour commit to seek to join with its Scottish and Northern Ireland partners, to pursue revisions to the arrangements that govern these matters with the U.K. Government so that a “four nation” response to any surge in this pandemic or in future pandemics is maintained. However, we do acknowledge that there will be times when it is necessary for the Welsh Government to take a Wales specific approach and we fully support its right to do so.
4. SHA Cymru Wales welcomes the Senedd’s early work to review the Welsh experience to date. This is important work in the event of a failure to fully eradicate the Covid-19 virus and if further waves of mass infection have to be faced.
Proposal 3: SHA Cymru Wales welcomes the First Minister’s support for a public enquiry to review these events. Its terms of reference should be agreed by all four nations. Further we believe that all advice given to Welsh Government in relation to the options for managing this crisis should be made available to the public.
5. SHA Cymru Wales recognises the pressure the Welsh Government faced in creating extra health provision as the Covid-19 pandemic began. This meant that the distinction between the health and social care systems became blurred as hospital patients were moved from acute beds to care homes in order to deal with an expected influx of patients with Covid-19. The result was that care homes were put at risk from viral transmission from hospital to care home settings. Further, people receiving domiciliary care services were also exposed to risks from itinerant care staff. Quickly the care system– comprising a range of privately run businesses of different sizes and types– required a degree of state support and guidance to sustain its operations. These took time to put in place. In this context SHA Cymru Wales congratulate the Welsh Government for ensuring a consistent supply of PPE to the care sector, for its extension of the testing regime in line with professional advice, and for the financial support provided to front line social care workers and others.
Proposal 4: The Covid-19 pandemic highlights the integrated nature of health and social care and the need for quarantine facilities, equity of equipment, training, pay and quality facilities for the social care sector as well as for the NHS.These arrangements should be put in place as soon as possible.
6. This scale of public service support needed for the social care sector must raise fundamental questions as to the long-term resilience of the current private sector business model.
Proposal 5: As part of a process of major reform SHA Cymru Wales urge that the social care workforce in Wales is immediately transferred to the public service and that the Welsh Government brings the management of the care sector back under public control and leadership.
7. Covid-19 has made it clear that the care system is fragmented – relying on multiple contracts with private sector providers especially those driven by commercial aims. Covid-19 exposed the inherent vulnerabilities in the present social care business model.
Proposal 6: SHA Cymru Wales believes that the time has come for the main components of adult social care in Wales to be brought under public control, stewardship, or ownership and funded broadly on the same basis as the NHS. Domiciliary care services should be brought under the purview of local authorities first.
8. “Personal care”, whether given at home or in a residential care setting, should be accepted as requiring oversight from the nursing profession and be delivered free under the NHS by staff trained to support individuals needing such care.
Proposal 7: SHA Cymru Wales recommend that work commences as soon as possible on assessing at what speed, and in what way, the transfer of selected services from the private sector in Wales to the public sector can best be achieved to forge a new and equal partnership of health and social care services in Wales. SHA Cymru Wales asks that work be done to assess the costs, benefits, and problems that would arise from such a change.
9. Room should be left for selected services to be operated by bona fide charities, co-operatives, and other voluntary groups where they have the skills and / or a reputation that resonates with the public. For example, Marie Curie Cancer Care, services supporting people affected by substance misuse, and charities supporting people through physical disabilities and mental ill health would meet this criteria. Here grants should be considered as an alternative to the formal contracts of a commercial relationship.
10. While the present pandemic is unprecedented in its extent it does highlight the problems that the NHS and social care face when placed under excess demand, as frequently happens with the regular “winter bed crises”.
11. The current DGH model combining elective and urgent surgery with emergency medical admissions alongside obstetric and paediatric services may need to be re-thought so that acute hospitals no longer operate consistently at very high levels of bed occupancy providing little head room for seasonal variations in demand. Elective capacity should be maintained in a protected environment by “built in” physical and engineering design and by so managing the protection and deployment of care staff so that transmission of any contagious infection is minimised. Similar considerations need to apply to ambulance services, primary care, community nursing, mental health and other health services, and indeed adult and children’s social care.
12. In England changes made to the public health function by transferring it to local government and then subjecting it (and other services) to reduced financial allocations have impaired its ability to react quickly and decisively to effect the necessary public health shut down testing and tracking arrangements long associated with controlling such diseases. The use of private sector contractors adds to fragmentation of the service. SHA Cymru Wales supports the current arrangements in Wales whereby a strong public health tradition set within a public service model has been preserved and is able to serve both Welsh Government, Welsh local government, the Welsh NHS, and the wider public interest. However, SHA Cymru Wales share the concerns of those who feel that the Welsh Public Health function has become too concentrated at its centre and has insufficient presence in or influence within local authorities, health boards, and their partners at a community and neighbourhood level.
Proposal 8: SHA Cymru Wales propose that Directors of Public Health should simultaneously hold statutory posts both in their local Health Board and in their local authority. This draws on past practice where medical officers of public health had a “proper officer“ function in local government with appropriate links with Environmental Health, Education, Community Development, and social care colleagues. Post holders should provide for both bodies an annual report describing local health status and how challenges of health inequalities should be, or are being met. The report should be taken in the public part of the agenda and drawn to the attention of community councils.This topic must feature highly in the performance regime linking Welsh Government, Local Government, and health Boards.
13. The pandemic has facilitated, or required, new ways of delivering patient services, managing organisations, and connecting communities. Many people have now experienced remote consultations with their GP or hospital services via video conferencing. Diagnostic results have been shared via the internet between clinicians. Engagement of staff and the wider public in remote discussions have brought into question the traditional ways of linking patients and their relatives. New ways of managing organisations have also emerged as “working from home” has expanded.
Proposal 9: Welsh Government should ensure that all citizens have reliable access to easy- to- use internet technology so that new forms of “ digital inequality” do not arise. Part of the work of WHACR cited above (Proposal 1) could be to assist people whose abilities or technical skills are not commensurate with relying on complicated technology.
14. SHA Cymru Wales believes, along with the Independent Sage Report, that these experiences have increased the desire and ability of communities and people to take an active part in debates about how their care services and indeed other facets of life – need to be re-fashioned “from the bottom up”. This sits alongside the ongoing development of GP clusters with a stronger community or neighbourhood focus.
15. Covid-19 will leave a harsh legacy and a massive workload in terms of both physical and mental health rehabilitation for patients. This will be in addition to the NHS and social care catching up with deferred elective care delayed due to the pandemic. There is clear evidence that the excess death rate experienced over recent months is not solely due to Covid-19. While it is not fully understood why this is the case, it is probable that a significant proportion is due to the failure to seek, or obtain, health care in a timely way. Also, Welsh Government must prepare for what has been described as a tsunami of rehabilitation care as patients recover from severe episodes of Covid-19 infections and the impact upon their mental health. It must also anticipate – and plan to deal with – a legacy of stress experienced by care staff in Wales.
Proposal 10: The Welsh Government should establish an urgent working group to plan how health and social care in Wales can recover from the longer-term consequences of Covid-19 on our country to both address the backlog in deferred need and the increased demand for physical and mental health rehabilitation. This should include consideration of making best use of recently commissioned health and care capacity.
C. A critique of the Stage 2 document
1. The Parliamentary Review on Health and Social Care in Wales concluded that there was an urgent need for rapid transformational change in Welsh health and social care services. This has been acknowledged by the Welsh Government. Welsh Labour’s consultation document however neither develops nor furthers this vision, nor does it convey an appropriate sense of urgency about the timing and nature of such change. It is a “steady as she goes” approach with “more of the same”. There is no clear set of priorities, sense of direction, or a picture of what the future of health and social care service in Wales ought to look like for service users, their families and carers.
2. The stand-still in life expectancy in Wales over the last decade with the persisting health inequalities scarcely merits a mention – again with no policy proposals as to how to respond. The Covid-19 pandemichighlights these inequalities where the most socially disadvantaged communities carried the heaviest illness burden.
3. Concerns remain about the failure to transform service delivery in line with both the Parliamentary Review and A Healthier Wales. This is exemplified by the tolerance of low levels of investment in primary care and a failure to recruit sufficient clinical staff.
Proposal 11: GP numbers should be increased to produce an average list size of 1,400 patients per GP.Starting in those clinical network areas with the poorest health profile and least health and social care inputs. Where the traditional GP contractor model is failing to deliver these numbers, health boards need to take the lead in directly employing multi- professional primary care team members, including well supported salaried GPs.
4. By reducing list sizes, patients will have easier access to, and more time with, their health care professionals so that a long-term caring relationship can be built biased towards prevention and anticipatory care. These communities, and other at-risk groups such as vulnerable children, care home residents, people with chronic illness and multiple morbidity etc. must be clearly identified and the outcomes from the care they receive be continually monitored with a view to continuing improvement. Clinical networks need to become a stronger focus for service innovation through a vision of health and well-being stretching far beyond a narrow medical horizon. The tools of public health and community development need to be harnessed to create stronger, healthier, resilient, and more engaged communities.
5. These networks must be further enabled to lead the shift away from over-dependence on secondary care and towards localised anticipatory and preventive services aimed at maintaining independence. This shift of resource must enable the GP:patient ratio to improve. It must respond to the challenge of “the inverse care law” and must underpin an increase in primary care resources and effort aimed at reversing the unexpectedly stalled improvements in mortality indicators.
6. General practice must no longer be viewed as a set of tasks carried out in isolation. It must regain its role as family practice committed to understanding local communities and the families that live in them and supporting them in pursuing their own good health. Practitioners in community development, social prescribing, and advocacy on community issues, must sit alongside continuity of care as part of a team of professionals serving the community.
Proposal 12: Each neighbourhood should have public health input and advice and should be integrated into the work of primary care clusters. This should be marked with a change of name; clusters should become “neighbourhood networks.”
7. Public health, primary care (including community pharmacies) and its estate should increasingly combine with other community assets such as post offices, food banks and community volunteers to create hubs which mix primary care provision with schools and community and leisure centres. In this way healthy living can be promoted and communities empowered to change the local culture and environment.
8. SHA Cymru Wales sees neighbourhoods as the basic democratic unit of the NHS where the local community, comprising both professionals and local people, work to bring about beneficial changes and fashion the NHS as a people’s endeavour. As an example, indicators of any local “food poverty” should be devised as a health measure – for Covid-19 has both highlighted the frailties in how people access food and also brought about beneficial changes locally to support vulnerable people and build new partnerships. Nutrition is recognised as a determinant of health. Food poverty drives health inequalities whether caused by low income levels, unavailability or inadequate skills and accommodation. One suggestion that should be explored is the development of a national food service in Wales tasked with removing food poverty in Wales.
9. SHA Cymru Wales is pleased to note that part of our submission last year urging the development of housing that supports the independence of older people and others with care needs was welcomed by the Party. SHA Cymru Wales looks forward to further work on developing emerging community models of engagement such as the Local Area Co-ordination arrangements operating in Swansea and similar initiatives elsewhere.
Proposal 13: SHA Cymru Wales request that the consolidation and expansion of initiatives cited above be included in the manifesto along with a prototype “ Resilient Communities fund” to be deployed in a number of challenged localities to underpin and build on existing volunteer / community efforts such as those operating food box schemes and medicine / prescription deliveries.
10. Further steps should now be taken to utilise technology so that patient medical and social care records can be “jointly owned” by care practitioners and citizens.
Proposal 14: SHA Cymru Wales supports pilot projects currently exploring how patients can access and “co-own” their medical records as part of the co-production of good health.
11. Primary care investment must not be at the expense of clearing the backlog that has built up in the mainstream service provision for cancer, stroke, heart disease and re-ablement surgery (e.g. hip and knee replacement). Nor should a current lack of capacity in services for children and young people with learning needs and mental health issues be allowed to continue.
12. As noted earlier, for years it has become acceptable to attempt to run the hospital sector on a 90%+ occupancy rate. We have seen the problems this creates with perennial winter bed pressure crises but the onset of Covid-19 has shown the other inherent risks from constantly running the service at maximum capacity most of the time.
Proposal 15: Staff and patient safety requirements must require the acute hospital system always to run with headroom for the predictable, cyclic variation in annual demand.
13. Another concern of members was an uncertainty about what the 21st century purpose of the Welsh health and care system ought to be. Twenty years ago Wales had a well-deserved reputation for the quality of its strategic planning processes – aimed at achieving a level of health in Wales on a par with the best in Europe – and its ability to make progress. Evidence was gathered about the best preventive programmes, diagnostic techniques, treatment options, and after-care services across Europe and used to counter the main causes of premature death in Wales and the main causes of significant but avoidable morbidity in Wales. Health Boards (then known as health authorities) – with their partners – used the evidence to craft “local protocols for health” that were resource effective, people-centred, and aimed at increasing the length and quality of life in all parts of Wales. Despite, or perhaps because of, the success of this approach, John Redwood’s arrival in Wales saw the end of this work, no doubt in the belief that market forces would do the planning for Wales. In the view of some, since then NHS Wales has struggled to design a clinical and managerial process that systematically tackles health inequalities and improves health status in Wales.
14. SHA Cymru Wales believes that Wales should draw heavily on that earlier strategic approach. For whileSHA Cymru Wales accepts that Welsh Labour has had a strategic vision since the Wanless report in 2003, and “ A Healthier Wales” that has merit, it has not been accompanied by processes that translate strategy into deliverable Health Board and Trust 3 Year Integrated Medium Term Plans (IMTPs) able to be fully implemented by Health Boards, NHS trusts, and their key partners. The chain of accountability is opaque. Boards are, or appear to be, still dominated by secondary care voices
Proposal 16: Welsh Labour should provide a clear statement of what the Welsh care system is meant to do (and by derivation what it isn’t) using a National Planning framework within which Health Boards and Trusts have to develop and deliver their plans. SHA Cymru Wales suggest that the Health Boards give a stronger voice for primary and community care and citizens in this process. A clear set of evidence- driven political and managerial processes are needed by which the aims of the Welsh NHS, and the resources needed to achieve those aims, are directly linked. Exhortations to “ do something”, on their own, are unlikely to achieve much.
15. Setting a national direction and strategic intent must be underpinned by effective local delivery mechanisms to deliver the objectives of A Healthier Wales. The abolition of the internal market in Wales provided a unique opportunity to develop an integrated planning and delivery system at a local level to give effect to the national strategic purpose and direction. However, this has proved more than problematic. Some health boards are subject to Welsh Government intervention of varying extent, and varying success. Repeated reviews have expressed concerns at the capacity and governance of local health and social care planning and delivery. SHA Cymru Wales welcomes the partnership working that is taking place at regional partnership boards, but this process has got to mature, be more transparent and be accountable.
16. In the light of the foregoing, SHA Cymru Wales welcomes the proposal for a “national executive” as outlined in the Final Report of the Parliamentary Review. The Parliamentary Review recommended that this “national executive” should be about strengthening executive functions to help align national strategic priorities with local service changes and innovations. The present slow pace of change suggests that this is urgently needed. It specifically suggested that the “national executive” should be aligned with national social care policy. SHA Cymru Wales recommends that the “national executive” should be the key national agency for integrating and driving forward both a National Health and a National Care service in Wales.
17. SHA Cymru Wales is concerned that the consultation document chooses to specifically mention “specialist and hospital-based services” when considering the roles of the “national executive”. This is at odds with the core message of both the Parliamentary Review and A Healthier Wales. Both speak of transforming our care services away from an over-reliance on the hospital sector. We also regret that the policy consultation document makes no reference to the Parliamentary Review’s proposal that the work of the “national executive” should be underpinned by an explicit and transparent performance framework by which progress can be measured with particular reference to measuring progress in improving public health and tackling health inequalities.
Proposal 17: SHA Cymru Wales believes that a National Health and Social Care Executive, tasked with delivering national health and social care in a clear, evidence based, and coherent way could deliver the transformational change needed. However, it must have clear terms of reference and its performance should be underpinned by a clear and transparent performance framework. The terms of reference, and the performance framework should both be subject to consultation with key stakeholders.
18. There is also a view that the wider public, and local communities, feel excluded from some of the decision making in the care system. Local Government services in principle have a direct line of accountability to their populations through elected councillors and scrutiny committees. If the proposals in 16 and 17 above are implemented, local government should have an increased oversight of the care system as a whole.
Proposal 18: SHA Cymru Wales recommends that Welsh Government place a legal requirement on Welsh local authorities to institute rigorous oversight and scrutiny arrangements in regard to the work of both Health Boards and the performance of the local care system as a whole. SHA Cymru Wales suggests that these scrutiny committees should have a minimum of three independent (non councillor) members nominated by local interest groups that can provide an informed view of how local service delivery is experienced by citizensand service users and what changes users desire.
- The policy document understandably makes little mention of the resources likely to be available the Welsh NHS and its local government partners over the course of the next four years. The damage done to the U.K. and Welsh economy by the pandemic is still to be assessed, as are the uncertainties of leaving the E.U. However, the NHS and social care in Wales already consumes over half of the block grant. Even with thesespending levels, the Welsh NHS is under- powered both in primary care and acute secondary care.
- SHA Cymru Wales has long held the view that not only is the Barnett formula in need
of refinement, but successive Conservative governments have not operated it fairly across the devolved polities. Further, there is limited scope to deploy the (limited) tax-raising powers now available to Wales in a way that can significantly increase the money available to Welsh Government. It is suggested that Welsh Government should adopt a four pronged strategy to address the issue of spending constraints. The first is to seek to increase – by a fair application of the Barnett formula –the funding available to Welsh Government from U.K. Government. The second is via Welsh taxation and growing the Welsh economy. The third is to examine in an ongoing way the operating costs of the Welsh NHS and social care, applying legitimate cost-saving measures where possible. One example is to examine critically the way in which newly licensed medicines are introduced in Wales. The current system requires only that the new product is not inferior to an existing (often cheaper) product rather than requiring either a superior treatment or lower spending. The fourth is to introduce a long term cost avoidance program that is driven by a primary care and public health preventive and anticipatory care approaches outlined in paragraphs C 14-17.
- The Welsh Government seeks to allocate its resources to health boards and local authorities on a needs-based formula. However, a thick fog hangs over how these allocations are used once these local organisations receive them. The First Minister correctly said that there are more inequalities within the populations served by health boards and local authorities than there are between the individual organisations themselves. Currently there is no obvious way to assess and compare how these inequalities within health boards and local authorities are addressed.
Proposal 19: Public Health Wales and Stats Wales should develop a methodology by which it will be possible to measure inputs and outcomes in terms of resource allocation to the most vulnerable communities and groups within health boards and local authorities.
- Finally, it is suggested that the efforts of the NHS (and its local government partners)
to contribute to the “green agenda” be welcomed. This aspect of its work should be highlighted and reported publicly as part of the overall performance regime. .
1. The unexpected arrival of the pandemic, and the havoc and loss of life it has wrought has altered the perspective from which future health and care policy can be assessed. It threw into sharp relief those individuals and communities that are our most vulnerable.
2. For this reason our response has been crafted in two parts – one to anticipate needed changes in order to make the Welsh care system more resilient to any future virus, and another to address challenges that were obvious prior to the arrival of Covid-19, but have proved resistant to change. SHA Cymru Wales believes that the 19 proposals described above will make a positive contribution to the health status of the people of Wales and it commends these to the Party.