Response to Welsh Government Consultation Paper: Services fit for the Future: 18th September 2017
This paper gives the views of the Socialist Health Association Cymru Wales to the Welsh Government’s Consultation paper “ Services Fit for the Future” which explores using legal powers to improve aspects of the Welsh NHS.
The consultation paper seeks to unlock the innovative potential of Local Health Boards by enabling measures that: promote effective governance and cultural change; encourage person centred care; and improve the voice of citizens in service inspection and service change. These areas have emerged from an earlier consultation seeking views on where the Assembly’s legislative capacity might be best deployed.
- SHA Comments on paper
The proposals in the paper are mainly about process. Good processes are always preferred to poor ones; however SHA Cymru Wales would stress that good health and care outcomes also depend on the wise inputting of relevant human, financial, technical and other resources. The U.K. Government appears belatedly to recognise the failure of its austerity programme but until it supports the devolved Administrations and drastically alters its own stewardship of the English NHS and English local government, our public services will remain in a precarious state until adequate investment in them occurs and their work both valued and lauded.
SHA Cymru Wales responded to that earlier consultation paper and highlighted many of the issues that Welsh Government now seeks to address. We therefore welcome many of the proposals in principle.
In the main, we urged caution in seeing more laws as the answer to the current challenges faced by the Welsh NHS, Welsh Local Government, and their partners. Organisational culture, strong and consistent political leadership, and an evidence – based strategic vision for the NHS and its partners are seen as important, and probably more powerful, as legal processes and powers. We understand other bodies also took a similar view.
Welsh Government led the abolition of the “internal market” in health care in Wales. A decade of experience based on the principles of co-production not competition exists and the outcome of this consultation exercise must draw upon what has been learned. With that in mind, SHA Cymru Wales would support some further legal powers as set out below. Our comments follow the headings used in the paper.
4.1. Membership of Local Health Boards and Trusts
Currently the roles of all executive members of LHBs are specified in regulations and the paper envisages less prescription in future. It is proposed that in future the regulations will specify a core membership of Local health Boards and Boards will be given the freedom to decide the scope of most executive posts providing that clinical and non clinical roles are recognised.
SHA supports this proposal in principle.
It is also proposed that, for NHS Trusts, Executive posts will be set out in regulations and Trusts must have both a Chief Executive and Director of Finance. SHA supports this proposal.
SHA Cymru Wales also recognises that many non executive board members appear to have professional and specialist skills that may render them less typical of many users of health and care services and thus less able to relate to, and reflect, the everyday experiences of such users. While members ought to have some ability to hold the Board Executive to account, there must also be an informed capacity to reflect user experience if services are to deliver user and patient centred services.
Additionally, SHA has some sympathy with commentators who suggest that some LHBs remain dominated by the immediate interests of secondary care providers at the expense of primary care services and whole population planning. SHA retains a view that, for Local Health Boards, more needs to be done to equip the Board to a) provide proper leadership of its “ provider” function b) strengthen the leadership of its longer term planning / commissioning function for its served population and c) create Board level machinery that is robust enough to mediate its provider and commissioner roles for its defined population. This may be done in a number of ways, most of which would benefit by being recognised in a legal framework that recognises the two distinct functions of LHBs.
4.2. Role of the Board Secretary
The role of Board secretary is a fairly new one and it is probably too early to evaluate how it has functioned as the guardian of good processes of governance – a mainly inward looking task. Despite concerns that the post may become over-burdened with many conflicting priorities, some consideration must be given to ensuring that health boards work effectively with other partners to deliver shared agendas.
The paper proposes that the role of Board Secretary should have a statutory underpinning – for example by requiring any proposed disciplinary action against a Board Secretary to be taken independently of the Board itself. It also proposes that the Board Secretary should have a right of access to the Chair or Chief Executive if he/she has concerns.
SHA Cymru Wales supports legislation to bolster the role of Board secretary in the ways described.
4.3. Promoting Cultural change
The paper proposes laying a duty of care upon Boards to deliver quality of planning and providing services for whole populations in addition to their current duty to provide quality services to individuals. The paper also proposes creating a legal duty on Boards to collaborate with other Boards, local authorities, and third sector agencies, to work in harmony in order to deliver regional services and All Wales aims.
In places there is a lack of precision about the intent of the proposals. It is crucial that Health Boards plan for the delivery of services to meet the needs of their defined population(s). On occasions the paper appears to be ambiguous about this when it wonders if local population planning is now outdated. The need for a new and greater priority to fashioning coherent services, especially where there are cross boundary and cross border issues, seems to be suggested.
In part this ambiguity seems to be motivated by a desire to, as far as possible, keep the Minister out of deliberations about service reconfiguration – keeping decisions at local Board level – even when regional and national services dimensions are clearly involved. (The current debate about whether a Major Trauma Unit is needed to service South Wales, and where it should be, is one such example).
SHA Cymru Wales supports the first proposal – to lay a duty of care on Boards for their commissioner / planning functions – as this follows on from 4.1. above where we argue for better recognition of the Board’s commissioner/ planning role.
SHA Cymru Wales is less convinced that inter Board and inter agency co-operation would be aided by introducing the proposed legal duty to co-operate. Instead, it is suggested that any contributions needed from Boards to promote the wider regional or national interest ought to be built into the performance management framework that applies to Boards and Local Government with much greater clarity about how regional and all Wales service delivery decisions are to be made.
4.4. Duty of Candour
To make progress in delivering the 2016 Labour Manifesto promises to build on the provisions in “ Putting Things Right”, it is proposed to place NHS and Social Care organisations under a duty to be open and transparent – a duty of candour. England has such a duty for NHS bodies only (excluding the contracting primary care services) while Scotland has wider powers.
The paper asks what issues are raised by this aspiration and SHA Cymru Wales responds as follows.
- a) If the intention is to include services that are contracted to either the NHS (such as primary care and third sector providers) or to Local Government for providing social care, such a duty may need to operate within a framework that is informed by the interests of insurers of such service providers (for example, insurers may have a view upon perceived admissions of liability). Forms of redress that are acceptable to both service providers and service users will be necessary.
- b) Likewise, similar issues may arise with bodies providing professional indemnity or other representative services for professional staff.
- c) A duty of candour about poor political and managerial decisions ought to apply alongside aspects of direct care.
4.5. Person centred health and Care
The paper proposes the application of a common set of high level standards across health and social care regardless of where that care is delivered. Thus it is intended to promote independence, autonomy, choice, and control – underpinned by an independent advocacy service for vulnerable people.
SHA Cymru Wales accepts this high level approach but is disappointed that there is no acknowledgement of some of the practical difficulties involved in giving effect to these aspirations. For there is a fundamental difference between the way health and social care is delivered. The former is comprehensive, free at the point of delivery and largely publicly provided. The latter is limited, means tested, and substantially delivered by the private sector. In addition, the Welsh Government drive towards individual / personal payments in social care makes implementation of consistent standards even more difficult.
Abolishing the differences between these two delivery models is not, we accept, in the gift of Welsh Government (except for individual and personal payments) but their existence, and the difficulties thus caused, need to be acknowledged.
SHA Cymru Wales is not opposed to these proposals in principle; however careful crafting of such standards will be necessary if they are to proceed beyond mere exhortation to something with a clear utility. Further, were such standards to possess such a utility, regular updating of them to reflect best practice would be necessary and machinery for agreeing changes would be necessary.
4.6. Joint investigation of health and social care complaints
The paper notes that more care relies upon joint action by services yet presently the complaints procedures for health and social care are clearly separated. The proposal is to change the current regulations – through legislation – to enable health and social care bodies to jointly investigate complaints where necessary.
SHA Cymru Wales would support the use of legislation for this purpose. We would also wish the legislation to allow for joint machinery to pursue complaints that are about both the planning / commissioning of care as well as the delivery of care, and to give powers to commissioning bodies jointly to investigate care delivered by private or third sector providers on behalf of healthy and social care bodies.
4.7. Effective Citizen Voice: inspection and regulation
The paper sets out a good case for the better capturing of people’s views, and for using this differently in the inspection and regulatory framework.
These two strands are addressed in Chapter 4 so SHA Cymru Wales comments upon these related topics below. (Proposals on co-production and the machinery for overseeing service change are considered separately in section 4.8 of this response below).
The paper describes the current Regional Partnership and Public Service Boards that are intended to offer arenas within which partnership working can flourish. Alongside these other means of involving the public in health matters are noted such as CHC’s and GP patient groups – both of which currently and deliberately have a discrete population to represent. Similar machinery for local government services is not laid down in statute, presumably because the democratic oversight of such services offered by the ballot box and by ongoing (and public) scrutiny processes of local government are judged to be sufficient.
Turning to the proposals, several strands of change are explored:
- Could the CHC model be built upon to expand to cover both health and social care?
- Is the discrete population focus (of CHC’s especially) a strength or a limiting constraint – and how well is the locality represented?
- Does the inspection role played by CHC’s conflict with, or duplicate, the role of HIW or future similar bodies?
The proposals in the paper include new machinery for “voice” across health and social care across public service boundaries. Further, unified machinery should build upon CHCs and “sit alongside” HIW and CCIW – retaining an independent capacity to work independently, set its own work programme, recruit volunteers, add value to the engagement work undertaken by health and local government bodies, and provide a competent advocacy service.
SHA Cymru Wales has the following views on issues raised in this part of the discussion.
- The independent positioning of an expanded and local CHC- style “voice” covering both health and social care within wider democratic and regulatory machinery, and its “localised” perspective, is a proper, necessary, element of “grit” in the system. It might be that such a deliberately partial perspective may, at times, be difficult for the political processes at local government and Welsh Assembly level to manage, but such a vehicle must have a place in offering a joined up and local view of how health and care services are perceived by the public.
- The expanded CHC model, with changes to paid personnel and to its membership, must equip it to be a channel for the experiences of users of both publicly run and publicly procured NHS and Social Care services – however provided. Its remit should explicitly require it to look for “whole systems” solutions to the concerns brought to its attention.
- The role outlined in 2 above is seen as complementary to the different inspection (and promotion / sharing of good practice) remit that a combined HIW/ CCISW body should carry. It would also complement the existing democratic representational mechanisms operating within the Welsh polity.
- Such a new style body should be able to deploy as it sees fit the resources it is given to enable it to deliver its remit. In particular, such bodies across Wales should aim to be seen as skilled at engaging different segments of their served populations using the widest range of techniques. “ Hard to reach” groups should have a particular focus.
- All new style “Voice” organisations in Wales should be required to share with their peers annually i) areas of new good practice in their care system ii) methods of engagement that were judged novel or effective.
4.8. Co-production of plans and services
SHA Cymru Wales is a strong supporter of the notion of “co-production” of health, drawing as it does upon the work of one of its most distinguished members, Dr Julian Tudor Hart. Here, a narrow definition of co-production is intended to refer to both health and wider care outcomes that individual patients / service users help achieve for themselves by balancing the pros and cons of different interventions and their outcomes, and by their own actions.
However, the paper appears to propose that the notion of co-production be expanded to improve the management of services changes by the better use of social media to increase engagement and by mediating the challenges arising from complex and controversial changes using “independent scrutiny” without the option of Cabinet member involvement.
SHA Cymru Wales is not convinced that co-production can always be employed in this way for the following reasons.
First, the “evidence” that has to be considered when weighing service change emanates from different sources and is of different types. Medical and other care professionals can opine on the evidence of likely benefits and dis-benefits of different interventions and care delivery options. However the “trade offs” – for example of which communities lose from re-locating services or which social groups lose more from ceasing (or reducing) the provision of different care services – will be perceived differently by those groups affected. SHA believes it is both inevitable and right that the choices that have to be made to modernise care services and keep them affordable are, in many cases, best made through a political process employing, inevitably, apolitical rationale. Currently this often requires the Cabinet Secretary to decide between competing options – sometimes on the basis of what is politically achievable rather than what is deemed to be the best option by care professions relying on a different (often scientific) metric.
Second, service changes, especially health care changes, often involve the re-location of services to new sites many miles away. It is then that “losing” and “gaining” populations will see the change differently, with the former wanting a robust process through which its concerns can be taken. It is difficult to see changes such as these being negotiated by several new style community councils coming together to “ co-produce” an acceptable outcome if, as is likely, such councils are perceived as existing to be effective advocates for the communities they serve.
In summary therefore SHA Cymru Wales is not convinced that the alternative arrangements proposed for determining contested service changes have merit. Where change has been fully explored at local level and an outcome agreed by the health and care system, any objections to that outcome ought to be capable of swift political oversight to ensure that the selected proposal has been properly considered and those objections properly weighed. This requires a more proactive role for the Cabinet Secretary that that proposed in the paper (intervening as a last resort) – and even within that limited context it is not clear what threshold would need to be crossed to trigger such an intervention.
In SHA Cymru’s view this debate once again highlights the need for enduring and competent All Wales Strategic Planning machinery that is able to resource and steer the Health and Care system in Wales as one inter –dependent entity with its preventive, assessment / diagnostic, intervention / treatment, and ongoing support / care components continually calibrated in the light of emerging or forecast needs. A 21st century version of the Welsh Health and Care Planning Forum that is able to weigh hard and soft evidence and apply political, managerial and professional judgement and leadership might be one approach.