Looking at healthcare in Wales ahead of Senedd elections

Matthew Taylor

Hello and welcome to the latest edition of Health on the Line produced by Health Coms Plus on behalf of the NHS Confederation. Now, I say NHS Confederation, but I won't be saying it for long. Because from April, as you may have seen our announcement this week, following our merger with the wonderful NHS Providers, we will be called The NHS Alliance. 

I'm really excited about what we're going to achieve together. Working with provider colleagues over the last few weeks has been an absolute choice and fantastic people are joining us in the organisation. So I'm really excited about what we're going to be able to provide for members and as an important voice in the debate will be a stronger voice. I think we'll have more influence with the government who sometimes played off the two organisations, but now we're united. We can deliver for all our members and critically, I think, representing all parts of the service, acute, mental health, community, ambulance, primary, systems. When we have conflicts within the service, as we often do, it's our responsibility, it's our opportunity in NHS Alliance to bring the different bits of the service together and work through those tricky and difficult issues.  

So, if you've been a member of either NHS Confederation or NHS providers or both, you'll be getting a letter from us soon, inviting you to join the new NHS Alliance. And of course, I encourage you all to do so. You mustn't miss out on what is going to be a fantastic organisation.  

If you're not currently a member and you'd like to join, please email membership@nhsconfed.org. That's membership@nhsconfed.org.  

Now you may also have seen that at this year's NHS ConfedExpo will be presenting the inaugural NHS Excellence Awards. Hundreds of NHS organisations have entered and we're looking forward to a great evening presenting awards to the winners. It's awards for the NHS, by the NHS, no profits being generated by a publication. It's all for us, it's all to improve what we're able to do and to showcase the best of your work.  

Now we are however, as a charity looking for partners to help sponsor the awards and it's a great opportunity for people who want to connect with health leaders and talk about the good work they're doing. So if you're interested in sponsoring our awards, you can find out more by emailing supporters@nhsconfed.org. That's supporters@nhsconfed.org.  

Before I introduce you to my guests for the main conversation today, I want to turn to the tricky subject of ICB reorganisation. In a newsletter I sent to chief executives, I described it as being a kind of classic blunder of government in terms of all the different things that have gone wrong with this reorganisation since it was first announced a year ago. Recently, we've seen the publication of a document from NHS England, which in our view is undone much of the genuine co-production between ICBs and NHSE, which was found in last year's model ICB blueprints. Very disappointing for our members. So with me is Ian Perrin, who's assistant director for our ICB network. Ian, welcome to Health on the Line.  

Ian Perrin 

Hi Matthew, good to be here. 

Matthew Taylor 

So just tell me about this story. I mean, you know, one could talk about it for hours, but we go back to the point at which we hear about the merger of NHS England and the Department of Health and at the same time the 50 per cent cut to ICBs and significant reductions in their kind of responsibilities. Take the story on from there. 

Ian Perrin 

Yeah, thanks, Matthew. So absolutely right. In March last year, ICBs were told to cut their costs by 50 per cent. Largely their saving was in staff and pay and has caused the process of some clustering and merging. Now each ICB must staff its functions within a £19.40 per head of population funding envelope. In May 2025, NHS England published the Model ICB Blueprint. As you say, this describes some of the core functions that ICBs should be fulfilling as a strategic commissioner and some of those functions that should be reviewed for transfer out of ICBs including continuing healthcare, medicines optimisation, SEND, safeguarding and so on. This was really important for setting out some of the expectations of what should be included within that £19.40 envelope.  

In the last few months NHS England has circulated an updated version of that which rose back on some of the expectations. So, 14 of the original 18 functions being reviewed for transfer out of ICBs are now signalled to stay with ICBs, at least for the coming financial year. As a result, ICBs are feeling significant pressure on their ability to resource all of these functions within the envelope, seeing different approaches in different regions, and for some this has opened the floodgates for some additional asks being made, such as performance management for urgent and emergency care that feels slightly out of kilter with the direction of national policy. 

Matthew Taylor  

And you can't be surely saying that the centre said to ICBs, this is how much money you get, but you don't have to do all these functions. And they just simply said, you have got all these functions, but you don't get any more money. I mean, that can't be true. 

Ian Perrin 

That is pretty much it, Matthew. Also, in some areas there are slightly different asks of ICBs than in other areas. There's a bit of variation around the country. 

Matthew Taylor 

Wow, so what are the risks then to ICBs in all of this, particularly when some people, it's not entirely consistent, but some people in NHS England talk about ICBs and strategic commissioning as being absolutely central to the delivery of the ten-year plan. 

Ian Perrin 

Yeah, so our members are saying there's a trade-off required here. If they're to be excellent strategic commissioners, then they need to really fund those functions well. And some of those are new functions like health economics and market management, which are things they want to be doing more of. Every new or existing function given to ICBs takes capacity and resource away from strategic commissioning.  

So, in terms of risks, there's a question about whether they'll really be able to deliver the ten-year plan and its biggest ambitions, or whether to an extent we're sort of setting them up to fail by overloading their limited resource.  

They also worry that changes to functions will continue in the months and years ahead and having an excellent people and expertise leave their organisations, they then find themselves seeking the exact skills that they've just lost as this picture kind of changes in the future. 

Matthew Taylor  

Yeah, well, of course, I was being disingenuous a moment ago when I asked whether or not they were really being asked to do these functions. Of course, I know that they are. It is a remarkable situation. I could talk to you for hours, but two final questions really, and possibly reflect in my own views a bit more.  

If you look at the whole history of NHS reorganisation, you see the same pattern, the same three-step pattern happening over and over again. So first of all, reorganisation of the NHS is always partly about addressing the fact that it was born as a service, too nationally centralised and too locally fragmented. So people see that and various forms of reorganisation come forward. But in each of those forms of reorganisation, I'm going right back to Ken Clark and GP Fund holding.  

Before you were born Ian, commissioning is always the answer. So how are we going to solve this problem of national centralisation, local fragmentation, well, we'll have commission. We'll devolve to commissioners and they can commission integration services. That's the second step.  

And then the third step is that really put our weight behind commissioning. We establish it. But having established it, the second there's conflict between commissioners and providers, the second things go wrong in the health service. The minister's saying, well, we've got to do something. We've got to abolish something. Something's going wrong. Let's abolish these pesky commissioners because no one's ever heard of them anyway. 

So we're on the fourth iteration of this, Ian. I guess if you're in ICB land, you must kind of feel a really big question about whether the centre is serious about backing commissioning. 

Ian Perrin 

Yeah, that's absolutely right, Matthew. And there's a difference, I suppose, between what's been described in national policy and I think how our members are feeling the reality on the ground. So I think there's a question about, what can we do in the future to kind of realign the national policy with what members are feeling. What our members tell us is that they want NHS England and the Department of Health to draw a line in the sand around these functions and allow ICBs across the country to move forward from a level playing field. 

I think also really important is, you know, our members have been asking for a national director of commissioning in the merged Department of Health and Social Care with commissioning experience to re-stabilise, I think, what has been a clearly bumpy period for integrated care boards and help steward them through really crucial years ahead. As you say, there's existential question around, you know, the future of services and we need to be delivering now in order to regain the public's trust. 

Matthew Taylor

One final point I make, is this - I write for a local government journal, the Municipal Journal, and I'm very interested in local government anyway. I read a lot about it. Now, if you look at local government reorganisation, which has also been a pretty problematic process, as it has unfolded, there has been a steady commentary from local authorities about its realism, push back against elections being cancelled, eventually a high court challenge. The policy had to change. 

And all of this is kind of taking place in public and, you know, that's been embarrassing for the government, but it has meant that those local authorities that are affected were able to say publicly why they were concerned to raise the issue to require central government to be accountable. Of course, it's not the same for ICBs. You're sharing with me their concerns. I've heard these concerns. But of course, as ICBs, they can't really afford to put their head above the parapets. They rely on us, don't they, to be their voice collectively because none of them individually would want to be seen to be causing trouble. 

Ian Perrin

Yeah, that's absolutely right, Matthew. I couldn't agree more. 

Matthew Taylor 

Thank you Ian. Thanks for spending time with me on Health on the Line.  

I'm really pleased in this episode to be turning our attention to our colleagues and members in Wales. These are interesting times for health and care leaders navigating their current challenges in what is, well, likely to be a shifting political landscape. So how are our Welsh members getting on? What are all the parties saying about the upcoming Welsh elections? 

With me to talk through all of this is Paul Mears, who's chief executive of Cwm Taf Morgannwg Health Board and the lead chief executive of NHS CEOs in Wales and our very own Nesta Lloyd-Jones, assistant director of the Welsh NHS Confederation. Welcome Paul, welcome Nesta to Health on the Line.  

Now Nesta, I'm really pleased to be focusing on our work in Wales. I've always been a great admirer of Confed in Wales. So for the benefit of our audience who may not be familiar, can you just give us a very brief overview of the Welsh health and care system, particularly the key differences between the Welsh and English systems. 

Nesta Lloyd-Jones  

Thank you Matthew and thank you for inviting us today to provide a bit of a spotlight, like you say, on the health and care system in Wales during a very exciting couple of months ahead with our Welsh Parliament election in May.  

Health and social care is devolved in Wales to the Welsh Government and also to the Welsh Parliament and other key areas that are devolved include education and housing, which we all know have a massive impact on the wider determinants as well as social care. 

The Welsh Government makes decisions and develops legislation and it's led by the First Minister. And then just to highlight in relation to the size of the Welsh Government, it's very much just the size of one Whitehall department. So even though it's got a massive budget of around £25 billion, it covers a range of devolved areas. In the grand scheme of things, it's still very, very small. 

The Welsh Parliament, which we call the Senedd, is responsible for scrutinising the Welsh Government and legislation and they have a vote to pass legislation and the budget.  

In relation to the NHS in Wales, which has been devolved since 1999, it's made up of several organisations and we're really lucky in the Welsh NHS Confederation that all the statutory bodies are our members in Wales. And those bodies are comprised of seven integrated local health boards, one being Cwm Taf Moganog University Health Board, which Paul is the chief executive of. And then we have three national NHS trusts, Public Health Wales, the Lindra University Trust, which specialises in cancer and also Welsh blood services and the Welsh ambulance services as well. And then we have two special health authorities which lead on education and also digital, so Health Education Improvement Wales and Digital Health and Care Wales. So those are the 12 statutory bodies but as part of our work we to work very very closely with local government partners. So we have 22 local authorities in Wales and health boards and the national bodies work closely with them through partnerships such as public service boards, which were established as part of the Wellbeing of Future Generations legislation, which is a unique piece of legislation looking at the long-term wellbeing of the nation of Wales, and also regional partnership boards. So your RPBs quite similar to ICSs in England in relation to getting or supporting health and local authorities to work closer together, especially around health and social care. 

Matthew Taylor 

Thanks Nesta, that's really helpful.  

So Paul, let's bring you in here. You've worked in both the English and the Welsh systems. What's been your experience of the two? What's the biggest contrast in terms of working in these systems? 

Paul Mears 

Thanks, Matthew. Well, I think as Nesta has just highlighted, one of the biggest opportunities we have in Wales is the fact that our health boards are integrated organisations. So as somebody who in England always worked in the provider sector, being the chief executive of an acute trust, worked in community trust, you know, we all know, don't we, that's one of the biggest challenges sometimes in England was trying to navigate between all the different bits of the system and how they work more effectively together to deliver better outcomes for populations. 

In Wales, the benefit I think is as chief executive of the health board, I effectively have all those levers in one place. So hospital services are done by my organisation, community services, all of the range of mental health services. We commission primary care, including GMS contracts and dental contracts and pharmacy. And we also have public health seated within the health board as well. So we've got a really comprehensive opportunity with a capitated budget for our population to look at how we improve the outcomes for our communities. And it gives us the flexibility to be able to look at how we design services as one team around the particular communities we serve, but also how we use the totality of the resources available to us to better improve outcomes for our communities. 

Matthew Taylor  

Well, thanks, Paul. I want to come back to some of that in a moment. But just before I do, tell us a bit more about the kind of context of your work as chief executive of Contafmorganic. First of all, Contafmorganic, points out of ten for pronunciation. 

Paul Mears

Well, probably about seven, I think you've done pretty well. I say I have probably the most unpronounceable name of an NHS organisation in the UK probably, yeah, Contafmorganic Health Board. I mean, look, the context is we serve a population of 450,000 people. We serve communities that are largely the ex-mining and industrial valleys communities. So the top of my patch goes up to edge of the Brecon Beacons, around the Tydfil. We come down through the Rhondda Valley, the Pen Valley. We go over to Bridge End and Porthcawl on the coast.  

So, a diverse geography topography is a real challenge and we'll come and talk about some of the challenges that the valleys communities particularly present, but also one of real challenge in terms of poor health outcomes historically. So some of the worst health outcomes in Wales, if not the UK, some really big intractable challenges of long-term chronic illness, disability, social challenges that you can probably associate with other ex-industrial communities across the UK. 

But also really strong communities in terms of that sense of community working together, supporting each other. Lots of families still living in the same village or indeed the same street, so lots of intergenerational support and a huge amount of voluntary and third sector community groups operating in those communities. So, opportunity to really think about how you engage and involve those communities in helping shape and improve the outcomes for their populations. 

Matthew Taylor 

Well, that's fascinating. And Paul, tell me how those challenges, those public health challenges, but those opportunities of strong communities have influenced how you work. I think you have an initiative called Community by Design. Tell us a bit more about that. 

Paul Mears 

Yeah, so across Wales we recognise that the scenario I've just described to you there in my patch is replicable in lots of other communities. You know, we have very dispersed communities in some of our more rural areas. Up in in north Wales, in west Wales. So there is a real need for us to think about how we develop and provide a greater degree of service to our communities in those local areas. So the national programme, which is Community by Design, which is being championed by the chief medical officer for Wales is really about how do we reorientate ourselves away from just focusing on what we do in hospitals, to thinking about how we engage and involve communities in and supporting the health and wellbeing.  

And look, know, I've been around the NHS for a while now and I think this is a narrative that we've been talking about for a long time and I know it parallels some of work in England with the neighbourhood development. But it is a real opportunity for us, I think, in Wales to tap into that network of communities and involve them more actively in how we improve the health and wellbeing.  

So, Community by Design is very much focused about primarily how we support people to live healthier lives, how do we get better at prevention in communities working with those organisations, support groups. How do we develop and support primary care much more actively in our communities around integrated teams working together in those communities. And then also thinking about how do we deal when people do need an urgent care service, how do we best provide that as local as possible and maximise the opportunities that digital presents, particularly applicable I think in some of our more rural and dispersed communities.  

So really good opportunity for us to try and start to develop that model across Wales whilst recognising that the model we develop in our organisation may look a bit different to how it works in north Wales or in central Cardiff, but the premise being that we should all be working to a model where services are designed with the community as the default rather than an afterthought. 

Matthew Taylor 

Thanks Paul.  

So Nesta, colleagues in England listening to this and listening to the way that Paul can commission primary, that he can get different parts of the service to work together because they're all part of the health board. People in England thinking, well, this must make integration so much easier. It must make the left shift so much easier. And whilst there's great practice in Wales, it isn't transformatively kind of different. 

So, how optimistic are you? Do you feel that Wales is using the opportunity that its structure provides to accelerate things like moving care into the community? And what are the barriers to that, Nesta? 

Nesta Lloyd-Jones 

I think there's fantastic opportunities in Wales and there's very clear evidence and people like Michael Marmot has said, you know, we've got the legislative frameworks, we've got the policy intent in Wales and also the vision.  

I think one of the key challenges, as Paul has highlighted, is around the implementation due to the challenges that we face in Wales, due to the demographic, due to the age of our population, due to the inequalities across our communities as well. So while we've got world-leading legislation such as the Wellbeing of Future Generations, looking at the future, looking at shifting services into communities and into more preventative services and for health boards and other public sector bodies, let’s all think about how can we make the population healthier. 

The challenge that we have, like in other systems across the UK and the world, is how do we shift the services from very much the acute into community and prevention. And I think from speaking to all our chief executives, they want to shift the services from the acute, from the hospitals into the community, but the demand is so high at the moment and the need is so high at the moment. It's really, really challenging. 

So there's fantastic work being done across Wales and innovative work being done across our communities, but still the challenges, the demand on our ambulance services, on our hospital services - you know, corridor care, like in England has been something that's been highlighted in Wales. But I think the key is that the legislation and the policy is there. It's a question now of how do we implement and support that shift, which we know that needs to happen because our demographic is getting older and sicker. And how we can work with other sectors such as the arts, such as the environment around the wider determinants of health to support people to stay well in their own homes and in their own communities. 

Matthew Taylor  

So I pull back to you on this because we talk about left shift, we talk about prevention. We assume that if we could get these policies right, we could reduce demand over the medium term. We could provide services in ways that were better suited to our patients. Seventy per cent of demand now comes from people who have complex long-term condition where we need to support the whole person, not just treat body parts.  

That investing upstream also enables us to tackle the kind of dangers of over medicalisation, over treatment by giving patient more choice, more control by providing solutions to problems which might not be medical in their nature. It might be to do with debt or to do with housing or to do with social isolation.  

Now that's the theory, Paul. As a leader, how much do you believe in that? Because it ought to be with the tools that you have in your hands that you are able to take that theory forward and really test it in practice. 

Paul Mears 

Yeah, absolutely. And I think, you know, as I said, I've worked in different places around England and Wales. And I think the more you do these jobs, the more you realise that actually the challenge is not really the ‘what’ we need to do. It's the ‘how’ we do it. We've got a ‘doing’ problem rather than a, you know, I think most of us could write what would the optimal care model look like for the future, wouldn't we? But it's how do we actually make that happen and how do we bring about the cultural shift because we need to recognise there is a cultural shift we need to make with clinicians where over the years we've grown and grown and grown the hospital side of what we do with more and more specialists, more and more money going into hospital services. And candidly, if you look at what we do and how much capacity we put into supporting transformation of primary and community care, I don't think historically we've done enough of it.  

So one of the challenges I'm posing in my organisation is how do we put more of our capacity into our primary community care model and that actually we need to start the conversations with the clinicians in hospitals about designing what their role will be in the future.  

We will always need people in hospitals to deliver the very high-end care for populations. But if we know, we know that as you've just said Matthew, that the large number of people consuming hospital services are people with multiple chronic conditions. And one of the conversations we were having yesterday actually in our community by design steering group was how do we get better at managing that multiple comorbid population? Because if you've just got people with single disease like diabetes or COPD, they generally would be on a pathway, relatively well managed, self-motivated maybe to look after their own condition.  

The people who cause a lot of the challenge, did work in Somerset under the Symphony programme. We showed there that 50 per cent of our resources were consumed by 4 per cent of the population. So that's a pretty stark statistic when you replicate that across the UK. Yet if we were any other industry, we'd be targeting that population. We'd be keeping tabs on them day by day to check to see how they were. We'd be monitoring them remotely. We'd be making proactive calls to them. And as soon as there was an inkling of an exacerbation, we'd be putting the clinicians around them to try and avoid an exacerbation.  

So I think sometimes we try and solve everything in one big go. And rather than thinking about who are the key market segments, if you like, who are the segments of population we need to be designing specific services for? Because it's a one-size-fits-all model that we've probably historically worked to is not going to work when we've got such a plurality of different need out there. 

Matthew Taylor  

Paul, I so agree with that. And it feels to me sometimes that so many leaders, particularly England, focus so much on getting the finances sorted out, on elective waits, on managing the kind of almost kind of rolling crisis of emergency departments. And it doesn't give us the space to work on the things that we really should be working on, which would be transformative.  

One is how actually do you move resources out of acute when acute have so many sunk costs? They can't simply put the money out because if the services go and they don't get the money for the services, they're still paying for the rooms sometimes for the staff. What is the mechanics of actually enabling that shift of resource? And I think it's a hard, hard question. Not many people are answering it at the moment.  

And the other is your point about how do we build care around people in a much more proactive, holistic way, because if we did that, I actually think it would reduce demand, because if we're supporting the whole individual, we will do much better for them and they will make a bigger contribution to their wellbeing than if they're just going from one episode to another.  

It is frustrating that we're not really focusing as much as we should on the things that really would be game changers.  

Now, Nesta, back to you. You have elections in a few weeks' time, the political landscape is shifting. don't think many people think that Labour are going to be in power in a few weeks, even though they have been since devolution in one way or another. Now we are a neutral, politically neutral organisation, but obviously we and our members are impacted by government policies. So what are you hearing at the moment? How are the elections shaping up? And what are the kind of most radical ideas out there from the different parties, which could have the biggest impact on the way the NHS works.  

Not asking you to say whether they're good or bad, that would be too political, but how kind of radical are the ideas? 

Nesta Lloyd-Jones 

We've been engaging, as you said, we've been engaging with all the political parties and with the changes to the Welsh Parliament, I think it is probably the most exciting, but also the biggest changing that we will see since devolution in 1999. The number of members of the Senate are increasing from 60 to 96. Out of that 96, it's likely that 70 of them are going to be completely new.  

So one of the key works that we're doing supporting our members is around supporting the candidates, but also the new members of the Senate after 7th May, to understand the health and care system in Wales. Because some of the candidates do have a background in health and care, but many don't. So I think for us to ensure that the debate is as honest and as fulfilled as possible during the plenary debates after the election, that we really need to raise understanding and awareness. 

The other key change is going to be around the cabinet. So we are going to have more cabinet members. So at the moment we've got 14 ministers, that's going up to 17. So there are opportunities there and I know that a number of organisations are calling for, for example, a public health minister, which is a cross governmental minister looking at public health.  

And there's also going to be big changes in regards to the constituencies. So at the moment we've got 40, that's going down to 16. And in, for example, in Cwm Taf Morgannwg's area, Paul and his colleagues are going to have 30 members of the Snedd to respond to and to liaise with, and who will be contacting him and his chair in relation to health and care issues.  

We know the NHS is going to be a key part of the election. At the moment, only two of the parties have published their full manifestos, while others have given us some snapshots, but we are expecting them all to be out by the end of this month.  

I think as you said, Matthew, it is going to be significant changes because at the moment, if you look at the polls, Welsh Labour are polling third, sometimes fourth, and they have been in government in some form since the evolution. And the possibility is that we will have a Plaid minority government with another party such as the Greens or the Liberal Democrats, or possibly a Conservative and Reform government. So that's why it's key for us and other charities and other organisations across Wales to engage with all the political parties.  

I think the key things that we are picking up is prevention is number one on everybody's speeches and what they're publicly saying. Waiting times is coming up really strongly, but we are talking and engaging with them at a national and local level about the importance of talking about health outcomes and not only waiting times and also the wider determinants of health.  

So there's a lot that we haven't seen yet, but there's a lot of influence that we are doing on behalf of our members to ensure that the debate is as knowledgeable as possible really during these very different times, I would say. This is my fourth election and it's unprecedented, I would say. It's unclear which party could form our next government. And that's why it's key that we continue and we've continued to build those relationships with all the parties in Wales. 

Matthew Taylor 

Great, thanks, Nesta. And it's also going to be a really important year for the Welsh NHS Confederation as you move towards a new member offer and a new name as part of the wider NHS Alliance.  

Paul, I know you've got to go. You're a very busy man. But I do want to leave the last word with you. What do you think is the single most important thing that the health and care system in Wales needs to get right in the coming period? 

Paul Mears  

I think Matthew, the big thing we need to be focused on is how we really engage our communities and our primary and community care teams in really shifting our focus away from hospitals. I understand absolutely the pressure and priority that's needed around elective waiting terms and ambulance handovers. Those are really important access measures that people judge us by, but we're never going to get out of this cycle unless we really start to reorientate our focus away from hospitals and spend more of our leadership capacity time focusing on transforming primary and community care alongside our communities to really promote that health and wellbeing, to try and stem the demand rises that we're seeing, but most importantly to improve the health outcomes for those communities. 

Matthew Taylor  

Well, Paul, I think you speak for so many leaders in saying that. Thanks so much, Paul, for joining us today. And thank you, Nesta, as well. And good luck over the next few weeks. 

 And listeners, if you have an exciting or innovative programme of work that you'd like to tell us about, please do. You might end up talking with me on health on the line.  

You can contact us at healthcomsplus@nhsconfed.org. That's healthcomsplus@nhsconfed.org.  

Thanks for listening. Goodbye.