Response to the Health and Social Care Committee consultation into the priorities for the Sixth Senedd
1. The Welsh NHS Confederation welcomes the opportunity to respond to the Health and Social Care Committee consultation into its priorities for the Sixth Senedd.
2. The Welsh NHS Confederation represents the seven Local Health Boards, three NHS Trusts, Digital Health and Care Wales and Health Education and Improvement Wales (our Members). We also host NHS Wales Employers.
3. We support the potential priorities for work during the Sixth Senedd that the Committee has put forward. In addition, we recommend that the Committee consider the following key areas during the next 12 months:
- The current demand on health and care services and how it could be addressed;
- The sustainability of the social care sector;
- How the Welsh Government and public bodies better engage with the public; and
- How digital can support the health and care system.
4. Furthermore, we are calling for an inquiry across all Senedd Committees on tackling health inequalities in Wales. Meaningful progress will require coherent efforts across all sectors to close the gap. An inquiry undertaken by all Senedd Committees will enable Committees to consider what action each Welsh Government department is doing to tackle the root cause of health inequalities and put forward recommendations around where improvements are needed.
Role of the Welsh NHS Confederation
5. As the biggest user of public money in Wales, it is essential the NHS is accountable, and Senedd inquiries enable this to happen. The Welsh NHS Confederation has built a strong relationship with the Clerking team from the Health and Social Care Committee during the Fifth Senedd. This relationship has been very beneficial for NHS organisations and also for previous Committee members.
6. Prior to Committee inquiries and oral evidence sessions, the Welsh NHS Confederation liaises with the Clerks to ensure the most suitable representatives from the NHS provide evidence. For all Senedd inquiries we contact our Members on behalf of the Committee Clerks to ensure the Committee hears from representatives from across the NHS in Wales. We hope this relationship continues during the Sixth Senedd term to ensure the Committee hears from experts within the NHS, enabling the Committee to fully understand NHS’ policies, processes and recent developments.
Context: The current pressures on health and care system
7. As a result of the pandemic the NHS in Wales, and across the UK, is currently experiencing an unprecedented period of demand on services. As our briefing, NHS Wales – System Pressures, highlights, there’s no single reason for the current situation, but a multitude of complex factors across the whole health and care system. Factors include; responding to a significant backlog of planned care; increases in non-COVID activity, as well as increased acuity in patients; frontline services operating with much reduced capacity due to the need for infection prevention and control measures; the workforce under continued pressure; public expectations not fully reflecting the current capacity limitation and restrictions on the NHS; and pressures being felt across both health and social care so a holistic approach is required.
8. Our Members are experiencing tremendous pressure and demand on their time. We would recommend that this be considered when the Committee is developing its forward work programme to enable NHS representatives sufficient time to develop written evidence to an inquiry or when asked to provide oral evidence. We would also recommend that all Senedd Committees liaise with each other to ensure that the same NHS representatives aren’t asked to provide evidence to a number of Committees in a short period of time e.g. in the final year of the Fifth Senedd one NHS representatives was asked to provide evidence on five occasions.
Q1. Which of the issues listed above do you think should be a priority, and why?
Public health and prevention
9. We are calling for an inquiry across all Senedd Committees on tackling wider health inequalities in Wales. A cross-Committee Senedd inquiry will enable consideration of action being taken in each Welsh Government department on the root causes of health inequalities. Health inequalities are the result of many and varied factors and arise as a result of the social and economic inequalities that shape the conditions in which people are born, grow, live, learn, work and age. The NHS alone does not hold all the levers required to create the necessary conditions for good health and wellbeing. Meaningful progress will require coherent, strategic efforts across all sectors – using their available resources, expertise and relationships – to close the gap.
10. While COVID-19 has revealed and exacerbated pre-existing health inequalities, there have been many detailed and well-evidenced reports on health inequalities in recent years. In just the past year, many reports have called for system-wide action on health inequalities including the Welsh Health Equity Status Report initiative, Placing health equity at the heart of the COVID-19 sustainable response and recovery (Public Health Wales and Welsh Government), The Marmot Review 10 Years On (Institute of Health Equity and the Health Foundation) and the most recent Unequal pandemic, fairer recovery (the Health Foundation). Every one of these reaffirms the need for coherent, coordinated activity across all delivery partners. COVID-19 recovery presents an opportunity to create a healthier and more resilient society by addressing the root causes of poor health.
11. In April 2021, the Welsh NHS Confederation’s Health and Wellbeing Alliance published a short paper, Making the difference: Tackling health inequalities in Wales. In this paper, we suggest initial steps that the new Welsh Government should take in their first year to respond urgently to health inequalities and make the greatest possible impact by coordinating a renewed commitment from all partners.
12. As we come through COVID-19 there is a real need and an opportunity to focus on public health and what individuals can do to optimise the preventable causes of ill health. This of course is wider than just the NHS contribution to healthcare and will need to focus on housing, employment and education. However, for the NHS it is important that we look at addressing obesity, smoking, activity levels and “healthy lifestyles”.
13. As part of the inquiry, it will be important that we are able to understand and measure our collective progress to ensure that we achieve the outcomes that matter most. To improve population health and wellbeing further, it is vital that meaningful person-centred performance measures and frameworks are developed across the NHS and local government which focus on patient experience, clinical outcomes, prevention, whole-system collaboration and applying value-based healthcare. The current NHS performance targets focus too specifically on acute and secondary care and do not always support the system to grow and redesign. While targets have a role to play, we must also look at the bigger picture, instigating a whole system change in the way treatment is delivered, how services are provided, and population health measured. A key driver within this is the Well-being of Future Generations (Wales) Act 2015.
The health and social care workforce, including organisational culture and staff wellbeing
14. We would support an inquiry into the health and social care workforce. Workforce, in relation to recruitment and retention, is widely regarded as the biggest challenge facing the NHS now and in the future. COVID-19 has compounded the issues of staff shortages.
15. Our health and care staff have worked tirelessly throughout the pandemic and it’s their continued efforts which makes the delivery of high-quality services possible. Their hard work and efforts have been praised by the public but the challenges they face have also been highlighted and must be addressed.
16. The impact of the pandemic has had a considerable impact on staff wellbeing, which continues to be a key priority moving forward. Health Education and Improvement Wales (HEIW) and Social Care Wales’ workforce strategy sets out approaches needed to place wellbeing at centre of workforce plans. Our recent briefing, Supporting Welsh NHS staff wellbeing throughout COVID-19, showcases some of the initiatives that have been introduced across NHS Wales to support staff health and wellbeing.
17. We support calls for parity of esteem between the health and social care workforces as this is essential to achieving a sustainable and well-trained workforce. The sector needs to be marketed as an attractive career option and the living wage provides an opportunity for structured career development. Consideration should also be given to how the private sector is engaged with to develop a sustainable workforce. The health and care sectors need to work in partnership and parity is important to this. Opportunities for supporting an integrated workforce and how to develop career pathways across the system and not just within sectors could also form areas of investigation.
18. Consideration needs to be given to the impact of UK immigration policy, following the end of free movement. There are several areas under this that need investigation such as the definition of skilled work and its impact on social care and the effectiveness of the EU settlement scheme.
19. As part of an inquiry considering the health and social care workforce the Committee should consider how well the current health and social care workforce is equipped to make use of innovations in digital systems in the delivery of care. Digital systems are playing an increasingly large role in the delivery of services and digital skills are an essential part of the day-to-day provision of care. NHS staff need to be supported to deliver care using digital skills and to manage workloads and caseloads more effectively. Access to the right information will enable staff to make better decisions and provide faster care. Technology also enables the sharing of care plans between staff in different settings so individuals in need of care experience a joined-up service.
Access to mental health services
20. We would support an inquiry around access to mental health provision in Wales.
21. COVID-19 is having a significant impact on people’s mental health and service demand is increasing. It is not only people with pre-existing conditions, although these have been exasperated, but many of the general public have been impacted by self-isolation, financial insecurity, bereavement, and increases in substance and domestic abuse. Population groups have experienced differing levels of impact on their mental health, with a Public Health Wales report recently highlighting that the clinically extremely vulnerable group were ‘at slightly higher risk of diagnosed depression and/or anxiety compared to the general population’.
22. People are not only seeking mental health support, but many are presenting with more advanced issues, often putting pressure on emergency and community services, and other sectors like the police. Services are continuing to deliver and plan support to populations across the various tiers in response to the increasing prevalence of mental health issues.
23. Mental health has risen up the agenda during the last two Senedd terms, with cross party support for new policy and legislation such as Together for Mental Health and the Mental Health (Wales) Measure, but the Committee could consider how high-quality mental health services are developed further. It could also investigate attitudes to mental health and how it can be de-stigmatised. It is important that the focus on mental health services includes CAMHS and specialist provision of mental health services in Wales, supporting local provision and access where appropriate.
24. We would recommend engagement with the Children, Young People and Education Committee to understand the impact on services for young people and fully address any barriers to access across adult and children services. This would allow for inquiries which range across the entire breadth of mental health provision.
25. A focus should be placed on low level and early interventions to help people support their wellbeing. The Welsh NHS Confederation and the Arts Council for Wales, as part of our Memorandum of Understanding, has brought together examples of how the arts are playing an important role in helping people deal with the challenges faced during the pandemic.
Evidence based innovation in health and social care
26. We would recommend that innovation form an important thread of investigation in other inquiries, as it impacts on areas such as the workforce, COVID-19 recovery, access to services and prevention, and not as a standalone inquiry.
27. We are supportive of current efforts to collate and embed the innovations which have been seen in the health service since the start of the pandemic. This includes the recently announced Welsh Government innovation programme for health and social care and the NHS Wales COVID-19 Innovation and Transformation Study Report.
28. The health and care system must continue to maximise the strategic and operational potential of digital technology as an enabler of change. Digital technology should be seen as one of the most significant strategic tools available to us to shift to a new preventative model of health and care. Digital technology provides a great opportunity to engage more closely with the public and patients, using social media and interactive technology to support self-care.
29. However, we must ensure that technology is accessible to all, with no barrier to equality of opportunity, and prevent digital isolation. Not everyone has the skills to use technology and support must be made available to people. This can be done by working with partners in education and in the community to promote digital skills and prevent people from becoming further disadvantaged.
30. Increasing people’s confidence in using digital technology also supports the NHS because it enables an increasing number of people to access vital services from home. This will be particularly important as the system continues to reset services following COVID-19. Care must be taken to mitigate against unintended consequences, such as an increase in loneliness and social isolation. The need for direct human contact and support, especially for people who are vulnerable, cannot be substituted by technology.
31. Opportunities presented by digital and virtual working might mean a re-evaluation of NHS estates and how the NHS engages with patients and service users in the future e.g. through further fostering agile working and more telephone and digital health engagements between health and care staff and patients/ service users.
Support and services for unpaid carers
32. We would support an inquiry into support for unpaid carers, which builds on the predecessor Committee’s work around the impact of the Social Services and Well-being (Wales) Act 2014. We would recommend any inquiry considers any additional support required as a consequence of the COVID-19 pandemic, with Carers Wales reporting the number of unpaid carers rising to an estimated 683,000. (Covid-19 Briefing: Impact on Unpaid Carers in Wales, Carers Wales, 2020).
33. In our evidence submission to the 2018 inquiry on the Social Services and Well-being Act, we recognised that health and care services rely on the support provided by unpaid carers and their ability and willingness to provide unpaid care. Unpaid carers are key partners in the delivery of services and for maintaining the health and wellbeing of the population.
34. Respite care, information and support services are key to unpaid carers maintaining their own health and wellbeing and ensuring they have an equal opportunity to stay well and active alongside their caring responsibilities. Access to these services is just as important for the person being cared for as they can be negatively impacted by a deterioration in a carer’s health. The result of this could be greater demand on unplanned and emergency NHS and social care services. NHS services are well-placed to support Local Authorities to provide high quality and accessible information and advice to carers.
Access to COVID and non-COVID rehabilitation services
35. We would welcome an inquiry into COVID and non-COVID rehabilitation services. Rehabilitation needs (COVID and non-COVID) require an integrated response across health and social care. There will be many affected by the pandemic whose needs manifest across the system and will require intervention, including from the third sector, local government and housing. Rehabilitation then needs to be understood as a whole-system issue.
36. When considering access to rehabilitation services it is important that the Committee considers the long-term impact of COVID. A survey by Asthma UK & British Lung Foundation Wales, in conjunction with Long Covid Wales, found that people suffering from Long-COVID face a huge range of symptoms for many months after catching the virus. Across the Welsh NHS there’s a huge amount of work being done to understand more about the implications of Coronavirus and the longer-term issues people face. All Health Boards across Wales are working with patients to make sure they receive the appropriate level of care for their individual needs and a NHS Wales Covid-19 Recovery App has been developed in partnership with patients and received very positive feedback.
Q3. What other key priorities the Committee should consider during the Sixth Senedd in relation to: health services, social care and carers, and COVID recovery.
Current demand on the system
37. We would recommend the Committee consider the current demand on health and care services and how it could be addressed. COVID recovery needs to be planned, resourced and delivered over the medium term, balancing the immediate needs of providing access to diagnostic and treatments with supporting a change in delivering more sustainable services.
38. The current demand is driven by number of complex and interwoven factors and an investigation into the backlog could highlight other issues such as the impact on acute care of unmet need, the sustainability of social care, workforce shortages and NHS infrastructure. The Committee could aim to set out the extent of these issues and the gap between where we are now and where we need to be.
39. It could also highlight innovations, with a view to wider adoption and make recommendations at a system level for steps to address the backlog.
40. A patient perspective could be taken as this would allow issues at all stages of the service to be explored including self-care, community, social care, primary and secondary care. The Committee might also want to visit NHS sites and engage with NHS management staff and patients directly to gather evidence.
Sustainability of the social care sector
41. The social care sector is currently facing significant pressures and we would recommend the Committee to undertake an inquiry to consider the key challenges and how they could be addressed.
42. The pandemic has once again demonstrated the need for a new settlement for social care and highlighted the critical role the sector plays in the delivery of health and care services. The challenges facing social care services include vulnerabilities in funding and market stability, the increased demand on the sector, growing unmet need, staff vacancy issues, contingency planning and the need for consistent standards and quality measures between health and social care. The sector requires a new funding settlement which stabilises its current position and allows it to plan in the long-term.
43. The NHS does not work in isolation and issues of capacity and workforce in adult social care and children services are currently having serious implications on the NHS, including the inability to discharge large numbers of medically fit patients from hospital. NHS leaders are undertaking significant work with local authority partners to minimise disruption, but the long-standing issues within the care sector further strengthens the existing calls for Governments across the UK to support integration between health and care and create a sustainable financial model for the sector.
44. We recommend the Committee considers how the Welsh Government and public bodies can better engage and communicate with the public. There is an urgent need for a meaningful dialogue with the public about the future expectations of public services, the reality of COVID-19 recovery and the different role they need to play, with public support critical to delivering and securing policy and service change. A social movement and a national campaign would be beneficial.
45. Public expectation has changed throughout the pandemic and people are understandably less tolerant and expect a speed of recovery the NHS is currently unable to deliver. There is a requirement for an open and honest conversation with the public about what the NHS can be expected to provide in future. The communication needs to be based on a real partnership of public and organisations, with an emphasis on a shared endeavour and honesty.
46. The public will need to be supported in taking more responsibility for their own health and wellbeing, with communication and co-production with the public, third and independent sectors required. Patients need to become partners in managing and improving their health, rather than passive recipients of healthcare.
47. With the new Special Health Authority, Digital Health and Care Wales, recently created to support NHS Wales organisations in taking forward the digital transformation needed to better health and care in Wales, we recommend that the Committee considers the role that digital has to play in supporting all the priorities outlined above.
48. As highlighted, digital delivery plays a key part in supporting the initial priorities for the Committee, making services more accessible and sustainable while supporting personal health and wellbeing. Lined to the initial priorities already identified by the Committee around evidence-based innovation in health and social care and public health and prevention, there is the potential to utilise health data to better identify the determinants of poor health and make timely interventions to improve population health. Ensuring seamless and safe transfer of patient data would support more effective planning, decision making and improved care and outcomes. The National Data Resource has been identified as a key enabler of this by Welsh Government and the Committee could consider how data is currently used and whether barriers to sharing data effectively could be reduced so that health and care services benefit from innovations.
50. We would recommend the Committee consider further investment in the NHS estate, which has come under considerable pressure during the pandemic.
51. In our 2021 Senedd election briefing, ‘Valuing, Engaging and Delivering A health and care system for future generations’, we called for a 5-year investment plan to reshape NHS estates and infrastructure. Investment in NHS estates is key for the system to be empowered and to transform. While there has been significant investment over the years in some areas of Wales, NHS estates are often in poor shape, with significant investment needed to bring old buildings in line with modern standards.
52. In relation to the impact of COVID-19 on NHS estates, the buildings and design of many hospitals make them unprepared for the kind of infection control required, the need to separate COVID-19 and non-COVID-19 patients and to maintain social distancing for patients and staff.
53. We would recommend the Committee communicate with the Economy, Trade and Rural Affairs Committee around the impact of the NHS as an employer, commissioner of services and anchor institution. Health services have a vital role to play in the wider recovery and rebuilding of local economies and communities and this could be thrown into sharp focus as the COVID-19 pandemic is expected to lead to a future social and economic downturn.