The Welsh NHS Confederation (WNHSC) welcomes the opportunity to respond to the Welsh Government’s consultation on the rebalancing care and support programme.
The WNHSC represents the seven Local Health Boards, three NHS Trusts (Velindre University NHS Trust, Welsh Ambulance Services NHS Trust and Public Health Wales NHS Trust), and two Special Health Authorities (Digital Health and Care Wales and Health Education and Improvement Wales). The twelve organisations make up our Members. We also host NHS Wales Employers.
The purpose of this response is to set out high-level and overarching comments about the rebalancing care and support programme. Our members have welcomed the Welsh Government’s ambitions as set out in the consultation document, with an intended move towards simplification, value and a focus on outcomes.
However, there were specific concerns raised by members about the proposals, including the timing of the consultation during a period of service and financial pressure across the health and care sectors. Also, the proposals appeared to complicate the situation in some areas rather than seek to simplify. Combined, there were some questions raised over whether the proposals would contribute to the necessary shift required to create an integrated and sustainable health and care sector.
Members have indicated that the proposals are too directive, with no clear indication as to how they further a strong strategic vision for the health and care sector. A strong strategic direction, with measures and objectives, will be required to drive the necessary change, alongside a clear understanding of how the proposed changes will interact with the current health and care landscape. There are concerns that the proposals could increase complexity and bureaucracy without this understanding.
Also, without a strong definition of what the intended outcomes will be, it is uncertain what value the proposals will ultimately contribute and how they will act as a step in the journey towards integrated care and a national care service.
However, this shift towards more integrated care has never been more pressing as the health and care sectors face sustained service and financial pressures. Achieving a more sustainable care sector will have an impact that extends to the NHS in Wales as it tries to offer timely hospital discharge and free up much needed hospital capacity. Due to the current pressures on the health and care system, now is the time for the UK and Welsh Government to hold a national conversation to co-produce a health and care service for the future as set out in our recent briefing, The NHS at 75: How do we meet the needs of future generations?
National Framework for Commissioned Care and Support
Whilst members considered the standards set out in the code as sound, all NHS organisations are facing unprecedented financial challenges, with the seven health boards forecasting a deficit this financial year (2023-24). They have been impacted by a range of external drivers; increased inflation and energy costs and the resulting cost of living crisis, lower growth, demand on services following the pandemic and staff recruitment and retention issues. Therefore, it will be difficult to deliver on the ambition set out in the consultation due to the serious strain on resources and the efficiencies that must be made.
The concept of value is welcomed but it is unclear as to how this will be weighted against the other elements, especially considering the described financial situation within NHS organisations and across the wider public and third sector.
Pay and Progression Framework proposals
In our briefing "It's not just a crisis, it's a national emergency": Addressing the challenges in social care, we outlined the results of a survey conducted in August 2022 with NHS leaders. The survey results evidence the significant challenges in relation to staff recruitment and retention, with 100 per cent of healthcare leaders agreeing that there was a social care workforce crisis in their local area, and this was putting the care and safety of patients in the NHS at risk.
In this context, we have called for the Welsh Government to provide sustainable funding for social care with a fully funded pay rise to enable recruitment and retention, alongside greater overall investment and career progression opportunities. We welcome that the framework indicates a step towards greater recognition and reward for social care staff.
However, members have voiced concerns that pay should be equitable across health and care if integration and the principles of fair work are to be achieved. There is no indication within the draft framework as to how the bands equate to the health sector and this does need to be outlined if the framework is to be successful in retaining and recruiting care staff.
National Office for Care and Support
It is important that proposals for the new national office give a clear indication of how the new body will interact with other organisations such as regulators, NHS Executive, Public Service Boards and Regional Partnership Boards (RPBs). If this is not established, there is a risk that the office may increase complexity and bureaucracy within the health and care landscape, inhibiting its ability to add value.
There is insufficient detail provided within the consultation document around the office’s relationship with NHS organisations and the lines of communication around key areas of integration.
Partnership Arrangements and Regional Partnership Boards
On the proposals relating to RPBs, members have suggested that whilst some were positive, there were some broad concerns over the nature of the amendments.
It was generally thought that partnership working cannot be prescribed or governed, instead it is based on strong relationships, brought together through a shared purpose. In this context, it was felt that the proposals are too detailed and run the risk of being overly instructive when what is required is national strategic direction under which RPBs can function. A detailed list of requirements could also draw the RPBs away from acting upon population need and the additional reporting will not ultimately support better partnership working.
There is also no indication on the levers that Welsh Government would utilise to ensure outcomes are effectively monitored and how statutory organisations will be held accountable.
Whilst some members did not have any strong objection to proposals around RPB membership, this already varies from Board to Board. Again, rather than a prescriptive list, it would be advantageous to allow Boards to select members based on local need and in the understanding that a large membership does not always equate to better decision making.
The current work within Welsh Government to create a more sustainable and integrated health and care sector is an ambition that our members support.
However, this aim does need to be supported by a clear vision for what future services should look like. The Welsh NHS Confederation has called on the Welsh and UK Governments to hold a national conversation on how the health and care system can innovate and transform to meet the needs of future generations. This includes consideration of the establishment of a national health and care service.
In relation to partnership arrangements, there are some broad concerns over the prescriptive nature of some of the amendments. Members feel strongly that partnership working cannot be prescribed or governed, but is based on strong relationships, brought together to deliver a defined vision.
Without this strategic vision and a clear set of outcomes to work towards, it will be difficult for the rebalancing care and support proposals to add value to the existing landscape.