The Welsh NHS Confederation (WNHSC) welcomes the opportunity to provide evidence to the Health and Social Care Committee on its latest monitoring report on NHS waiting times.
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 NHS continues to experience the most challenging period in its history. The pandemic severely reduced the service's productivity and the significant waits for planned care are having a damaging effect on patient's lives.
To effectively tackle this issue, it is important to understand the nature of the challenge is complex and multi-faceted, converging to create a difficult environment in which the service must operate. Support will be needed to address a number of long-standing issues which have severely limited the capability of the NHS to deliver on Welsh Government targets.
Some of these issues include: the on-going impact of COVID on services; the impact of emergency demand on key resources and facilities; the state of the NHS estate; limited short-term funding; pressures across social care; and critically, significant workforce recruitment and development challenges.
Workforce is the number one limiting factor for NHS capacity and its ability to care for people awaiting treatment in a timely manner. Welsh Government targets still require support to ensure the correct workforce is in place and investment is needed to continue to drive up the number of students and trainees across professional groups. While previous investment in training new NHS staff has been welcomed, without the provision of a long-term, sustainable funding plan to recruit and train NHS and social care staff, these issues will continue for years to come.
Staff morale must also be considered within any discussion around waiting times. Staff have been hard-hit by the pandemic, the cost-of-living crisis and the increasing pressure on services. They must be supported to rest and recover and maintain their own health and wellbeing, but this does create challenges when addressing the backlog at pace.
Whilst recruitment efforts are important, engaging, developing and supporting current staff to aid retention is fundamental. The impact of staff morale on retention needs to be considered as staff struggle with moral injury due to the impact of pressures on the care they are able to deliver.
Social care services play a crucial role in care pathways – keeping people well for longer outside of hospital and enabling faster, safer discharges home. Therefore, the sector plays a critical part in protecting NHS capacity and its ability to deliver high-quality, safe care.
Being unable to discharge patients from hospital has a huge knock-on effect on NHS capacity. This is most visible in both ambulance response times and ambulance handover delays, where they can be seen stacked up outside hospitals, unable to get out to other patients who urgently need their care and causing long waits in emergency departments. This in turn can affect hospitals’ ability to carry out scheduled care, such as hip and knee operations.
Our briefing, ‘“It’s not just a crisis, it’s a national emergency”: Addressing the challenges in social care’, presented the results of a survey of NHS leaders regarding the impact of social care on the NHS in Wales. Many of the 50+ leaders surveyed said care pressures are driving urgent care demand, with a lack of social care capacity having an impact on their ability to see and care for patients.
Therefore, efforts to address the number of people waiting for treatment must consider the role of social care and how it can be supported, through appropriate resource and a sustainable workforce. The work of the National Care Service Expert Group and consideration of a national care service does provide an opportunity to address issues in the sector and improve system wide integration.
NHS organisations have been taking steps to mitigate pressures within health and social care, and we have published a briefing which highlighted these recent actions and initiatives.
Reducing the number of patients waiting for treatment is one of the key financial challenges currently facing the NHS. It will take a commitment of sustained investment from Welsh Government and must consider all parts of the health and social care system, not just acute hospital settings. For example, mental health, primary and community care services form an ecosystem that helps patients wait well before elective treatment.
Financial constraints persist within NHS organisations, making resource prioritisation a continuing challenge. We understand the current budget limitations on the Welsh and UK Governments and believe both the Government and the NHS will need to work together to create more innovative solutions across a streamlined set of priorities.
While NHS leaders share the Welsh Government’s commitment to boost NHS productivity, the lack of capital funding is a major barrier. The NHS is faced with an ageing estate, which was not designed with current demands in mind. We have called for the Welsh Government to develop a ten-year investment plan for service change to reshape NHS estates and infrastructure, including digital.
Clinical Need and Waiting Well
The Board of CHCs published a national report in November 2020, ‘Feeling Forgotten: Hearing from people waiting for NHS care and treatment during the Coronavirus pandemic’. The report revealed that more still needs to be done to help people whose care and treatment has been delayed. The feedback shared identified a number of common themes, including people experiencing physical and mental pain, worsening conditions, employment and income worries, feelings of isolation and loss of trust in service providers. Since the publication of the report, individual Health Boards have undertaken engagement surveys and validation exercises to gather patient views within their area, which address concerns and issues raised with them by patients waiting for treatment.
Our members have previously stated that addressing greatest clinical need will not necessarily prioritise those who have waited longest and there will inevitably be a conflict for clinicians to balance clinical need with consideration of length of wait.
Due to the current challenges around patient flow and difficulties in social care, and its subsequent impact on the health service, it is essential that as many people as possible are supported in their own community, rather than in a hospital. It will be important that efforts are therefore focused on reducing avoidable hospital admissions. NHS organisations are taking action to incorporate transformational ways of working. In our report ‘Bringing Care Closer to Home’ we highlighted a number of initiatives that are helping people stay well in their communities and aim to reduce future demand.
However, the levels of pressure within the NHS are having an impact on patients, and there is a need to engage the public in an honest dialogue about what the service can deliver to manage expectations and direct people to appropriate services. The WNHSC’s briefing, Reshaping the relationship between the public and the NHS, expands on this issue.
We have also published a briefing which outlined some of the initiatives to address planned care waiting lists.
Improving services for future generations
While providing care for current patients is a key priority for NHS organisations, it is important to consider this issue within a wider debate about future service. Efforts are being made to address waiting times, but the sustainability of the health and care service must also be an active consideration for the benefit of future service users.
There are a number of areas of investment which would make a tangible difference in transforming the service and modernising healthcare, such as digital. Through the Welsh Government increasing investment in digital data, technology and opportunity across NHS Wales and benchmarking the level of digital investment against other health systems across the world, it will give staff the best tools for the job and drive transformation of services. Importantly, digital technologies can enable patients to do more to diagnose themselves and manage their condition and recovery; reducing waiting lists and demand for planned care.
While innovation within the system will make a difference for future generations, action must also be taken outside of the health service to create sustainable change and reduce the demand for NHS services overall. This will require consideration of the social determinants of health such as inequality.
As highlighted in the Welsh NHS Confederation Health and Wellbeing Alliance report, ‘Mind the gap: what’s stopping change?’, addressing the factors that cause ill health in the first place should be a central focus for the UK Government, Welsh Government and local government – a whole a cross-government and public service approach to inequalities is needed.
The NHS in Wales is working tirelessly to care for and treat patients, recognising the serious negative impact the situation is having on their lives. This is a resource-intensive effort, leaving organisations with little space to consider and invest in the long-term shape of the service.
Any discussion around the current pressures within the service must therefore consider the impact on what decisions made today will have on the ability of the service to plan in the future and must support the system in creating a balance between short-term need and long-term vision.