Local health and care services – final report
Today I have released the final version of my report titled “No one is a bystander – everyone is an ally” in which I set out some thoughts on local health and social care services in Merthyr Tydfil and Rhymney. My challenge now is to crystallise some wider reflections on this report in to this blog piece.
So what are the key messages that I take from this summer and autumn of work?
- The need to keep a focus on the key determinants of physical and mental health in the constituency. These are housing, education, employment, poverty – which means we still face a significant uphill struggle to start closing the gap with other, healthier communities. We must not forget the lessons given to us by the work of, the late, Dr Julian Tudor Hart about the operation of the inverse care law: “the availability of good medical care tends to vary inversely with the need for it in the population served”. The Royal College of Psychiatrists argue “Inequality is a key determinant of illness, which then leads to further inequality”. UK and devolved policy still needs to move more people out of poverty so we break help to break the cycles of mental and physical distress.
- To keep a focus on improving the emotional health and wellbeing of the community. During my ‘drill down’ in to local services I came across issues relating to mental health in so many different settings. So I am not convinced that simply “ring fencing” the spending on mental health in itself is sufficient. Neither does it tell us enough about the quality of the services offered. We must direct more of the spending at early interventions and invest in the most effective outcomes. I believe these challenges have been made worse by the impacts of welfare reform and austerity. In “The Psychological Impact of Austerity” PAA identify:
“Austerity policies have damaging psychological costs. Mental health problems are being created in the present, and further problems are being stored for the future. We have identified five ‘Austerity Ailments’. These are specific ways in which austerity policies impact on mental health: 1.Humiliation and shame 2. Fear and distrust 3. Instability and insecurity 4. Isolation and loneliness 5. Being trapped and powerless”. This rings true with my experience from cases coming to my constituency surgeries.
- We all carry a responsibility for wellbeing – I previously wrote a piece for the Welsh Fabians about wellbeing in all policies (see here). I was subsequently contacted to start thinking about “wellbeing in all decisions”.
My report recognises that we all carry a responsibility to heed the lessons of studies like the Caerphilly Cohort, the evidence of which, tells us that not smoking, a sensible diet, regular exercise and drinking less alcohol mean we can all help to reduce the burden on our health and care services. This is not me ‘preaching’ at people, and further progress will always rely on a mix of carrots and sticks to encourage behavioural change. I visited good practice, like the National Exercise Referral Scheme, which provide us all with lessons to follow. I include oral health and eye care in this preventative work and these are services in which we must place a sharper focus on outcomes for users. NHS Wales must be recognised as The Wellbeing Service for Wales, not just an ill health service.
- Is care the undervalued partner? I am left with an unanswered question about the quality of, and value we place upon care services. Much of the current “integration” and “innovation” work is focussed in primary and strengthening social care. But I received reports of immense cost pressures in our care system, and we know the care workforce is relatively neglected. So it is good news that more recently the social care sector has been identified as a national priority in Wales, which will hopefully drive further improvements in the coming years.
- Good Housing = Good Health I hold to a simple belief that if people do not have a safe, warm home then everything else in life becomes more of a challenge. I feel this is now especially true for too many younger people who face insecure work prospects, zero hours contracts, welfare caps and rent levels that are unaffordable.
I was impressed by the work of local social housing providers in promoting the wellbeing agenda and supporting interventions to help tenants. I want to explore the extent to which mental health support could be strengthened in frontline housing services, as it recently has in emergency control centres. Can we support more front line interventions through housing, and reduce the need for referrals with associated delays and lost opportunities?
- Conditions – My impression is that by and large people are generally satisfied with the support they receive when they access a service/treatment. But for some the wait to receive that support sometimes takes much longer than they wish. So while it is right to focus our efforts on improving the whole pathway from initial appointment to treatment, there are conditions where the speed of diagnosis is also critical. This is why I believe we should continue to reform our Welsh NHS as, in many cases, only more specialised centres are going to provide the capacity, and speed of response, required. This remains a significant organisational and political challenge for us all. Patients of our local NHS told me that they were treated with dignity and respect when using services.
- Boundaries should not be barriers – what do I mean? Well too often, and that includes evidence before the Assembly Health Committee, we hear about local examples of good practice that has improved outcomes for patients. Yet it seems we are slow at then adopting and adapting success across organisational boundaries. Breaking down barriers is a key message in the NHS Planning Framework for 2019-22 and we should all focus more effort on it. Sometimes it is not a matter of money but adopting and adapting best practice.
- Technology is an asset – use it! Other more expert voices are currently having their say on technology and digital services in Welsh public services so I will keep this short. We increasingly use digital services in our everyday lives, why has that not yet widely permeated in our health and care services? We need a step change in practice.
- Workforce People generally have kind words for the NHS and care workforce, yet these staff have been put under the pressure of austerity, and suffered years of pay freezes. I believe there is great potential to be unlocked in these staff if we trust groups such as the professions allied to medicine, skill up the home care workforce and generally invest in the skills and talents of the people we have. The uncertainties around our future relationship with the EU make this task even more critical.
- Measuring what matters – prior to becoming an AM my experience I was a trade union negotiator working with the Wales Ambulance Service Trust. That taught me that the things we choose to measure, and report upon in our NHS, can have a critical influence on a service. We have to increasingly measure the things that really matter, report on the actions that help to drive improvements in quality and performance, overcome inefficiencies and promote wellbeing. It sounds sensible, but I fear we have not yet got it right.
- Innovation and the Third Sector – there is currently a wave of ‘innovation’ in local/regional/national health and care services that we must all quickly learn from. The drive to strength primary services in the community means we must also recognise the expertise of voluntary and third sector services as brokers who can help to build the capacity we will require to meet new demands as users are directed away from GPs to more appropriate interventions. Local residents also suggest that in addition to any innovation they want improvements in some of the basics – being able to make appointments at the GP surgery and out of hours support.
- Resources and democracy. Finally even at a local level I can see that our health and care services face massive and competing demands. There is no immediate prospect of a huge increase in funding – see the IFS analysis here. It is therefore rightly the role of democratic decision making to resolve the conflicts and set the priorities. That is why delivering further improvements through the new strategy “A Healthier Wales: Our Plan for Health and Social Care” is a key test for Welsh Labour in the years ahead.
My report is not for Government, though the key incoming key members of the new Welsh Government will receive copies for reading over Christmas! It is not a report tasked with the making of specific recommendations, but is more reflective on what I saw, discussed and read about in my local ‘drill down’ to local health and care services. I hope it forms part of an ongoing conversation.
The report is in two PDFs here: