Impact assessment: Health and social Care COVID-19 looking forward

Since March 2020 the NHS has been under significant pressure to respond to the COVID-19 pandemic and maintain Essential Services. As the pressure eases there is a need to consider the impact and opportunities there are to reset and rebuild services whilst continuing to respond to COVID-19 which will be with us for the foreseeable future.  The Welsh Government intends to issue the Health and Social Care in Wales COVID-19: Looking Forward (‘Looking Forward’). It sets out at a high level the approach we will take, building on new ways of working and opportunities to do things differently. A series of more detailed plans will be developed as the complex task of recovery continues.

The document complements the NHS Wales Annual Planning Framework 2021-22 which was issued on 14 December 2020. The Planning Framework already sets out direction and priorities for NHS Wales to adopt as organisations develop their annual plans to be submitted by 31 March 2021. The 'Health and Social Care in Wales – COVID-19: Looking Forward' document is public facing and seeks to set high level direction for overall recovery and a renewal pathway for the health and social care system, and does not negate the need for services to ensure their service planning is aligned with the policy requirements or the Ministerial directions already in place.

Rationale for recovery document

The 'Health and Social Care in Wales COVID-19: Looking Forward' sets out the high level expectations for NHS and social care recovery, the challenges and constraints and priorities for each part of the system. It brings together the whole system approach in one document to demonstrate a clear direction for rebuilding key services.

Our challenge now is to build the integrated health and social care services that we want going forward and to deal with the long-term impacts of COVID-19. It is an opportunity for health and social care services in Wales to change for the better, recognising that COVID-19 is still with us. With COVID-19 still present in our communities, the NHS and social services will continue to need to plan in the context of significant uncertainty with agility and flexibility.

The four harms, which have been used to describe the broad priorities which the NHS and social care in Wales have focused on over the past year, are still relevant.

Assessing the impact of improving health and social care on equality of opportunity.

• Harm from COVID itself
• Harm form overwhelmed NHS and social care system
• Harm from reduction in non-COVID activity
• Harm form wider societal actions/lockdown

'Looking Forward' builds on what has been learnt over the past 12 months, since COVID-19 impacted. This impact assessment looks at how the document has been constructed and what opportunities have been taken to ensure fairness and equality have been adopted in this approach. In this respect 'Looking Forward' builds on existing policies, rather than create new ones, drawing therefore on the impact assessments that have already been conducted.

Long term

'Looking Forward' continues the focus on strategic direction, and should be seen as the next step to sustainable reset and recovery for health and social care in Wales, in the longer term. It is recognised that this will take many years and is not just about short term fixes.

It links longer term goals and commitments, such as decarbonisation, socio-economic duty, and the well-being of future generations, to ensure recovery and operational decisions will be taken against a backdrop of these wider strategic matters. 

The lessons learnt from the work undertaken to respond to the pandemic will be critical in supporting recovery and long-term continuity. 'Looking Forward' recognises the need to reflect the opportunities that have emerged during the pandemic to support new ways of working, such as the introduction of innovative and digital solutions, financial investment and strengthened partnership, governance and planning arrangements

Prevention

'Looking Forward' supports the prevention agenda, requiring health boards and other NHS organisations to plan their activities to ensure they address the balance between preventing the spread and impact of COVID-19 and supporting those people with other health conditions. It also considers the need to address the wider determinants of health through an emphasis on prevention across all settings and pathways in order to tackle inequalities.

The vaccination programme remains a significant priority. The programme is a priority because it covers both the usual childhood vaccinations and immunisation in order to keep children and young people safe, influenza vaccinations and the COVID-19 mass vaccination exercise, which is rapidly underway and will continue throughout 2021-22.

Continuing focus will be made of the Test, Trace and Protect strategy. The expectation will be for organisations to work closely with local authorities, to ensure people are tested and traced as quickly as possible to contain the spread and impact of COVID-19.

Similarly, organisations must consider how best to treat those with non COVID-19 conditions, to ensure that patients with symptoms are able to get rapid diagnosis and treatment to prevent their disease developing further, particular those with life threatening illnesses. 'Looking Forward' is intended to support organisations in their ongoing response to COVID-19 and towards the re-introduction of the wider, more routine services.

Integration

Prosperity for All has been considered. 'Looking Forward' is in line with the framework which sets the context within which health boards and other NHS organisations are expected to plan for. This high-level document for the health and social care recovery is underpinned by a refresh of A Healthier Wales. 

'Looking Forward' reflects the approach for health and social care in Wales and adds further focus to a number of key areas such as reducing inequalities, learning from the impacts of COVID-19 and mental health and well-being. We must now use the learning to build:

• solid primary and community care
• supportive mental health services
• efficient and effective hospital services
• seamless social care services
• a resilient workforce
• an effective digital infrastructure

The 'Looking Forward' document highlights work to develop a 'Race Equality Plan'. This represents an important statement by Welsh Government of its vision and values. The practical actions will address racial inequality and improve the life chances and outcomes of Black, Asian and Minority Ethnic communities in Wales. A toolkit to help employers and employees to feel safe and well at work has been developed to address the issues that COVID-19 has shown all too clearly.

The Welsh Government is committed to tackling all forms of harms as we move towards recovery. This includes harm from delays in access to treatment or care, the impact on mental and emotional well-being and the impact of wider social and economic issues.

Collaboration

'Prosperity for All' champions working collaboratively across boundaries to deliver improvement in health and well-being for the population of Wales. 

'Looking Forward' is an additional supportive tool for Ministers to support the direction for our health and social care system and will be consistent with the strategic planning discussions taking place with the range of stakeholders to support delivery.

All partner organisations will be required to demonstrate their contribution to tackling COVID-19 and to preventing further spread and impact from the disease. The expectation is that COVID-19 will still be circulating in our communities for some time to come and all partners will need to work together to ensure the spread and impact of COVID-19 is reduced as much as possible.

While the time period to produce 'Looking Forward' has been short, the Welsh Government have ensured that a range of stakeholders, including key clinicians and professional bodies, have been made aware of its development to ensure a consistent and collaborative approach. This will also seek to provide assurance to members of the Senedd.

Involvement

'Looking Forward' has been discussed with a range of stakeholders, including NHS Chief Executives. This helped shape and influence the document as it developed.

COVID-19 has had a significant impact on people from ethnic minority communities, and those with obesity and multiple health conditions. It is important to continue research to understand what the risk factors are for vulnerable people and how best these can be reduced, whether by vaccination, treatment or well-being interventions. 

We must reduce the disparities in living conditions that have negative impacts on the health and well-being of people in Wales. Access to secure good quality housing is important, and the support offered to those who are homeless during COVID-19 needs to be built upon. Our strategies must provide support for the most vulnerable parts of Welsh society.

The pandemic has highlighted the need for even stronger cross-government actions in the area of prevention and the protection of mental health. The Review of the Together for Mental Health 2019-2022 in response to COVID-19 report outlines a range of commitments to address the wider socio-economic impacts of the pandemic and their effects on mental health and emotional well-being, most of which sit outside the health and social care system. 'Looking Forward' recognises the need to build on this evidence to build stronger and more resilient services.

We recognise the importance of ensuring that those in greatest need are central to the future health and social care system. Without this direction in 'Looking Forward', there is a great danger of significantly increasing existing disparities, with major negative impacts upon the future health and well-being of people in Wales.

Impact

'Looking Forward' will provide direction around what will be needed across health and social care to develop stronger and more resilient services, building on the learning from the pandemic. It is committed to developing models of care and improving outcomes for patients and service users.

It will provide clear messages to the public and stakeholders of the work being undertaken, including the need to continue focussing on greater levels of testing for staff and people and delivering an expanded vaccination programme. 'Looking Forward' recognises the significant capacity and workforce challenges that lie ahead with the aim to building to what will be a new normal health and social care service in Wales.

'Looking Forward' draws on the learning of the past twelve months with the benefits of strong partnership working between the NHS, social care and wider public services to create a whole system approach have been clearly demonstrated during the pandemic response. Strengthening this way of working is consistent with 'A Healthier Wales' and will be a priority, building on the benefits seen through joint approaches to the pandemic.

We will expect recovery plans to be built on collaboration between the NHS and social services, working with key partners.

'Looking Forward' will generate more focussed attention on specific areas of recovery, such as backlogs of patients waiting for treatment. It will also highlight and prioritise the need to reduce health inequalities and to ensure the well-being of the health and social care workforce continues to be paramount.

Costs and savings

No financial cost will be incurred in scoping and developing 'Looking Forward' by the health and social services group within the Welsh Government. There has already been considerable investment in the health and social care infrastructure during 2020-21 to support the main requirements. For example this includes:

• Over £1.3bn allocated to support the NHS response to Covid. This includes the £800m stabilisation funding for NHS Wales announced in August.
• £45m for Test, Trace and Protect Strategy implementation
• £62.7m through the Local Authority Hardship fund, to support providers of adult social care.
• £40m to support the social care workforce.

However, we know that we will have to continue to consider the significant resources needed as we manage the changing demand on our services and the considerable backlog of patients that will need to be treated following the unprecedented global pandemic. 

The scale of the costs of recovery, whilst not yet known, will be considerable. The detail of plans which have to balance the continued response to COVID-19 with recovery, implications for the workforce, and the costs will take time to develop. We have an opportunity to allocate resources differently to encourage the right behaviours and approaches in recovery. This will support the system to focus on effective interventions, which deliver the outcomes that matter to people.

Mechanism

Legislation is not proposed as part of this work, a regulatory impact assessment is not necessary.

7.1 How have people most likely to be affected by the proposal been involved in developing it?

Health and Social Care in Wales COVID-19: Looking Forward has been developed rapidly in order to provide our health and social care services in Wales with clarity on the strategic direction and priorities needed to reset and recover.  As we remain in an unprecedented global pandemic environment, we must take a flexible and robust approach to our planning so that our services are best able to deliver for their local populations.

This impact assessment identifies opportunities have been taken to ensure fairness and equality have been adopted in the approach, however it also recognises that 'Looking Forward' builds on existing policies and approaches, rather than create new ones. As such much of the evidence for these policies lay in the existing impact assessments that will have been conducted when they were formulated.

This is not to say that there is not any new evidence that has emerged in the last 12 months that people from ethnic monitory communities, older people, children and young people, those with mental health issues have all felt an impact not only from COVID-19 but also from the restrictions that were imposed to keep us safe.  

There is growing recognition and understanding of the impact that staff across the health and social care sector have faced and will continue to face as we emerge from the pandemic and look to rebuild better.

'Looking Forward' was developed through discussion with colleagues across the health and social services department within Welsh Government, professional leads and senior colleagues from within the service such as NHS Chief Executives, Directors of Planning and Directors of Finance, etc. 

Policy Leads will continue to listen carefully and take account of the expert advice received from the WHO and since mid-March 2020, a number of population surveys across the UK and in Wales have reported the impact of the pandemic and lockdown measures on aspects of individual’s mental health. This includes:

• a survey by the Children’s Commissioner which highlights the impact on children and young people Coronavirus and me results,
• a Cluster development ‘A Big Conversation’ commenced in December 2020 which will inform a delivery plan to be reported at the end of March 2021

As we move forward staff surveys and patient experience will continue to be gathered and played back to examine what more needs to be done. 

7.2 What are the most significant impacts, positive and negative?

'Looking Forward' should have a positive impact on people across Wales and sets out the strategic direction for rebuilding key health and social care services.

Organisations will not be starting afresh but will be building on the developments they have already made over the past twelve months and Looking Forward provides a clear direction going forward.

Health and social care services need to plan to meet the needs of their respective populations and must do so regardless of age, race, religion, sex and sexual identity, etc. It makes clear the need for organisations to ensure that people have equal access to diagnosis and treatment across the four harms.

It recognises that some groups of people have been adversely affected by COVID-19 and reinforces the need for organisations to mitigate this, deploying the test, trace and protect arrangements that are geared to reducing the spread of COVID-19 and supporting vaccination programmes for children and young people, influenza and COVID-19. 

'Looking Forward' recognises the need for essential services to operate to ensure that people with non COVID-19 conditions are able to seek advice and treatment safely and in a timely manner, as well as working towards the reintroduction of the more routine services. 

7.3 In light of the impacts identified, how will the proposal:

• maximise contribution to our well-being objectives and the seven well-being goals and/or
• Avoid, reduce or mitigate any negative impacts

'Looking Forward' is underpinned by the Well-being of Future Generations (Wales) Act 2015, providing the overarching building blocks that are needed, through the five ways of working (long term, prevention, integration, involvement and collaboration), to support the health and care system recover. It is also underpinned by ‘a Healthier Wales’. This approach will support our health and social services in Wales in providing appropriate treatment and care for people with COVID-19 symptoms and those with non COVID-19 other conditions.

The Welsh language is important in the delivery of health and social care. For many people, being able to access information or describe their symptoms and talk with professionals in their preferred language is key to getting the right treatment and care. Health boards and trusts are subject to Welsh Language Standards (regulated by the Welsh Language Commissioner), which are a set of legally binding requirements that aim to improve bilingual services. The Welsh Government’s More Than Just Words Action Plan sets out a range of actions which will underpin the recovery of our services.

This promotes an integrated approach to health and social care and using the four harms as a structure promotes positive impacts and seeks to reduce health and well-being inequalities. 

7.4 How will the impact of the proposal be monitored and evaluated as it progresses and when it concludes? 

The impact of 'Looking Forward' will be monitored through a range of mechanisms which involves ongoing engagement between Welsh Government, NHS organisations and key partners on a regular basis. Building on the partnership arrangements in place through Regional Partnership Boards, will also be key for local organisations to work together across the health and social care sector to achieve better outcomes for citizens.

Regular surveys of staff and patients will be undertaken by organisations to understand how people feel and what matters to them as we move forward into an environment in which we learn to live with COVID-19 as part of our health and social are community. Likewise new measures of how the health and social care community are functioning will need to be developed to further support the greater focus on outcomes rather than outputs.