Mark Drakeford, Minister for Health and Social Services
This is the fifth update about Together for Health, the Welsh Government’s five-year plan for the NHS in Wales, which informs Assembly Members about some of the key developments over the last 12 months and sets out the priorities for delivery over the next 12 months.
Together for Health sets out a vision to improve the health of everyone living in Wales while also reducing health inequalities. It states our commitment to supporting a modern NHS, which consistently delivers high-quality care and meets the considerable challenges it faces with confidence.
Continued austerity, at a time when the population is ageing and people have a greater expectation about what the NHS can do for them, means that the NHS needs a government which is prepared to support the health service to take radical, and sometimes unpopular, action to secure its long-term future.
To deliver the vision and challenges set out in Together for Health during 2014, we have focused on:
- Developing the prudent healthcare principles to underpin the way NHS Wales operates;
- Increasing our drive to rebalance healthcare by building a new model of primary care, supported by the launch of a new primary care plan;
- Encouraging health boards to improve and refine their approach to the three-year planning system to enable them to take advantage of the financial flexibilities available as part of the National Health Service Finance (Wales) Act 2014;
- Driving further integration between health and social care;
- Investing in the NHS to make it sustainable.
Improving health and treating sickness
Improving the health of the population and address health inequalities remain central to the Welsh Government’s work. Legislation can be a key tool in this agenda. The Public Health Bill, to be introduced later this year, will include a series of bold proposals to address specific public health challenges in areas including tobacco control, e-cigarettes, alcohol misuse and access to toilets for public use. The Wellbeing of Future Generations (Wales) Bill will make improved health a central goal for all public services in Wales.
Action taken by the NHS to reduce health inequalities and tackle the inverse care law is a key driver in the Tackling Poverty Action Plan. Aneurin Bevan University Health Board launched its Living Well Programme aimed at reducing the number of people dying prematurely from cardiovascular disease and cancer. The programme is an example of targeting resources to ensure those with greater need get the facts they need and help in deciding how best to deal with their personal health issues.
We want to improve the way health boards assess local need and plan the use of resources to meet that need. There is evidence that needs assessment and service planning is most effectively undertaken at the level of communities of around 25,000 to 100,000. As part of the drive to improve primary care services, 64 primary care clusters have been set up across Wales to begin this work.
Progress has also been made against population health measures – the latest figures from Public Health Wales show uptake of routine childhood immunisations in Wales is at its highest ever level. Breast and cervical screening uptake is also increasing.
Wales is at the vanguard of an emerging global movement, which stretches from the Americas, across Europe to New Zealand, and challenges us to think about healthcare differently. Together we are questioning conventional wisdom about the way healthcare is provided; about the relationship between professionals and public and about the way we make decisions about our own health and that of our country.
Prudent healthcare means that clinical need and clinical prioritisation determine how services are provided and our efforts are concentrated on those things which make a real difference to people’s health and make the most effective use of resources.
The Bevan Commission has codified prudent healthcare into a set of principles, allowing Wales to move from a concept shared by just a few keenly-interested individuals to a topic which is now widely-discussed by many and is increasingly becoming embedded in the day-to-day business of NHS Wales.
There is already good evidence of prudent healthcare making a difference in Wales. We will further test the principles in diabetes, hypertension, oncology, primary care prescribing and eye care this year.
It is particularly important that we apply the prudent healthcare principles to primary care, as we remodel and expand the primary care workforce – helping to share the workload which has traditionally fallen on GPs’ shoulders alone; changing the relationship between those who use our health services and those who provide them; and providing end-of-life care.
The work to make prudent healthcare a reality in Wales has been captured on the interactive Making Prudent Healthcare Happen website – www.prudenthealthcare.org.uk.
Providing care closer to home
Nine out of 10 patient contacts are in primary care, however we have a health service dominated by hospitals. We must do more to move services out of hospitals and into communities, closer to people’s homes.
Over the last year we have redoubled efforts to ensure we take a preventative, primary and community care-led approach, which is integrated with social care to deliver as much care as possible closer to home. This was a key element of the vision in Together for Health.
In November 2014, the Welsh Government launched a new primary care plan for Wales backed by a £10m primary care fund, building on the £3.5m provided to health boards in 2014-15 to develop the primary care workforce. The plan identifies a set of key actions to improve the planning and delivery of high-quality, sustainable primary care services for all.
It outlines what people can expect from primary care and identifies five priority areas for action to March 2018. The aim is to draw in all those organisations and services, which can help identify and meet local need and to work collaboratively in planning and delivering more services closer to home and, very importantly, to develop and diversify the primary care workforce.
The 64 new primary care clusters, which will be engine room of the Welsh NHS, will receive £6m of the £10m primary care fund for 2015-16 to implement local solutions to local challenges. This demonstrates the Welsh Government’s commitment to developing clusters to plan and meet needs at very local level. A further £3m will support strategic pathfinder schemes or allow health boards and their clusters to accelerate primary care service reform. The remainder of the fund - £1m – will be used to support a programme of work best done once for Wales, including training to remodel the local workforce and education and organisational development support.
A further £50m of funding for the NHS in 2015-16 will directly support the delivery of priorities identified in the primary care plan, including improved population health, reduced inequalities in health and better and more modern access to a preventative and integrated health and social care system.
Together for Health is underpinned by the concept of “ always with our staff”. Wales’ integrated health system enables the effective design and planning of a workforce which meets future needs. A prudent healthcare system depends on a workforce in which people only do what only they can do – they work at their level of clinical expertise and not below it.
A 10-year national workforce plan for the NHS will be developed, bringing together work already underway to plan for the workforce of the future, including embedding the prudent healthcare principles. It will be informed by two areas of work – the primary care workforce plan and an independent review of the NHS Wales workforce, which was commissioned as part of the Agenda for Change pay deal.
The primary care workforce plan will tackle a number of the immediate issues faced by the primary care workforce, including what can be done to support GP recruitment and retention and the role of advanced practitioners. It will also take a longer term view of how the onward development of clusters can be supported by health boards, the Welsh Government and other partners.
We invest more than £350m million every year in professional healthcare education and training. I commissioned a review of the arrangements underpinning this investment to establish whether they represent the best value for money. It is important this is used to support and help drive the change to community-based services. The outcome of the review will help inform future investment decisions.
Prevention, health protection and primary care services are crucial to improving health and reducing inequalities, Wales must also have safe, sustainable and high-quality hospital-based services for those who need them. Health boards have made significant progress in developing regional plans to deliver sustainable services. There has been some natural public concern about changes to long-standing and cherished local services but changes are essential to secure the long-term security and safety of the NHS in Wales.
In South Wales, consultant-led maternity care, inpatient children’s services and A&E services for the sickest and most seriously-injured patients will in future be concentrated at five hospitals in the region. Consultant-led services will, in the future, no longer be delivered at the Royal Glamorgan Hospital, in Llantrisant.
In Mid and West Wales, Hywel Dda University Health Board is continuing to implement agreed changes to services. Consultant-led maternity services were centralised at Glangwili Hospital, in Carmarthen, in August 2014 – the new, purpose-built midwife-led unit in Withybush Hospital, in Haverfordwest, has received positive feedback from mothers. The new neonatal service in Hywel Dda now meets many of the all-Wales standards which the previous two-site service did not.
The independent Mid Wales Study has identified many of the issues and potential solutions for providing accessible, high-quality, safe and sustainable healthcare services, which meet the specific needs of people living in this largely rural part of Wales. The Mid Wales Health Collaborative, led by two independent chairs, is taking the work of the study forward.
In North Wales, Betsi Cadwaladr University Health Board is continuing to implement changes to services and a number of old community hospitals have closed. New services will provide more care closer to patients’ homes.
Ann Lloyd was commissioned to carry out a lessons learned review of the engagement and consultation exercises conducted by the health boards on the first phase of changes to health services. Further work is being undertaken on the recommendations to accelerate the pace of essential service change in Wales in the future.
Significant progress has been made in implementing the recommendations of the McClelland review of the Welsh Ambulance Services NHS Trust. A chief ambulance services commissioner has been appointed to ensure health boards work together, through the Emergency Ambulance Services Committee, to deliver an emergency ambulance response.
The Welsh Ambulance Service has received additional funding to upgrade its fleet and to recruit more than 100 frontline staff. However, performance against the eight-minute category A response time remains challenging.
Aiming for excellence
Together for Health includes a commitment to ensuring better safety and quality to improve health outcomes. The Welsh Government has consulted on a revised Health Standards Framework for NHS Wales, which has been developed following an extensive process involving a review of international and national evidence and engagement with key stakeholders. The new standards bring the existing Fundamentals of Care standards and health standards together in one framework.
There will be one integrated Health Standards Framework, which streamlines the 26 Standards for Health Services in Wales and the 12 Fundamentals of Care standards into seven quality themes and 24 health standards.
Trusted to Care
In May 2014, Trusted to Care, a report about the quality of care for older people at the Princess of Wales and Neath Port Talbot hospitals, was published. The report was about care at two hospitals but it has been used as a driver to improve standards of care across the whole of Wales.
Following the publication of the report, a steering group was set up to drive implementation of the recommendations for improving quality and patient safety for older people across NHS Wales.
A series of unannounced spot checks on wards in all district general hospitals were carried out, which found no widespread issues of concern about patient hydration, continence needs or the use of sedation and they praised the good examples of care they witnessed. However, they did highlight some individual areas where improvements are needed, specifically around medicines management, which are being addressed.
The spot checks were extended to older people’s mental health wards over the winter. The findings from all the spot checks will help the NHS to continue to improve the care of older people in Wales and the lessons learned will be shared across the Welsh NHS.
We have issued detailed delivery plans for each of the major services, which specify service improvements and have published annual reports for many which detail progress made, in line with the Together for Health commitments. Progress since the last update in December 2013 includes:
- The second Cancer Delivery Plan annual report was published on January 31 2014, together with the results of the Cancer Patient Experience Survey;
- All health boards have published action plans outlining local activity to implement the Palliative and End of Life Care Delivery Plan;
- Each health board has produced a Heart Disease Delivery Plan;
- The neurological and respiratory delivery plans have been published;
- The second annual report on Together for Mental Health was published in November 2014;
- The first annual report on the critical care services plan was published in July 2014 setting a clear baseline for the provision of services for the critically ill, complementing the individual reports that have already been produced by health boards;
- The Diabetes Delivery Plan Implementation Board has focussed on developing a new diabetes patient information system; improving access to diabetes structured education; and providing a stronger emphasis on paediatrics and related type 1 diabetes cases;
- Each health board has published a local oral health plan for their area.
Making every penny count
Together for Health committed the Welsh Government to put in place a new financial regime to improve the planning and use of financial resources in line with clinical priorities.
Despite the significant service and financial pressures facing the NHS in Wales and the increasing demands being placed on the Welsh Government’s health and social services budget, expenditure for 2013-14 was successfully managed within the overall resources approved by the National Assembly for Wales.
The Nuffield Trust’s report, A Decade of Austerity in Wales?, unequivocally shows that health services in Wales have responded to the age of austerity by improving efficiency and productivity significantly in response to the pressures of funding and demand. By doing so, the report concludes that the health service in Wales will continue to be affordable in the future.
NHS Wales received an addition £40m in 2014-15 to help it deal with winter pressures from the Welsh Government’s reserves. This follows the announcement of an additional £200m for 2014-15, bringing the extra investment in the NHS this financial year to almost a quarter of a billion pounds.
An additional £295m will be invested in 2015-16, which demonstrates our clear commitment to a sustainable NHS in Wales based on the reforms outlined in the Nuffield report.
The NHS Finance (Wales) Act 2014, which came into force on April 1, 2014 gives health boards the flexibility to manage their finances over a three-year period, providing them with a real opportunity to plan more prudently and avoid inappropriate short-term decisions being taken at the end of the financial year. The Act and the supporting planning framework sets out a clear ambition for a stronger, more rigorous and better integrated planning system. Under the regime, all NHS organisations must develop integrated medium term plans, which are subject to Ministerial approval.
Four organisations secured Ministerial approval in the first planning cycle (2014-15). The remaining organisations agreed one year plans and set out the steps they would take to strengthen their medium term plans for submission in January 2015. Delivery against all plans is being tracked through the national performance and delivery arrangements including, where appropriate, use of escalation and intervention arrangements.
We continue to make good progress across our key health policy commitments. The improvements and innovations taken forward as part of Together for Health and now underpinned by the prudent healthcare agenda seek to ensure the NHS in Wales remains safe and effective and strives to become more integrated, sustainable and resilient.
Patient satisfaction ratings rightly remain high, largely thanks to the dedication of staff delivering services. I would like to put on record my thanks for all their hard work.