We can’t carry on like this.  How can we better invest in health and wellbeing of Wales?

Allen ni ddim parhau fel hyn.  Sut allen ni fuddsoddi’n well yn iechyd a llês Cymru

A recent event hosted by the Morgan Academy attempted to tackle the not insubstantial challenge of health and wellbeing in Wales.  The Pierhead building in Cardiff Bay was a fitting venue dedicated as it is to providing a space to “inform, involve, and inspire a new generation to forge a Wales for the future”. 

Health and wellbeing is a massive subject with many interwoven complex issues – so a challenge to address in any great depth.   Nonetheless linking up a range of siloed issues is essential to find the solutions and the day managed to shine a light on many of these.

My main take always though were:

• It is very difficult to plan for the long term in the middle of a crisis: the healthcare system, local government, and social care are under such intense pressure that it means the leadership is focussed on firefighting and this limits the ability to make long term plans.
• For those on the front line this is like stating the blindingly obvious to the point of being insulting: they know it all too well and see the repercussions in their daily work.
• However, with a healthcare system designed for a different era, improving wellbeing of the whole community and future generations is essential.
• We continue to measure the cost and health improvements of biomedical advances but overlook the value that investment in a holistic view of health can bring.
• Investment in all areas needs to be seen in light of health: roads, environment, education, poverty reduction, employment, all have a role to play and in fact contribute more to overall health than simply treatment of sickness.
• Many of the actions are already set out both by the recent parliamentary review and in Making a Difference by Public Health Wales.
• The finance minister reflected on seeing no one smoking at a community festival this year – a huge change from 20 years ago.  Now is the time to set out a clear vision of community wellbeing for 2038.

 

Evidence Panel:

This panel starting with David Phillips from the Institute for Fiscal Studies set out some of the context for Wales in the context of austerity and Brexit.  Adam Roberts from the Health Foundation attempted to address the question of whether the NHS in Wales should have additional funding in the context of less cash overall for devolved services.  The conclusion was yes because i) it is a priority for the population of Wales and the current administration has a mandate to protect the NHS budget; ii) money spent in the NHS helps overall economic development; and iii) NHS Wales has a plan, as set out in the recent parliamentary review.

Much of this discussion focussed on healthcare and social care so it was not clear whether the question of how best to invest in health and wellbeing in a holistic sense had been answered.

Edward Davies from the Centre for Social Justice took up this challenge reflecting on the need to invest in the wider determinants of health.  Citing evidence that only 10% of good health results from access to healthcare services he highlighted projects including Men’s Sheds and those to develop social capital such as lunch clubs that appear to be having a positive impact on health outcomes and therefore demand on health services in Somerset and Froome.

Overall – a lot of talk about the crisis in NHS and social care funding and one lone voice calling for investment in health in the wider sense as a possible solution.

 

Investing in the Wider Determinants of Health and Wellbeing

Alison Davies from the Royal College of Nursing made a pitch for the need to work with communities.  She saw a need for meaningful conversations to happen about what activities communities would see benefit and indeed what wellbeing means to them.  In turn this would inform service redesign which could draw on international examples including home care provider as found in the Buurtzorg model.

She also made the really good point that the healthcare and public sector workforce in Wales is large and improving the health of this population is really important.

The introduction of the Future Generations Commissioner for Wales has received much attention and this was my first opportunity to hear Sophie Howe speaking.  What she had to say made attending the day worthwhile on its own which included:

• Who is asking why these people ill or needing care in the first place?
• Continued thinking in organisational silos is a problem.
• Finance indicators are short term.
• There is an epidemic of loneliness and social isolation.
• A lack of physical exercise is an important factor in health and wellbeing.
• Poor air quality needs to be addressed.
• Investment in public transport and active travel is essential.
• Wales should be looking at the question of health outside of just healthcare.

The Commissioner put forward really practical examples / calls to action including that new [additional] money for the NHS should be spent in partnership with other services to encourage breaking down silos; she challenged the mantra of investing in the M4 relief road ahead of other factors that might benefit health.  It was clear that the Future Generations Commission gets the message that Wales should be planning funding for social care demands in 2036 not based on current requirements.

Next, the day jumped into a laser-like targeted dissection of the economic issues in the future funding of that care and also (hurray!) a proposal to do something about it.  Gerry Holtham, Hodge Professor of Regional Economics at Cardiff Metropolitan University set out his proposal for a community insurance fund in Wales.  I would say his vision but he actually made it very clear that Welsh society needs to have a discussion about what the right solutions are with experts such proposing workable proposals to the community’s vision for the future.  This could have been an entire day in its own right and this paper sets out the proposal in more detail.

Debbie Wilcox of the Welsh Local Government Association and leader of Newport Council drew out that promoting wellbeing is in fact a key goal for councils, something that doesn’t always come across in the day to day of local government.  However, this needs to be set in the context of local government facing unprecedented cuts.  Nevertheless she called for council services to adapt cost effectively to promote health and noted the importance of the many preventative services that local authorities provide including housing, libraries, leisure centres, and parks.  Many of these are discretionary services though and as a result have been cut to meet budget pressures.  In passing research from Canada was referenced showing that jurisdictions that invest in social care as a priority over healthcare have improved overall health outcomes.

Alun Thomas, from the charity Hafal highlighted a number of pertinent issues in the context of Wales including the fixation to find a single solution to many problems across Wales when often there isn’t one solution.  Part of the problem here he suggested to be a tendency to ‘consult to death’ but not actually listen to what local communities are saying.

Hafal has undertaken its own investigation into these issues through Making Sense looking at children and youth health services in Wales.  This highlights the need for specialist support to be focussed on the most acute problems with the education sector in particular playing a significant role in supporting the wellbeing of all children and young people.  Hafan have developed their own 16 bed unit at a lower cost than a similar unit in the NHS would cost in part by looking at what are ‘acceptable’ standards for facilities.

Finally there was a welcome call to move from minimum standards in care homes to acceptable standards noting that staff must be valued in this equation – minimum wage: minimum standards.

Tracey Cooper of Public Health Wales closed this session on wider determinants of health.  It is worth highlighting that Public Health Wales was established as an NHS Trust in 2009 and as such is part of the overall healthcare system in Wales.  Therefore when the health minister later talked of investment in NHS this does include public health – but notably less than 2% of the overall budget for health in Wales (FY15/16).

It was no surprise therefore that Public Health Wales has undertaken a survey of the Welsh population to find backing for its activities.  Tracey Cooper noted the majority (53%) agree that more money should be spent on treating illness and less on treating it.  Public Health Wales have already set out priority actions known to work for Wales in the Making a Difference proposals including for example ensuring a good start in life for all.

 

Investing in Health and Social Care

Robin Roop, an emergency medicine doctor and representative of the Royal College of Emergency Medicines set out an impassioned view of the situation doctors in emergency departments (A&E) find themselves in currently.  How could we not sympathise with the family who have lost a loved one and the doctor who despite all their training and effort has to explain that an ambulance wait or delay in the hospital has likely contributed to their relative’s death.

This puts into context just how powerful a message it was that Robin Roop then said that if he had £10 million extra cash, now, he would chose to give it to social care not A&E.

The afternoon continued with a downbeat assessment of the political will to address the issues from Steven Philips from Neath Port Talbot County Borough Council.  Nonetheless he saw value in the proposed community insurance proposal by Gerry Holtham.

These reflections which seem reflective of a broader view from local government included the complaint that debate is focussed at high level concepts not practical action.  There was a call to get on with identifying the issues and addressing them.  Nonetheless New Zealand’s health and social care system was held up as an apparently successful model including looking at failure demand approaches – i.e. the demand created by a failure to get it right first time.

 

Keynote from the Welsh Government Finance Secretary

Mark Drakeford AM and conference chair Bethan Rhys-Roberts.

Whilst billed as a keynote one could not feel like Mark Drakeford AM had the almost impossible task of resolving the day’s challenges – remembering that the best minds in the room didn’t have the solution.

Despite this, he spoke with conviction and passion for the health of people in Wales and a commitment to taking on these challenges.

The finance minister highlighted that austerity has changed the landscape: by his figures the devolved administration in Wales would require £1 billion more cash just to stand still in real terms compared to 10 years ago.  He outlined three competing views of this challenge:

1. We can’t go on like this.  Health is a monster taking over Welsh Government which is becoming a glorified NHS Health Board.  Therefore we should divert money away from health service to do all those other good things.
2. The health service is in such need and the gap between what is needed and what we’ve got means the only solution is to provide more money without condition.
3. Whole system reform is needed but the money is an issue too.  Much of what we do today doesn’t deliver the outcomes we want and we are using the structures of a different era to deliver today’s expectations.

The last reflects his own position and some key points made were:

• He could not see the NHS having less money.
• Cuts to NHS funding would not be aligned with the Welsh Government’s course of action.
• The Parliamentary Review does indeed set out many of the solutions.

Much was said about the Prudent agenda developed with the Bevan Commission but an agenda of investment in prevention, rather than efficiency, was harder to pick out – no clear commitment to increase investment in the wider determinants of health or Public Health Wales’ budget.

 

Reflections:

It is a big conversation: the day was a wave of topics, issues, and discussion.  Joining up the conversation is essential but it needs to focus on practical actions and priorities, as Steven Philips called for.

Pilots are no longer enough: a reflection on my own practise – I’ve always advocated pilots – after all who can say no to a pilot of some new idea.  These challenges are bigger though and need addressed with vision, scale, and significant investment.

Priorities mean choices: the finance minister has a clear direction of travel.  How does this respond to the evidence mentioned during the day that investment in social care over healthcare can improve health of a population and what about the challenge that 90% of health is not associated with access to healthcare when less than 2% of healthcare funding in Wales goes to Public Health Wales?  How do these issues inform investment decisions: there is no indication that government will change investment decisions in light of the Future Generations Commissioner questioning the value of the M4 motorway relief road – where is the investment at scale in active travel that was called for?

Long term planning in a crisis is hard: clearly healthcare, social care, and local government are under huge financial pressure.  Based on what I heard they are almost exclusively focussed on and struggling to deliver existing services to minimum standards.  Looking at prevention and investing in wider determinants of health is like another world.  Something needs to happen to allow longer term thinking without simply taking resources off these services.

A crisis in A&E: Robin Roop, a voice from the front line of the NHS did not skirt use of the word ‘crisis’.  When the Vice President of the @RCollEM in Wales says they’d give an extra £10m to social care not A&E it shows how cuts in one area cause pressures in others – it’s all health and needs joined up.

Let’s plan for the Ely Festival 2038: The finance minister reflected on attending the Ely (Cardiff) Festival in 2017 and how he had not seen anyone smoking despite looking: compared to two decades ago this is a major change which has a profound impact on wellbeing.

The Future Generations Commissioner made a call, specific to care, but applicable to all areas, to start thinking now about what the demand / the world / Welsh society will be like in future decades not just now.

In part this is about ‘prevention not just treatment’ and ‘health not just healthcare’ however Alun Thomas points are well made that communities need to be listened to and there should not be an assumption that there is one solution for Wales but rather the solutions need to be tailored to the benefits the community wants to see.

Now is the time to set out a vision of what that future could be though.  The frames of reference for what we value in health need to be addressed; there must be a broader acceptance of and voice for the wider determinants of health including poverty, environment, social isolation, and education; the funding pressure in the NHS and local government needs addressed or this will be the sole focus of the public and politicians in a short term decision taking cycle.  If we know where we want to be in 2038 then now is the time to start doing something about it.