‘Our Health Our Health Service’ in Wales consultation
Eight Points for Consideration
Once again Welsh Government is consulting on the governance and management arrangements for the NHS in Wales. The NHS has been fortunate to avoid a wholescale re-organisation in this five year period of government – the last one was badged as a reorganisation to last a generation after all. At the moment it is local government in the spotlight for change. Someone has to be there?!! And as we are so close to an election any changes put forward as a consequence of this consultation are bound to be subject to which parties form the next government in May 2016. More of that in later blogs.
We are already beginning to see the first signs of what might be included in manifestos in the spring. The abolition of health boards proposed by Plaid Cymru, investment from the Conservatives at the expense of further education, and continued commitment to the Cancer drugs fund from the Liberal Democrats seem to be some of the things under debate? We will keep you posted on the politics as it develops. So whilst this consultation on ‘Our Health, Our Health Service’ is from the party in government, and they are almost certain to remain the largest party in any Welsh Assembly election, this is clearly an opportunity to influence all parties as they craft and draft their plans for the NHS in their manifestos.
What seems unlikely is any appetite to fundamentally change the nature of the purpose of the NHS in Wales, so changes in how the NHS is governed and managed can be viewed as significant. Feel free to use this blog as source material for your discussions on the future of the NHS in Wales, and help form your views for your response to the consultation.
1. The NHS in Wales needs clarity on who it is accountable to, and for what
Navigating the complexities of accountabilities for Health Boards and Trusts in Wales has become increasingly challenging for NHS leaders. Organisations can be facing in several different directions at once. Politicians, the public and numerous organisational and professional regulators hold them to account as they see the health service as theirs, but not always from the same perspective, or recognising similar priorities. A government in Wales that has a high level of detailed engagement in the NHS beyond setting strategic direction, yet also seeks a co-production model with the public, lacks strategic coherence?
The residents of Wales are the people who most staff in the NHS truly believe they serve, but is a direction that many organisations may feel they do not face comprehensively. A look at the websites of most NHS organisations demonstrates this clearly. Continuous engagement with the public takes resources, effort and resilience – often, it would seem, that the main focus of attention for the public is when there is major change and a conflict of views. The route open to the public for real accountability is unclear – maybe through the increasing use of Judicial Review, that results in organisations putting in place increasingly complex arrangements to avoid such legal proceedings. Yet the use of new technologies to build lasting and sustainable engagement mechanisms is very limited. The avenues open to the public to engage with the NHS remain highly limited, as NHS organisations remain, sceptical, risk averse or ignorant of the opportunities that technology can provide for meaningful and comprehensive engagement and co-production.
At local level there is an elected politician present at 5 levels of government, so each of us is represented by six elected members (taking the Welsh Government regional list members into account) not to mention the elected Police Commissioners to add to the pot. All of these elected members have the potential to hold NHS organisations to account on behalf of their electorate. Frequently they do this with their constituents sitting alongside, through the various parliaments, through local representation and through local government scrutiny. Politicians have a clear mandate to represent their populations – the review of local government already considers we have too many local councillors and not sufficient diversity. We may need fewer, more diverse, higher skilled and possibly salaried elected members who have more available time. There is an opportunity to capture the opportunity of this proposed new cadre of elected members to the benefit of the NHS, rather than a further tier of NHS specific elected politicians.
Government needs to be smaller, setting strategic policy – sweating the big stuff. This will promote co-production, and local elected politicians should support the engagement process with the public, mandated by what they say about the NHS at election time. Government should also recognise and simplify the wide range of regulators of the NHS and their relationship to government, to ensure there is a clear focus and direction.
2.Health Boards should have full responsibility for leading the planning of healthcare for the geographical population they serve
The fundamental purpose of health boards is to be accountable for the health and healthcare of the geographical population that they serve, and for this to be centre stage of how they plan and operate. The current arrangements are muddled and cause confusion.
The need for population level planning (based on local authority populations) needs to be identified as a clear responsibility for a single health body for each population, and similarly for local authorities, which is the basis of the Social Services and Well-Being of Future Generations Act. This is a key issue of definition that is important in relation to the statutory duties placed on health boards that includes for example old established functions such as public health duties and civil contingencies planning, aswell as new duties being introduced through newer legislation.
Health Boards are asked to prepare plans that lack clarity in regard to the organisation’s twin roles of planning for their resident population and delivering services to the people who use them. This is not helped by an approach from Government that fails to adequately recognise this difference in the roles of organisations, and the further different role of NHS Trusts who are not accountable for the health of a defined population.
If other NHS organisations, and hosted services are asked to prepare their own plans, and held to account for them by government, there is a risk that the system is not building from the needs of the population and the service, and lacks coherence. At present Government intervenes when this confusion fails to work, adding to the complexity, rather than solving the root cause of the problems. Some areas of delivery that should clearly be in the domain of the Health Boards at times seem independent, or driven by Government. IT system development for example should be driven by the clearly articulated requirements of clinicians and the service, not by politicians. Wales has a much less complex system of organisations than England, but even so, more can be done to produce a more coherent, strategic healthcare system that would be more agile in its response to the problems of Wales.
The link between the financial allocation and population health need has already been lost, and this is compounded by the size of current health boards, where the very local nature of inequalities is lost in the scale of geography that the organisations cover.
3. Engagement with the public needs to recognise the tension between a public desire for local service delivery and the professional priority of clinical safety
All organisations, including government, seem to be looking for holy grail of engagement and co-production that leads to a harmonious programme of change agreed with the public. The NHS is constantly changing as the nature of healthcare moves forward. Sometimes this is imperceptible and in line with patient expectations. Sometimes it leads to the need to consider radical change.
Some time ago I ran a workshop relating to the move of a service from one town to another. The room composed of around half NHS staff and half local residents. We were looking at the criteria against which the move would be assessed, and the weighting of those criteria. At one point we split the voting on the criteria to expose the difference in view of patients and professionals. The public favoured access and location of the service as the highest weighted criteria. The professionals weighted clinical safety as the highest. This is a simple and understandable difference in view. It is however also at the heart of nearly every high profile publically contested change.
4. NHS organisations need greater autonomy in determining the composition of their boards
A one-size fits all prescriptive approach to defining the make up of Directors and Independent members on the Boards of public sector organisations is unhelpful. Any organisation needs to be able to structure themselves and recruit the skills they need to meet the challenges that they face at any given time. This is how it would work in the business world. There are some general principles to which adherence needs to be maintained: the primacy of clinical leadership within organisations, the independence and non-partisan nature of the appointments process, drawing the membership of non-officer members from the local community. Such freedom, supported by the appropriate regulatory processes (The Wales Audit Office already members undertakes an annual review of the governance of organisations through its structured assessments for example) would greatly enhance the flexibility and agility of organisation to respond to the challenges they face.
The average age of Boards is also too high. There needs to be a programme to encourage and support young people to participate on NHS Boards as part of the overall diversity programme. In particular this would help and encourage the rapid adoption of new technologies, where the NHS severely lags behind other sectors – my view is this is because the age of boards is an impediment to understanding the opportunities that technology provides for supporting modernisation.
One of the challenges for Board members is the level of commitment that is required. The NHS is complex. Boards need stability to be able to understand their local area, its needs and build trust with staff and the community as a whole. The amount of time that Board members are asked to contribute is not sufficient to meet the demands of the role, especially in large complex organisations. Board members need a much greater level of visibility at ground level to have a full understanding of the reality of the services they are governing. To achieve this, they need to commit a greater amount of time to the role.
5. The size of the leadership and governance teams of health boards should reflect the demands placed upon them
Put simply, NHS organisations do not have the organisational capacity to manage the multiple demands placed upon them by government. Strengthening the accountability of individual Board members for organisational performance is more likely to discourage, rather than encourage members to come forward. The changes that need to happen is to ensure that the recruitment and availability of Board members is of a high calibre and that they are able to offer sufficient time to the role to enable good governance. Time and again reports into failing organisations demonstrate that one of the main causes is Board members that are disconnected from the organisation as a whole and the narrow upwards focus of governance that prevailed.
One of the limiting factors on Boards is the time available. Government needs to assess the governance requirements that are being placed on the members of Boards and resource them accordingly, relating both to the predominant skill sets that are required, but also the capacity of the individuals. For example one challenge currently is the independent members on Boards who already carry significant portfolios in other roles such as in local government. Inevitably a primary focus on their local government responsibilities will be their priority. Given councillors are not salaried then the expectation to fully participate in Boards is a challenge. This relationship needs to be re-thought, given other structures in place to ensure partnership working.
6. The role of local democratic representatives in the NHS should be strengthened, but not added to.
Wales has layers and layers of elected people: Brussels, Westminster, Senedd, the Local Authority and Community Council. Five layers of elected members, plus of course the Police Commissioner.
As health boards respond to and enact Welsh Government policy, who also control resource allocation, it is difficult to envisage on what mandate an elected member of the public would function on a health board, and be held to account by their constituency. The approach would seem to be at odds with a more general approach to engaging the wider population.
Local politics can be highly volatile, so tying Board membership to cabinet status is a mistake, as these members can change so often. The NHS is not managed and run locally on political or democratic lines – the democratic deficit in Health Board’s cannot be filled by one or two members on a Board. I am not opposed to elected member engagement in Boards per se, but placing a couple members on Boards does not meet this gap, especially given the current number of local authorities per health board.
7. Wales needs modern healthcare facilities across the Country
If we look at the very best facilities across Wales, the UK and the world, we can see that many of the buildings that we run our services from in Wales are at best described as tired. The availability of capital funding has been cut, and new development in primary care has all but stopped completely. Undoubtedly there is a need for more creative ways of funding world class facilities. Introducing borrowing powers to support capital build is likely to have a revenue cost, though better facilities will also help save money.
To some degree these mechanisms already exist. The capital costs of most GP practices for example is funded by the GP themselves, or commercial property providers that specialise in GP premises. The cost of capital is then serviced through the reimbursement of the rent for these properties that are held on long term leases.
In a small number of cases GP premises and other community facilities have been built and leased from the not for profit sector. This is not dissimilar to the model that Housing Associations operate where they are able to leverage commercial capital to fund developments. Setting up a similar property vehicle for NHS Wales that is able to build, fund and rent back property to the NHS on a ‘not for profit’ basis, is a better fit. The advantages are many. Property management is not one of the NHS’s strengths, and separating out some of the property management over time might assist in improved maintenance and continuous upgrading.
Non-clinical staff and functions need to move from the clinical sites or old redundant sites. Hospitals are some of the most expensive real estate to build and run, and old buildings are expensive to run and maintain. Yet many NHS staff are stilling working in these facilities and don’t need to be. Shifting office based staff into purpose built office accommodation, supported by agile working should be the way of the future to reduce the pressure on clinical space.
Government also needs to bite the bullet and demonstrate on a cross-Wales, cross party basis that we have too many hospitals for the model of healthcare required for the next 50 years. There is a need for rationalisation and modernisation, with full reference to the relationship with cross-border facilities. Such a planned system can only be led at national level.
All in all the people of Wales deserve fewer, higher quality, world class facilities.
8. The role of the Director of Public Health in advising all organisations on the health of the population should not be confused with management and employment arrangements
The arrangements for public health are already complex, as the Director sits in one organisation, and leadership for the public health agenda nationally is driven by government and Public Health Wales. Public Health has always fulfilled a function that serves the population, rather than a specific organisation, and the Director already has an independent role in relation to local authorities. Joint appointments of Directors of Public Health will not add to this arrangement and will increase complexity as there are currently 7 LHBs and 22 local authorities.
