P 62

Ymchwiliad i’r Adolygiad Blaenoriaethau ar gyfer y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Inquiry into the Priorities for the Health, Social Care and Sport Committee

Ymateb gan: Cymeithas Feddygol Prydain Cymru

Response from: BMA Cymru Wales

PRIORITIES FOR THE HEALTH, SOCIAL CARE AND SPORT COMMITTEE

Consultation by the National Assembly for Wales Health, Social Care and Sport Committee

Response from BMA Cymru Wales

2 September 2016

INTRODUCTION

BMA Cymru Wales is pleased to provide a response to the Health, Social Care and Sport Committee’s call for suggestions as to what the priorities of the Committee should be during the Fifth Assembly.

The British Medical Association (BMA) is an independent professional association and trade union representing doctors and medical students from all branches of medicine all over the UK and supporting them to deliver the highest standards of patient care. We have a membership of over 160,000, which continues to grow every year. BMA Cymru Wales represents over 7,500 members in Wales from every branch of the medical profession.

RESPONSE

We would broadly agree that the areas the Committee has identified in its initial discussions, as possible areas for consideration, are all valid and important.

We do feel however that, for at least some of them, a significant amount of work has already been undertaken in considering these subject areas – and as part of that, in collecting views and evidence from key stakeholders. This volume of work, we would argue, has not however been matched by action or tangible change – resulting in an abundance of reports, recommendations and strategies but very little action or change visible ‘at the front line’. This is especially the case on the subject of the NHS Wales workforce, and primary care – our evidence on these subjects will not differ widely from that given to other inquiries and consultations on these subjects conducted over the last few years, albeit our areas of concern may have deteriorated further in that time.

Our main observation in relation to this is that we are in danger of being in a state of perpetual evidence gathering, and that organisations will begin to suffer from consultation fatigue. Further, on many subject areas (GP workforce being one of them) there is a broad consensus on what needs to be done to improve on the status quo.

Whilst understanding that the Committee’s role is to hold the Welsh Government to account and to examine legislation, we would urge the Committee to look at such subjects from a new perspective. Such an approach could be, for instance, to follow up on the reports and recommendations of previous inquiries – for instance the 2015 GP workforce inquiry by the previous Health and Social Care Committee (HSCC), but also on its own inquiries going forward. It would be a useful exercise to examine how many of the recommendations have been taken forward, and which ones the Committee feels are still valid – whether or not they were accepted by Welsh Government at the time of original publication. Examining the impact of any changes that have previously been introduced, and whether or not they have achieved the desired impact, including in terms of population outcomes, should also be undertaken as a first step before any new actions are considered.

It would therefore be worthwhile for the Committee to examine progress on recommendations that have previously been put forward and agreed in other external inquiries and reviews – such as the recent NHS Wales Workforce Review chaired by David Jenkins and progress against the commitments in the Welsh Government’s workforce plan for primary care, ‘A Planned Primary Care Workforce for Wales’. We make this suggestion with the issue in mind that recruitment and retention are currently the key challenges for the NHS in Wales.

Below, we offer comments on the subject areas identified by the committee:

· Integration of Health and Social Care services – BMA Cymru Wales holds that collaborative cultures with shared values, good professional relationships and effective leadership are essential if integration is to get off the ground. As confirmed by doctors in our surveys, these elements are also vital to securing what should be the key measures of success of efforts to integrate – improved clinical outcomes and better patient experiences. Therefore the individual must be the organising principle for any changes. They key role that is played by the GP practice should also be considered.

We do not believe that the full integration of health and social care (structures, budgets and staff) is absolutely necessary to produce genuine joint working and more coordinated care. We believe that coordination is best achieved by creating long-term stability across the NHS and local authorities and allowing integrated care to become a priority, not by further reorganisation. The Committee might therefore focus on good information sharing, and facilitating effective professional relationships across disciplines and organisations. It is often the case that frontline staff across organisations are hindered in working together as effectively as they might by organisational requirements, so it could also be helpful to look at how such barriers to integration can be addressed.

The Committee might also wish to consider the inter-relationship between social care and health care provision and how an inadequacy of social care provision can lead to health services being overwhelmed. There is currently considerable variability of social care provision across Wales, with services having been substantially reduced in some localities, and this is leading to an increase in both avoidable hospital admissions and incidences of delayed discharge. To underpin the Welsh Government’s often stated intention of delivering more health services within community settings, it might therefore be worth considering if enough is being done, and enough resource being provided, to support independent living and effective implementation of the Social Services and Well-being (Wales) Act 2014.

Further information on our views on this subject area can be found within our evidence to the NHS Wales Workforce inquiry – here.

· Waiting Times–The focus of this work seems to be placed on finding solutions to the current pressures of meeting waiting time targets. This area would also offer the opportunity to look at the appropriateness of some targets, and consider where organisational or financial targets might better be replaced by clinically derived or outcome focused measures, including looking at whether some targets may inadvertently distort clinical priorities (e.g. prioritising first appointments with a consultant at the expense of follow-up appointments) and the merits of moving to a model that is better able to take on board the clinical needs of individual patients. The extent to which individual targets add value needs to be properly considered, including whether or not they simply divert a proportion of activity towards ensuring they are met rather than towards improving care.

· Primary Care–This is an obvious priority area to consider and one where we have a wealth of expertise and policy to offer. The key areas to look at, we suggest, are: workforce (recruitment and retention, including GP training); workload pressures (including how the Welsh Government can address this to better support practices); finances into primary care (including looking at how a continual erosion in the proportion of NHS funding in Wales going to general practice can be addressed, and ensuring that when work is transferred from secondary to primary care this is matched by an appropriate transfer of resources); clusters and how they are both operating and delivering; and infrastructure (such as IT systems). It is worth noting that when looking at such areas, the whole practice team needs to be considered.

The Committee might also wish to consider the extent to which progress is being made against the relevant recommendations of the report published earlier this year by the Organisation for Economic Cooperation and Development (OECD)[1] which compared the performance of the different health care systems in the UK. This could include looking at what action is being taken by the Welsh Government and local health boards to advance the OECD recommendations which called for primary care to be put ‘front and centre’, including by reserving a seat on every health board for a GP. Such action might help ensure that health boards have access to greater knowledge about what support they can provide in order to assist GP practices.

As we have touched upon above, we think it is important that any work undertaken in this area should take account of how previous work by the former HSCC and existing Welsh Government strategies are being taken forward, rather than seeking to simply look at these aspects afresh.

Further information on our views and suggestions in this area can be found in our strategy document for general practice, here, and our response to the HSCC inquiry into the GP workforce, here.

· Efficiency within the NHS and modern management practices – we would be wary of looking at this with a sole objective of identifying efficiency savings or suggesting other cost cutting measures. However, looking at instilling organisational learning and sharing of best practices would be extremely valuable – as well as looking at the appropriate use of resources as set out in the BMJ’s ‘too much medicine’ work, for instance. This work could also consider whether we have the right balance between non-clinical and clinical management, including looking at the merits of better empowering effective clinical leadership. The inquiry could also be expanded to take on board many of the suggestions we previously put forward in our response last year to the Welsh Government’s Green Paper, ‘Our Health, Our Health Service’, here. These include looking at the culture within the NHS in Wales, to ensure that staff feel able to raise patient safety concerns knowing that these will not be ignored, and that they can raise such concerns without fear that they will suffer bullying, harassment or other adverse consequences as a result.

· Neonatal services; Use of antipsychotic medication in care homes;Ambulance Services – We would support these topics being looked at by the Committee as a follow-up to the previous work and consideration of them, and would be interested to have sight of any progress made. We are particularly interested in ongoing concerns about staffing and the sustainability of neonatal services in Wales.

· Loneliness and isolation amongst older people – whilst this is not an area where BMA Cymru Wales could make a comprehensive contribution we nonetheless recognise the significance of loneliness and isolation and its impact on health and wellbeing. A wider review of healthy aging in Wales might allow for consideration of an array of pertinent issues relating to physical and mental health and wellbeing of older people in Wales.

· Gambling addiction – this is an important area which we consider should be treated alongside measures for other addictions such as for smoking, alcohol, and substance abuse for instance. Gambling addiction is associated with a number of health problems and for health and social care professionals can be hard to detect.

· Sport and Public Health – obesity is a major public health concern. Sport and exercise may have a part to play in addressing the obesity epidemic, but they are only one element and need to be considered alongside other important factors such as high energy food promotion. We believe that this topic requires further thought, as currently as it is written it appears ‘tagged on’ just because sport is now within the committee’s portfolio. We do, however, believe that looking at how our growing obesity epidemic can be more effectively tackled is an important topic for the Committee to consider. The recently publicised criticisms of the UK Government’s strategy for childhood obesity might offer an opportunity for Wales to take a lead on this issue, albeit within those powers that are exercisable by the National Assembly. On the subject of sport, the committee could seek to capitalise on the momentum, enthusiasm and interest generated at the international level (from Euro 2016 and the Rio Olympics for instance) to look at a range of areas seeking to build exercise and healthy living into individuals everyday routines – for instance, how easy it is to access sporting activities and groups/classes, opportunities to exercise or to undertake leisure pursuits across Wales, options and access to active travel, for all age groups and abilities.

Below we offer suggestions for other topics which the committee might consider:

· Data collection – There are many areas where there is a paucity of data available compared to that available in England, including in relation to the NHS workforce in Wales. This might be an area the Committee would therefore wish to look into. Another area of concern is the current lack of collection and publication of meaningful data on workforce vacancies, with such data not having been routinely published in Wales since 2011. We have significant concerns that this hinders effective workforce planning. When data has been obtained since 2011 on vacancies amongst hospital consultants through the use of Freedom of Information (FoI) Act requests, the responses, despite showing worryingly high vacancy rates, would appear to significantly under-represent the true situation owing to the use by some health boards and trusts of what we would consider to be a flawed definition which means vacancies are only counted as such when an active process is underway to fill them. There is also a lack of consistency between health boards and trusts regarding how vacancy data is recorded, possibly as a result of it not being routinely published. The FoI responses also revealed that a variety of definitions of a vacancy are currently in use.

· Occupational health/staff wellbeing – The Committee might wish to look into the current level of provision of occupational health services for NHS staff. Although it has recently been agreed that these services can be extended to cover primary care, something we fully support, we have concerns regarding how well resourced the current provisions is. We are aware, for instance, that a number of health boards have unfilled posts for occupational health consultants.

· Deprivation, inequalities and health – Recognising that education can be a major determinant of social wellbeing and health, this could include working with other relevant Assembly Committees to look at what action needs to be taken to improve the levels of literacy and numeracy in Wales, with a specific focus on health literacy.[2]

· Child health – The Committee might consider looking specifically at the topic of child health. The BMA’s Board of Science has published a number of relevant reports which might guide the Committee’s consideration of this topic including ‘Growing up in the UK - ensuring a healthy future for our children’ in 2013, and ‘Food for thought: promoting healthy diets among children and young people’ in 2015. The Committee might also which to look at following up on the inquiry undertaken in 2013 into childhood obesity by the Assembly’s former Children and Young People Committee.

· End of life care – Throughout 2015, the BMA undertook a major project seeking views from our members and the public on their experiences, views and perceptions on end-of-life care and some aspects of physician-assisted dying. We found that there is significant variability in the type and quality of services provided, both within and between geographical areas, and also, sometimes, between conditions. We published the final report in three volumes; it makes recommendations for governments; for providers of education and training; for doctors; and for healthcare providers. All of the reports and more information about the project can be found at: www.bma.org.uk/endoflifecare.

[2] Health literacy can be defined as 'the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health.' (WHO, 2015).