The Tipping Point: Where next for health and care in Wales?

On 6 July my colleague Sue Newham and I attended the second day of this Bevan Commission conference at the Celtic Manor Resort in Newport. The Bevan Commission is Wales’ leading health and care think tank - aiming to “challenge, change and champion thinking and practice to ensure sustainable health and care that is fit for the future.”

Celebrating 75 years of the NHS in Wales, the conference was described as the “opportunity for an open and honest conversation about the future of our health service.” It was attended primarily by NHS and social care professionals from across Wales, and perhaps more importantly the organisers asked those attending - “What role will you play in finding ways to influence and make change?”

“We are at a tipping point. It is now time for us to face these challenges together and rebuild our health and social care systems to thrive in tomorrow’s world.” 

Bevan Commission

The day was packed with knowledgeable and inspiring speakers, presentation sessions broken up by break-out workshops where Bevan Exemplars* and others described their ground-breaking work within the NHS and social care sectors in Wales. The previous day our colleague Sharon Healey (PAVO Head of Health, Wellbeing & Partnerships) had spoken on the work of the PAVO Community Connector Service alongside Dr Carolyn Wallace (Director of the Wales School of Social Prescribing Research) in relation to social prescribing.

The key message that came out of the day for me was that the NHS can no longer continue to provide care in quite the same way as it has for the past 75 years. It’s just not sustainable. The NHS employs more people than ever before in its entire history, yet the demand for services is insatiable and cannot be met. It never will be. Because as new treatments are developed, rolled out and information about them shared, people’s expectations and demand for services increases.

The day was a bit of a roller coaster mix of highs and lows. Some of the stats around health inequalities were very concerning. But the enthusiasm for innovation, the stories I heard of good practice already happening around the UK - well, there was plenty to be excited about.

So here is a small dip into Day 2 at the conference. All of the speakers referred to challenges as well as opportunities.

"The world will not be destroyed by those who do evil, but by those 

who watch them without doing anything." 

 Albert Einstein

Frank Atherton - Chief Medical Officer for Wales

Frank spoke about some of the “wicked problems” or constraints to refreshing and carrying out the Welsh Government’s route map of A Healthier Wales - the long term plan for health and social care:

• An ageing and frail population.
• The need for the social care system to mirror the NHS.
• Vacancies in the workforce.
• Capital infrastructure is not fit for current times.

Frank also spoke about the public health agenda. In 2003 Sir Derek Wanless, a banker and health advisor, was asked to identify cost-effective approaches to improving public health, prevention and reducing health inequalities. His final report, Securing good health for the whole population, suggested that a shift in focus was needed away from just caring for the sick and into promoting good health.

Frank believes that our health is shaped by our environment. He described how all our communities are being increasingly exposed to fast food restaurants, gambling and vaping shops, for example. We need to think about how we address some of these concerns and have “deep, deep engagement with our communities.”

After highlighting some of this year’s priorities around redesigning the model Frank said that the “NHS will survive. It needs to grow, transform and develop … with public health at its absolute heart.”

Eluned Morgan - Minister for Health & Social Services

“The very fact that we have an ageing population is a sign of the success of the NHS. But we all know that the system is under strain like never before:”

More people will be living with dementia, cancer, coronary heart disease, vascular challenges, diabetes and poor mental health. And many people will be living with multiple examples of these challenges.

There is a worldwide shortage of health workers.

The vision:

• People live longer and healthier lives.
• They remain active and independent.
• They live in a whole system approach which achieves high quality care for everyone in Wales.
• Focusing not just on physical but on mental health.
• A switch to a system which anticipates health needs and prevents illness.

Eluned was clear that If we want a sustainable NHS to hand on to our children and grandchildren we need to work at managing our own health conditions, and also look at our lifestyles - around healthy diet, increased exercise, and alcohol reduction for example - to help lower the demand on the NHS. We need to listen to what matters to patients, but they also need to listen about the limitations of a sustainable NHS.

Whilst researching the conference I came across an online piece by Marion Foreman, an NHS nurse, who wrote powerfully in 2018 about an individual’s responsibility to look after their own health: Our health, our responsibility.

Prevention is key… but how to ensure that this message is heard and taken on board by the population of Wales…?

“Change will not come if we wait for some other person or some other time. 

We are the ones we’ve been waiting for. We are the change that we seek.” 

Barack Obama 

Professor Sir Michael Marmot - The Marmot Approach

Michael Marmot is Director of the (University College of London) Health Institute of Health Equity, and author of “The Health Gap: the challenge of an unequal world”.

Michael’s concern is with the social determinants of health - “the conditions in which people are born, grow, live, work and age and which can lead to health inequalities.” The 2010 Marmot Review looked at the differences in health and wellbeing between social groups and “describes how the social gradient on health inequalities is reflected in the social gradient on educational attainment, employment, income, quality of neighbourhood and so on”.

“Why treat people and send them back to the conditions that made them sick?”

People in more deprived areas used more NHS services/money than those in less deprived areas. “The UK is a very bad place to be poor.”

The framework for action created at the time of the review is known as the Marmot Principles, of which there are now 8 (the original review was revisited in 2020) - early years development (x 2), employment, living standards, communities, ill-health prevention, discrimination, and environmental sustainability. These principles have been taken on by some health boards and Gwent is the first Marmot region in Wales - Building a fairer Gwent: Why Gwent is a Marmot region.

Derek Walker - Future Generations’ Commissioner for Wales

“Acting today for a better tomorrow” - in essence sums up what the Wellbeing of Future Generations (Wales) Act 2015 is all about. “And that means in practice, for health, a long-term integrated preventative approach to our health system here in Wales.”

One of the five ways of working in the Act is prevention. Everyone agrees that prevention is key, Derek said, but not enough is happening. Derek asked “what is preventing us from putting the focus on prevention?” He pointed out that mental health issues in young people are continuing to rise, and 50% are established by as early as age 14, but there is not enough emphasis on early intervention.

Derek spoke of the 4 levels of prevention that have been developed with the Welsh Government and his predecessor Sophie Howe. Each level can reduce demand for the next. The levels start at Primary prevention - building resilience, and build up to Acute spending - which speaks for itself! “(According to Public Health Wales, mental ill health costs society in Wales £7 billion a year.”) The question now is how we spend more time at Level 1.

“We need to increase our spend on the social determinants of health faster than acute medical care spending.”

Derek noted that the Fire Service has managed to achieve massive change to bring about a 52% reduction in incidents through its investment in prevention and education. Whilst the “example doesn’t transfer automatically across to health care, it is a clear demonstration of where investment in prevention efforts can make a difference.”

A Journey to a Healthier Wales, from the Future Generations’ office, with a big emphasis on prevention and social prescribing, is well worth a read.

Professor Donna Hall - The Wigan Deal

Donna Hall, who is described as a “public service pioneer,” is the Chair of Innovative National Think Tank “Think Local”. She was awarded a CBE in 2009 for innovation in public service.

In this 2018 video she speaks to Chris Ham about what happened in Wigan, where she was Chief Executive of the council in 2011, when £160 million was taken out of their budget. They had to transform services and their relationships with the community, NHS and other providers. One of the elements of The Deal was that people took better care of their health. Amazingly The Wigan Deal improved services and resident satisfaction!

Ashley Gould - The Big Nudge

As part of this inspirational day Sue and I attended a workshop called The Big Nudge on changing people’s behaviours. It was facilitated by Ashley Gould, Programme Director of the Behavioural Science Unit at Public Health Wales. He introduced us to “Improving health and wellbeing: A guide to using behavioural science in policy and practice.”

Here in the mental health team at PAVO we’re more inclined towards the small nudge, and encouraging people to adopt positive behaviours by showing how much difference they have made to other people’s lives, specifically their mental health, be that by walking, gardening, getting active or singing, for example.

We’d like to make more of a difference, of course, and look forward to working more closely with not just the NHS but other organisations in Powys to help make the Prevention agenda key to improving people’s health and wellbeing. (We absolutely want the NHS to be around for another 75 years!) If you have any ideas about how we, and the Third Sector in Powys, could work more collaboratively to help bring prevention to the fore, then please get in touch!

You can watch videos of all the keynote speeches at this conference here.

* Through the Bevan Exemplar Programme, health and care staff across Wales are supported to develop and test their own prudent ideas to improve and transform health and care. Their projects, which are exemplars of innovation and transformation in clinical and community settings, can inform and inspire others to adopt and spread new ways of working across Wales and internationally.