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.

Freda Lacey on her new role in the Health and Social Care (H&SC) team, PAVO

Handing over the role - Senior Officer Health & Social Care
L - R: Trish Buchan (now on Powys Teaching Health Board), Freda Lacey (new in post)

One of my Health and Social Care team colleagues recently said to me that I should introduce myself to the Sector and tell people who I am. Because I’ve worked for PAVO in the Mental Health team for several years, I’ve assumed people know who I am. However, I recently met and had a very good conversation with the manager of the Brecon Volunteer Bureau who hadn’t heard of me before, so, I thought it probably was time to make myself more widely known.

The role

I have been recruited to fill the vacancy of Senior Officer Health & Social Care, as left by Trish Buchan who is now the Third Sector Organisation rep on the Powys teaching Health Board. At the time I started the nature of the role needed to shift to respond to current changes within procurement and commissioning, both in terms of the national context with new European Union guidelines, and locally, as more joint commissioning initiatives between the Health Board and Local Authority are developed.

I’m in the 7th week of being “inducted” into my new role and, in many ways, I feel familiar and comfortable with the direction of travel. I’ve been reflecting on the changes I’m witnessing and while the nature of the work is somewhat different to what I had been doing within my previous role in Mental Health, this new work also relies on a foundation of forming good relationships and engendering open, timely communication between the Sector and our colleagues within the Health Board and Local Authority.

My role can be broken down into several key activities:

• To help broker possibilities for collaboration within the commissioning process.
• To act as a conduit for timely information and response.
• To offer general and focused support to organisations and networks responding to business development opportunities.
• To represent the third sector on strategic management boards with Health Board and Local Authority colleagues.

Ultimately I am there to help ensure that voluntary organisations involved in Health and Social Care are engaged and equipped with what they need to respond quickly to changing needs within public services.

This is me 

So who am I personally? I’m drawn to use a process/initiative which forms part of caring for people who have been diagnosed with a dementia to help me tell you who I am. Publicised by Alzheimer’s Society, their “This is me” activity provides the tools for telling the key parts of someone’s life story. I’ve found the process very fruitful as an exercise in self-reflection and hope that it gives you a flavour of who I am - you can read it here. 

L - R: Freda Lacey, Claire Powell, Anne Clark, Ruth Middleton - Health & Social Care team

Who are we as a team and what are we about?

Pete Lathbury is the Head of Third Sector Support and as such helps give our team direction.

There are four of us (two part-time and two full time) in the Health and Social Care team. Myself, two third Sector Brokers – Anne Clark and Claire Powell, and Ruth Middleton who helps collate and provide vital information to the Sector on Health and Social Care news and manages our network events.

In reflecting on my first seven weeks’ highlights:

• I have helped plan and deliver a recent Health and Social Care Network event.
• Attended a Virtual Ward meeting in the North in addition to engaging with the Third Sector Brokers as they attend others that are being developed or rolling out rapidly.
• Helped facilitate two Sector meetings with colleagues providing Carers’ Services that are being recommissioned by the Council.
• Initiated 10 meetings with Sector, Local Authority and Health Board key influencers.
• Met with the Local Authority commissioner and Disability Powys relating to the Physical Disability and Sensory Loss (PDSL) commissioning engagement strategy.
• Met and discussed service level agreements with three Health and Social Care third sector organisations delivering services for older people.
• Attended a scoping workshop with the Health Board looking at their Strategy for Consultation and Engagement.

Freda updates attendees at the recent Health & Social Care Network event

To say my first seven weeks have been eventful would be an understatement and yet, I am finding the work very varied, interesting and exciting. I am also endeavouring to be mindful of my capacity, that of the team and balancing priorities.

The process of change, in having to respond to the Council and Health Board’s challenges about reducing costs, the needs of the citizens of Powys, and the current landscape of shifting more public services into and onto the community, are all driving the strategic public agenda forward at a rapid rate of acceleration.

While there are always opportunities in transforming services, there are also threats to the ways things have currently been and expected to be (sometimes for years) and the levels of discomfort and fear that rapid change engenders cannot be under estimated.

One of the important parts of my role, and the team’s going forward, is to ensure that we provide timely communication about what is happening, provide a forum for sharing information, and ensure that the Sector can jointly collaborate within local, strategic service planning and delivery.

I am very much looking forward to getting to know Health and Social Care colleagues in more depth and gaining greater understanding of the pressures being faced. I welcome open contact, communication and feedback.

So do get in touch by emailing freda.lacey@pavo.org.uk or calling 01597 822191.

Health & Social Care Network events - a mental health perspective

PAVO teams in Health & Mental Health
L - R: Ruth Middleton (Health, Social Care team), Anne Woods (Mental Health team),
Pete Lathbury (Head of Third Sector Support), Freda Lacey (Senior Officer HSC),
Jackie Newey (MH), Claire Powell (Third Sector Broker & Info-Engine Officer)

Have you come across the PAVO Health & Social Care Network events? I was asked to help out at the latest one (well, it does say Health in our team title) along with colleagues from Mental Health and Health & Social Care. The event took place at the Subud Centre in Brecon last week on 8 July. Anyway, whilst I was more than happy to help shift tables, take photographs and scribe for part of the day, it also seemed like the ideal opportunity to find out more and share any updates to the wider world - so, here we go! I hope you find it useful.

Three of the key benefits available to members of the Health & Social Care Network, (which is open to any voluntary sector organisation providing support to individuals and those close to them) are:

• Opportunities to contribute your views and those of the people you support on current and future health & social care services.
• Networking opportunities with other third sector organisations and key partners.
• A catalyst for cross agency collaboration to meet changing health and social care needs.

Top table, L - R: Pete Lathbury, Gloria Powell (PAVO Trustee & HSCN Chair),
Freda Lacey, Jayne Bevan (Strategic Programme Manager, Powys County Council).

This particular event provided an opportunity to question Commissioners on procurement and commissioning strategies for Powys, to hear updates from the Welsh Government about new procurement regulations and how that would impact locally, to find out more how Primary Care services are interacting with the voluntary sector, and the key aims and objectives of Powys teaching Health Board, specifically in relation to working with the sector.

First up was Jayne Bevan, Strategic Programme Manager at Powys County Council. Jayne led on the consultation around proposed changes to the Eligibility Criteria for Adult Social Care in Powys which took place earlier this year. Welsh Government's aim was to ensure an equitable service across the country, and on 1 April this year PCC decided to change its eligibility criteria which means that access to some social care support services will only be available to those with critical and substantial needs (previously it was available to those with moderate needs). Those with low or moderate needs will be signposted to universal services, such as services to prevent social isolation. This change comes into effect on 1 April 2016, but prior to that there will be engagement with people in contact with services and local organisations in Autumn 2015. Find out more in Jayne's presentation here.

Jayne was followed by Pete Lathbury, Head of Third Sector Support at PAVO, who spoke about the recent survey on the Third Sector's capability in Powys in relation to health and social care. The survey looked at three service areas: formal advocacy, specialist information and supported independent living. Questions drilled down to explore who provides mainstream services, to look at the health and resilience of the services both now and in the future, and to explore the support needs of organisations looking to provide a strong and healthy service. Pete's presentation is here.

L - R: Trish Buchan, (Independent Member Powys teaching Health Board)
and Freda Lacey, her successor at PAVO as the new Senior Officer Health & Social Care.

Trish Buchan, Independent Member Powys teaching Health Board, recently left her role as Health & Social Care lead at PAVO to focus on her position with the Health Board, and at this event she introduced everyone to the PtHB Strategic Plan. With the help of some new acronyms (Integrated Medium Term Plan - IMTP), and a Vision - "truly integrated care based on the needs of the individual", we then found out more about the key aims and themes of the strategy. Two headlines - 'care closer to home' and 'an increased use of technology' were particularly relevant to mental health. We have already written about the computerised Cognitive Behavioural Therapy scheme called Mastermind, currently being rolled out in Powys.

Trish emphasized the need for increased effective partnership working, with a specific mention of mental health again here. You can read Trish's presentation here.

Pete followed with the Third Sector perspective on the new health board strategy (read here). With the move to more localised services, there was a sense that there could potentially be more activity for voluntary sector intervention. Pete then discussed in more detail specific issues relating to this, including volunteering, community capacity, co-ordination and integration and commissioning. If I remember one fact from this presentation it is that there are over 26,000 volunteers in Powys - the physical and emotional wellbeing impact from that is clearly huge.

Alan Lawrie (pictured above left), Director of Primary Community Care (South) followed with an update on Primary Health Care & Third Sector Engagement. Alan has worked in health services for 33 years now, and said that the situation in Powys "is generally pretty good" compared to other parts of the UK. However, there are vulnerable areas, especially around recruitment, and he supported adoption of new workforce models, so for example, pharmacists would be able to prescrible independently, and advanced paramedics taken on in certain situations. Alan was clear about what the NHS wanted from the voluntary sector, solutions around: social isolation, admissions prevention, discharge support, transport, chronic disease support and links to social enterprise. No pressure there then! Read Alan's presentation here.

Nicola Maliphant (above) is a Senior Project Manager, Policy, at Value Wales, Welsh Government. She was at the event to give us an overview of Public Procurement Policy in Wales, and specifically further details of the new European Commission regulations which came into effect on 26 February 2015. This is particularly relevant for those organisations which will be taking part in a tendering process with either Powys teaching Health Board or Powys County Council over the coming months. Nicola was keen to impress upon her audience that Value Wales is there to provide support, in particular sessions on joint bidding and consortia are recommended. Read more here.

So we'd heard the national policy around procurement, and it was time for a more local view of things. This was supplied by Shelley Davies - pictured above (speaking on behalf of Dominique Jones, Health & Social Care Implementation Manager), who gave an update on Powys County Council's Commissioning Strategy. Shelley explained that good practice in the Children & Young People's team (her speciality) was being brought across to adult services. It was particularly interesting to hear about the aim to develop more social enterprises in the sector, though Shelley had some valid questions around - who would facilitate these social enterprises and who are the people to kick start activity? 

Alan Lawrie then summarised Powys teaching Health Board's Procurement Strategy (slides 12 - 14). Alan again talked about applying the children's model around procurement to an Older People's Perspective.

Powys teaching Health Board's Integrated Services Wellbeing Wheel

Throughout the day Freda scheduled a number of question and answer sessions with the speakers which gave everyone the opportunity to get involved. There are also some additional documents available on this PAVO webpage.

So, is this kind of information of interest to your organisation? Please let us know by commenting below, or join other mental health organisations such as Hafal, Ponthafren Association, Mid Powys Mind and Brecon & District Mind, who all attended this HSCN event to find out more about current issues relevant to them.

Mental health spending falls for first time in 10 years

A recent article in the Guardian Newspaper:

http://www.guardian.co.uk/society/2012/aug/07/mental-health-spending-falls