Response to Welsh Government's plan for transforming planned care

Introduction

1. The Welsh NHS Confederation (WNHSC) welcomes the opportunity to respond to the Health and Social Care Committee’s consultation on the Welsh Government's plan for transforming and modernising planned care and reducing waiting lists.

2. The WNHSC represents the seven Local Health Boards, three NHS Trusts, Digital Health and Care Wales and Health Education and Improvement Wales (our Members). We also host NHS Wales Employers.

3. The scale of the challenge in planned care cannot be over emphasised as the NHS continues to go through the most challenging period in its history. Despite the best endeavours of NHS leaders and staff, the backlog will take years to reach a healthier position and there must be an effort to manage public expectations around what the NHS can deliver. The WNHSC has called for a clear and sustainable long-term funding strategy for health and social care to allow for the necessary long-term investments in staff and capital required to meet the needs of the people of Wales.

Whether the plan will be sufficient to address the backlogs in routine care that have built up during the pandemic and reduce long waits.

4. Members said the plan could be a helpful framework to support recovery and reduce long waits. However, there were some very clear concerns relating to whether the plan provides the clarity and detail required to address the backlog, which represents a significant challenge to the NHS and patients. It is always important to remember that behind the numbers, lie people and their families and members have expressed concern over the physical and mental health impacts which long waits can create.

5. NHS organisations have to overcome significant barriers to deliver on the plan and will require support to do so. Some of these issues include: the on-going impact of COVID on services; the impact of emergency demand on key resources and facilities; the state of the NHS estate; limited short-term funding; and critically, significant workforce recruitment and development challenges.

6. Members highlighted that the health and care workforce is the key factor in whether the plan would be able to reach its aspirational targets. The successful delivery of the plan will be compromised without clear detail and support to ensure the correct workforce is in place. This will require an increased investment to continue to drive up the number of students and trainees across professional groups. Specifically, members did highlight a need for emphasis on ‘double recruiting’ to plan earlier for retirements. The current pressures on the workforce due to the backlog will also have an effect on driving forward the transformation agenda at pace.

7. Concerns were also raised in terms of the growing demand and the inability of patients to access General Practitioners’ adequately given the increase in demand across the system. Members called for clarity in terms of a GP strategy and any further work to be undertaken with primary care to support the plan.

Whether the plan strikes the right balance between tackling the current backlog, and building a more resilient and sustainable health and social care system for the long term?

8. Members observed the plan does attempt to strike this balance, but it was expressed that there needed to be more emphasis on long-term sustainability, e.g. workforce solutions, training timescales and how health boards and NHS trusts can manage patients presenting with more complex needs. It should not be assumed that transformation will drive sustainability at this time due to the scale of the backlog and the pressure on staff.

9. Members also observed that the plan did not directly address the issue of patient flow and the significant number of clinically-optimised patients in hospital, and potential social care sector solutions. It will be essential going forward that the social care sector receive adequate support if the recovery ambitions are to be realised due to the interdependent nature of the system. The WNHSC have previously called for a sustainable financial model for the care sector, to ensure it has the required long-term investment to attract, recruit, train and retain a sustainable domestic workforce.

Whether the plan includes sufficient focus on:

• Ensuring that people who have health needs come forward;
• Supporting people who are waiting a long time for treatment, managing their expectations, and preparing them for receiving the care for which they are waiting, including supported self-management;
• Meeting the needs of those with the greatest clinical needs, and those who have been waiting a long time;
• Improving patient outcomes and their experience of NHS services?

10. Adequately addressing the above points will require a strong dialogue with the public and our members did note that the plan contained no assessment of public opinion regarding these increased levels of engagement. Therefore, there needs to be an effort to reach out to the population to take on more responsibility for self-help to allow the treatment of those most in need.

11. Whilst the commitment in the plan to coordinate national messaging in relation to public health campaigns and availability of waiting list information was welcomed, members highlighted that it did not go into detail about how hard-to-reach and vulnerable communities will be targeted.

12. In our briefing, Reshaping the relationship between the public and the NHS, we called for Welsh Government and political leaders to engage in an honest conversation with the public on the scale of the challenge to ensure the public’s expectations are managed. The briefing also argued for a ‘Deal for Health’ which sets out what the public and staff are entitled to from the NHS and the contributions that patients and the public can make to their own health and wellbeing. This engagement will be crucial in creating healthier communities and contributes to the creation of a sustainable service by reducing pressure on the NHS.

13. Members were clear that addressing greatest clinical need will not necessarily prioritise those who have waited longest and there will inevitably be a conflict for clinicians to balance clinical need with consideration of length of wait. Whilst the plan does reiterate clinical need as the primary driver for patient prioritisation, the advent of phased maximum wait targets will pose challenges for health boards in placing an appropriate balance between both priorities.

14. In terms of outcomes, members noted that the plan does not provide a lot of detail and suggested more clarity is needed in terms of timelines on delivery.

15. Members have suggested that greater emphasis and clarity is also needed in areas such as rehabilitation and how patients can be supported and motivated with self-management.

Whether the plan provides sufficient leadership and national direction to drive collective effort, collaboration and innovation-sharing at local, regional and national levels across the entire health and social care system (including mental health, primary care and community care)?

16. Members have highlighted examples where NHS organisations are working collaboratively and opportunities for regional and national working will continue to be sought to effectively address the backlog.

17. Members felt that the plan did offer a direction for increased partnership between organisations to enable equality of access for populations across Wales and generally presents a position of national leadership from NHS Wales. However, concerns were expressed that solutions presented in the plan lack pragmatism. Members cited a focus on areas such as see-on-symptom and patient initiated follow up within the plan, but stressed that delivery will be down to individual clinicians as to what is appropriate for a patient.

18. It was felt that the plan needs to articulate both transformation and recovery in terms of overall national resource, which is UK-wide. Members also sought more detail in terms of the role of private providers and third sector, and within the wider community.

Whether the plan provides sufficient clarity about who is responsible for driving transformation, especially in the development of new and/or regional treatment and diagnostic services and modernising planned care services?

19. Members felt that there was an expectation that health boards would work closely together on regional priorities, with the establishment of a National Diagnostics Board an important step in this direction. However, it was noted that organisations will often not have the additional resources to deliver, and the role of regional solutions will be limited by challenges of demand and capacity.

Are the targets and timescales in the plan sufficiently detailed, measurable, realistic and achievable?

20. Members raised concerns over the targets contained in the plan, with key delivery risks being the volume and rate at which demand, that reduced during the pandemic period, might return, and the success of efforts to generate sufficient workforce resources to sustain increased activity over the longer term.

21. There were specific concerns around the 52-week outpatient target, with members saying this will be very difficult to achieve by the end of 2022 for a high volume of specialities. Members cited the depletion of outpatient accommodation as one of the reasons why this would be a particular challenge.

Is it sufficiently clear which specialties will be prioritised/included in the targets?

22. Members noted that the plan overall focuses on the NHS system and how patients access it rather than how different specialties should be prioritised.

23. Also, it was highlighted that the plan offers some scope for local variation with regard to those specialties that will achieve the 104-week target by March 2023. This reflects the size of the challenge faced by health boards and the reality that waiting times prior to the pandemic varied across Wales.

Do you anticipate any variation across health boards in the achievement of the targets by specialty?

24. Members anticipate variation across health boards due to factors such as existing variation in clinical risk and workforce availability. 

Is there sufficient revenue and capital funding in place to deliver the plan, including investing in and expanding infrastructure and estates where needed to ensure that service capacity meets demand?

25. Investments outlined in the plan cannot be viewed in isolation and must be understood within the wider financial settlement for health boards. For those who remain in a financial deficit, prioritisation of resources will be a continuing challenge. Capital funding has also reduced this financial year therefore moving forward transformation will be more difficult.

26. Members did observe that the full revenue implications of meeting the ministerial priorities are unclear, and a costed programme could usefully be developed. It was also suggested that early notice of when funding becomes available would be helpful to accommodate timelines for recruitment, practice change, etc.

27. Members highlighted a number of factors which could compromise the plan within the funding allocated, including reliance on premium cost private sector capacity in the short to medium term while longer term solutions are developed and workforce shortfalls are addressed. Financial planning is also subject to uncertainty around the hidden backlog in community and primary care, which will have a consequent impact on conversion rates and demand for diagnostic services.

28. In a previous response to the Finance Committee, the WNHSC has called for the development of a 5-year investment plan for service change to reshape the NHS estates and infrastructure. This remains vital to support the NHS to deliver on the plan’s ambitions.

Is the plan sufficiently clear on how additional funding for the transformation of planned care should be used to greatest effect, and how its use and impact will be tracked and reported on?

29. The plan does not specify how the additional funding should be used to greatest effect, however there is an expectation that it will be targeted to ensure its ambitions are met. Members anticipate reporting mechanisms to mirror those currently in place for 2021/22.

30. Digital funded investment, both capital and revenue, are an essential part of transforming and modernising planned care and waiting lists. The COVID response demonstrated the value of standard digital solutions, deployed nationally at pace and developed and enhanced through a lean but effective governance and service process. This does not appear to be a consideration and digital investment should be part of the allocation alongside estates and infrastructure.

Does the plan adequately address health and social care workforce pressures, including retention, recruitment, and supporting staff to work flexibly, develop their skills and recover from the trauma of the pandemic?

31. Workforce supply and current workforce pressures is a key limiting factor in delivering on the plan, with many examples of difficulties to recruit required personnel across a range of professional groups and an increasing level of retirements. Members suggested that a collective approach to recruitment of specialist skills is required to both bolster the current theatre staffing and support the proposed developments.

32. There will inevitably be a conflict between recovery priorities and the continuing need to allow staff to rest and recover after their experiences of the pandemic. Members expect this to be a continuing challenge, and the rate of improvement will be directly influenced by the availability of staffing resources to deliver the increased volumes of care required.

Is there sufficient clarity about how digital tools and data will be developed and used to drive service delivery and more efficient management of waiting times?

33. Digital can be a key enabler for transforming and modernising planned care and reducing waiting lists but members felt there was insufficient clarity on this point, with calls for the plan to make a stronger commitment to digital services. Investment in new tools could allow existing staff to work effectively as recovery efforts face the challenge of finding and maintaining increased capacity.

34. Members said the plan lacked a strategic commitment to ‘mainstreaming digital’ as a primary driver of transformation across the whole system. There is a need to ‘lock in’ the lessons of the pandemic, particularly the accelerated delivery of services which were funded centrally and delivered nationally.

Conclusion

35. Among NHS organisations, there continues to be a number of concerns over the ambitions set out in the plan and the system’s capacity to achieve them. Whilst staff are working tirelessly to help patients, there are limiting factors which prevent the effective address of the backlog.

36. Capital funding and investment will continue to impact on the service, with the current state of the estate having major implications on the physical capacity of the NHS to make inroads in planned care backlogs.

37. Challenges in social care are also having serious ramifications across the whole system and on the ability of the NHS to tackle the backlog. This will require a sustainable social care funding model to address problems in care in the community and hospital discharge.

38. Workforce is the number one limiting factor for NHS capacity. Recruiting and retaining staff is a priority, with wellbeing support, flexible working and upskilling all being considered by NHS leaders to effectively support existing staff whilst attracting new employees.