Wanless puts premium on creativity in bid to modernise Welsh services

Make changes or face the bleak prospect of services becoming
unsustainable in the future. That is the uncompromising message of
a new review of social and health care services in Wales.

The review urges much closer working between social services and
the NHS to tackle a range of problems, not least delayed discharges
from hospitals.

It calls for immediate action in some areas, and the Welsh assembly
has recognised that urgency by immediately allocating £4m for
dealing with delayed discharges.

The findings of the review, carried out by Derek Wanless, are being
seen as a watershed for the development of care services as a whole
in Wales.

Wanless carried out a similar UK-wide review that was published
alongside the chancellor’s pre-budget report in April 2002. But, to
the disappointment of social services chiefs, his earlier review
only looked at the long-term resource requirements of the health
service.

The Association of Directors of Social Services and the House of
Commons health select committee have since called for a similar
review of funding for social care across the UK.

In Wales, practitioners in health and social care are backing
Wanless’s calls for closer working.

“This is one of the most challenging reports to come before the
Welsh assembly and what is significant is the commitment to see the
issues as covering a whole economy,” says Hugh Gardner,
vice-chairperson of the ADSSin Wales. “There is an acknowledgement
that we have to come to terms with some very serious problems and
the underlying message is that we cannot carry on as we are.

“The really significant factor in this is that social care is
acknowledged as being a vital part of the support system for people
at different stages in their lives,” Gardner adds. “The review also
looks at the implications of demographic change and what that will
mean for social care providers and the cost pressures that need to
be addressed.”

Gardner says an important aspect of the report is its recognition
of the need for a national service across Wales that can deliver
services locally.

He says that, in Wales, local authorities have been slow to learn
the lessons of the joint reviews carried out by the audit
commission and the social services inspectorate for Wales. The
report emphasises that local authorities must now get to grips with
the need for interdependency and come together as a shared learning
community working collaboratively to improve services across the
board.

But the report also acknowledges the scale of the problem facing
service providers and the workforce in Wales.

An ageing population with high rates of poverty and deprivation
places great strains on services that are already under pressure,
and Wanless and his team found that demands on health and social
services are outstripping their ability to supply the necessary
care.

The report warns: “Generally, the current position in Wales is
worse than in the UK as a whole, reflecting trends evident over
decades. The impact extends into social care. Long hospital waiting
lists and assessments without subsequent social service provision
are the unacceptable consequences and are symptoms of the deep
underlying problems needing to be faced.”

It adds: “Currently, people working in health and social care try
hard to keep up with demand but the system in which they operate
does not make success easier.”

The report goes on to say that, although there is some excellent
performance in health and social care, under-performance associated
with systemic defects is rife.

A lack of performance management and incentive systems is blamed in
the report as limiting the spread of best practice. It adds that:
“Different areas of national policy-making need to be better
integrated. The quality of information, and the decisions based on
it, is unsatisfactory at every level.”

Tony Beddow, senior research fellow at the Welsh Institute of
Health and Social Care at the University of Glamorgan, says that
the report stresses the need for change in social care and social
services.

“The report highlights the need to carry out projections on social
care services and there are references to the shortfalls that we
will face in Wales if this is not tackled,” he says.

“The report also says that there is a need to both update and
standardise social care information systems and to link them with
health care systems. That is a really fundamental statement about
the balance between local and national approaches to the management
of services.

“Traditionally, social care has been managed by local government,
but if you start to talk about information systems being tailored
to a national agenda then that begins to raise all sorts of other
questions about why have social services run by local government at
all,” he adds.

The Welsh Local Government Association says that the report
contains interesting proposals for a longer term seamless approach
to service provision.

“Our submission to the review argued for a whole systems approach,
capable of tackling the current pressures and capacity problems
affecting both the NHS and local government,” says Shan Wilkinson,
WLGA spokesperson on social affairs.

“In recognising the importance of shifting investment into
prevention and health gain, the review team’s findings appear to
recognise this. Delivering the most appropriate services and
achieving significant health improvement will depend on everyone
becoming much more skilled and creative.”

While there is widespread acknowledgement in Wales that the review
is likely to mark the beginning of a fundamental rethink of the way
services are provided across the principality, there is also an
acceptance that tackling issues such as delayed discharges is going
to require difficult decisions.

The Welsh assembly will produce an official response to the report
in the autumn, but the minister for health and social services,
Jane Hutt, has already earmarked £4m to tackle
priorities.

Hutt says the link between health and social care is vital and that
it is essential that both sectors work together. But she also
acknowledges the report’s challenges. “The issues are not new, we
are already addressing many of them. What is new is bringing the
analysis together in one place. In doing so it provides a powerful
insight into the challenges and difficult choices we face.”

The Review of Health and Social Care in Wales from www.wales.gov.uk/subieconomics/hsc-review-e.htm

Key findings

– Expertise spread too thinly to meet modern standards.

– Too much reliance on care in institutions rather than the
community.

– Unacceptable variation in performance within social care and
between NHS trusts.

– Significant variation in spending on social services and
repeated overspending in NHS.

– Number of people of retirement age projected to rise by 11 per
cent over the next 20 years, compared with 3 per cent for the UK,
leading to extra demand for social care.

Key recommendations

– Immediate action to reduce delays in transfer of care.

– New approach to the management and funding of the continuum of
social and health care.

– Greater focus on young people and children and older people.l
Greater public and user involvement in shaping social care
services.

– Shared decision-making between professionals and service
users.

– Integrated thinking across social and health care
boundaries.

– National standards for social care services.

– Emphasis on rewarding success rather than punishing
failure.

– Rewarding of good performance with greater freedom and
autonomy.

– Encouragement of best practice.

– Enhanced training for all staff.

– Shared IT systems between social and health care including
protocols for exchange of information.

– Adoption of principle of local solutions to local issues.