NO ONE IS ABYSTANDER -EVERYONE IS ANALLY

A ( D R A F T ) R E P O R T B Y D A W N B O W D E N A M

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YOUR LOCAL HEALTHAND CARE SERVICES INMERTHYR TYDFIL ANDRHYMNEY

A R E P O R T B Y D A W N B O W D E N A M

 CONTENT 1. NHS at 70 2. Background 3. What it is not! 4. Determinants of health – local context 5. Facing up to our local challenges 6. Emotional Wellbeing and mental health 7. Housing and Health 8. Care – the undervalued partner? 9. Conditions 10. Oral health and eye care 11. ‘Boundaries’ should not be barriers 12. Technology is an ally 13. Who gets the best slice of the cake 14. Measuring what matters 15. Workforce 16.What to do when things go wrong 17. Third sector expertise 18. Findings 19. Close Appendices - Activities - NHS Planning Framework - Health Inequalities - Local survey

THANKS FROM DAWN

I can only offer my most sincere thanks to everyone whohas helped me with this piece of work whether by hostingvisits, giving of their time to hold conversations, includingthose who I didn’t meet directly but I know wereinstrumental in facilitating the opportunities fordiscussions, or those people who took the online survey. I greatly appreciate the time you have given me as part ofthis detailed look at local health and social care services.   Thanks also to my team of staff for helping me to preparethis pamphlet and for their support with the survey andwith a lot of the background work for my Summer andAutumn of detailed work on local health and care services. However any errors of fact are my responsibility. Thereport is initially being released as a draft report tocoincide with the AGM of Voluntary Action Merthyr Tydfil.Please send any corrections to me by Friday December14th so I can finalise the report by Christmas. E-mail comments or corrections to my Senior Adviser: Martin.eaglestone@assembly.wales

D A W N B O W D E N A M

Merthyr Tydfil & Rhymney

NO ONE IS ABYSTANDER.

EVERYONE IS

AN ALLY. 

1. INTRODUCTION - NHS AT 70

1.1 In July 2018 events were held across Wales to celebrate the 70th anniversary of theNHS. In a busy week I attended events in our Senedd and at the Keir Hardie healthpark in Merthyr Tydfil. I also hosted a celebratory coffee morning in the constituency. Iwitnessed, at first hand, the affection of staff, patients and the wider community forthis unique, “made in Wales” response to the health needs of our population. 1.2 However as we celebrated this landmark event I was however also very consciousof both (a) the scale of activity undertaken in our modern NHS/ social care services,and (b) the continual process of change that is always needed in these services. 1.3 Standing still is never an option. That is a challenge for providers, staff and theusers of these vital services. We know that so many people depend on them and, as aresult, our NHS often generates significant emotional reactions whenever servicechanges are suggested. Our challenge is to keep renewing Bevan's vision so theservice remains ready to for the challenges of the years ahead.   1.4 Following a major Parliamentary review of health and care services the WelshGovernment has published its strategy for health and care in the years ahead basedon:    • health and care services which work together, • shifting services out of hospital in to communities, • getting better at what really matters to people, • making Wales a great place to work in health and care, • a single system with everyone working together, pulling in the same direction.

Review and a new national strategy

2. BACKGROUND TO MY LOCAL"DRILL DOWN"

2.1 After my election to the National Assembly for Wales in May 2016 I undertook ageneral survey of local residents which identified the NHS as their number onepriority. During the summer and autumn of 2018 I decided that I should “drill down”in to the local experiences of these services and speak to the users and providers ofthese vital services to learn more. It has proven to be a busy and fruitful period ofactivity. 2.2 This project has been a very useful complement to the work that I already carryout as a member of the National Assembly’s Health, Social Care and SportCommittee. As a member of that Committee I frequently have the opportunity toquestion senior leaders of our health and social care services about national policy,budget pressures, financial management, access to conditions and treatments,service delivery arrangements, system design, workforce planning, recruitment andretention issues etc.    2.3 I am however aware that while in the Assembly considering the 'national' and'regional' picture that could easily mask local experiences of these health and careservices. So I want this report to reflect on the breadth of the issues I have recentlylooked at, and thought about, during my local ‘drill down’. But I also try to set this’local’ view in an appropriate regional and national context as they often set thedirection for our local services. I am however grateful that all of the activities I haverecently undertaken mean that as a constituency AM I can now more easily comparewhat I hear about in Assembly Committees with practical local experiences.  

Presenting a 70th anniversary cardto staff and trade union reps for

their work.

NHS at 70

Thank you to NHS staff

2.4 The activities that I have undertaken during the project are listed at Appendixone. They led to the title of this report. It became very clear to me that no one canbe a bystander if we are to deliver a wellbeing service – in place of an ill-healthservice - and everyone is an ally in making sure we can sustain our health and careservices going forwards. 2.5 We have celebrated 70 years and it is now all of our responsibility – users andproviders - to support our NHS and care services as we move forwards. That in turnwill mean we give these services the best opportunity to meet all of the challengeswhich arise from the significant determinants of health that affect the constituencyof Merthyr Tydfil and Rhymney. 3.1 In addition to the work that I cover in this report it is important for me to beclear on what my work, and what this report, do not provide: - it is not presented as an academically rigorous study, - it is not based on expert medical knowledge, - in a few months it is not exhaustive in scope, rather I seek to draw on key themes, signals and related messages that have struck mefrom the work undertaken and the visits I have carried out. This includes the workthat my team have read, seen and heard about to support this project. 3.2 There are of course aspects of our local services that I have not yet had thechance to visit. I know this includes: radiography, district nursing teams, mentalhealth in joint control rooms etc let alone the porters, catering, administrative andsecurity staff who I know, as a former Unison representative, are key parts of thehealth and care teams. I am sure this will happen in the months ahead as I continuewith my constituency engagements. 3.3 A range of reference sources have been used to inform this project and as theymay be of interest in providing background information on the issues raised anddiscussed they will be added to the final version of the report in December. 

3. WHAT IT IS NOT!

4.1 I am going to start my story on a Wednesday morning in Merthyr Leisure centre.I paid a visit to the National Exercise Referral Service (NERS). Here I met a range of people, with varying health conditions, who come together to learn more about diet,wellbeing and to undertake exercise. It was clear they also enjoyed social timetogether and were having fun. 4.2 NERS is a well evidenced example of how listening to sound advice and in takingpractical action – improved diet and regular exercise – can bring significant benefitsto each individual participant. Running in parallel to NERS was the Leisure Trust’sown wellbeing activity group which provides similar, but more informal,opportunities for social and wellbeing activities. 4.3 I heard of similar experiences when I visited the COPD group activity at PrinceCharles Hospital. In this group physiotherapists were leading exercise classes for arange of people recovering from more severe health conditions. A key part of thiswork is encouraging rehabilitation through exercise, by building the confidence ofeach individual’s ability to carry out exercise activity in a safe manner. 4.4 I have previously visited ‘Inspire Fitness’ and discussed their work with 'MerthyrGirls Can' which has now extended to include 'Merthyr Men Can'. Of course theMerthyr Leisure Trust provide facilities for the same wellbeing and fitness purposesof the general population.  

4. DETERMINANTS OF HEALTH -LOCAL CONTEXT

4.5 In Rhymney I visited the self-organised exercise group in the community centre.Originally formed out of the Communities First programme, but since that fundended, this group has reformed under their own constitution so they can fund raiseto continue with a long term programme for exercise and social activity. Thesessions also provide opportunities for other partner organisations to come alongand offer advice on a wide variety of issues.     4.6 In a sense these are all practical local examples of the lessons which emergedover many years from the study of the Caerphilly cohort and the broadrecommendations that emerged from that study. In summary we can all take actionto improve our personal wellbeing and fitness, and therefore help the NHS andsocial care systems by reducing demand at source: - Stop smoking, - Drink less, - Eat well and - Take exercise. 4.7 Public Health Wales report on these issues, health and its determinants, for thewhole of Wales. Indeed the existing evidence about issues like obesity for the healthour future generations is stark. Over 36% of children in Wales are unhealthilyoverweight. I also noted that in Merthyr in 2003/4 58.1% of persons aged 16+ werereported to be overweight or obese which rose to 66.7% in 2017 and is projected tobe 73.3% in 2025. This is a 15% rise over some 20 years. This will also be some 9%higher than the projected Welsh average by 2025 (62.4%). 4.8 Yet at a national level the people of Wales appear to show a great awareness ofthese issues when responding to surveys run by Public Health Wales, including 'StayWell in Wales'.  This awareness in many ways reflects the 10 key evidence-basedways to make a difference to levels of ill health and inequalities set out in the report'Making a Difference' (2016):

(Rhymney - visiting a communityexercise group that is wellsupported and encourages

regular exercise, and promotessocial support.)

1. Ensuring a good start in life for all. 2. Promoting mental wellbeing and preventing ill health. 3. Preventing violence and abuse. 4. Reducing prevalence of smoking. 5. Reducing prevalence of alcohol misuse. 6. Promoting physical activity. 7. Promoting healthy diet and preventing obesity. 8. Protection from disease and early identification. 9. Reducing economic and social inequalities and mitigatingausterity. 10. Ensuring a safe and health-promoting natural and builtenvironment.

4.9 Wales is no different to say England in this respect. I noted that the BMAhad recently made recommendations about “Prevention before cure” in NHSEngland and securing the long-term sustainability of the NHS by ” highlightingthe high risk health factors that need to be addressed – especially the contributionof lifestyle factors". Similar evidence can be found for Scotland. 4.10 In our communities across Merthyr Tydfil and Rhymney we know that thelocal context for delivering health and social care is challenging. The firstpaper I published during this piece of local work set the 'Context' for thiswork. Across a range of determinants the general health of people in MerthyrTydfil and Rhymney is a source of worry. We also know from the recent“Futures for Wales” report how our local data sits in a national Welsh picture,the wider context of our societal trends and what this could mean at anational level if we don’t correct some of these factors. Also in “Is Wales Fairer”the Equality and Human Rights Commission Cymru also recently reported ona range of determinants of health and social care in assessing whether Walesis becoming a fairer nation.

(The exercise class - COPD - atPrince Charles hospital,

encouraging patients to return tosafe beneficial exercise).

5. FACING UP TO OUR LOCALCHALLENGES 5.1 The second paper I published at the start of this project talked about some ofthe 'Challenges' we face in sustaining our health and care services in to thefuture. It was a number of the questions raised in this paper that guided mydiscussions with local groups and organisations: • Personal and community wellbeing, • Seamless health and social care, • Physical and mental wellbeing, • Technology and digital services, • User and patient voices, • Measuring success, • Resources, • Delivering the new vision – A Healthier Wales. 5.2 I felt that this set of headings would cover some of the key challenges facingour local health and care services. The questions that I had posed would also beuseful prompts in reviewing local experience alongside regional and nationalresearch.    5.3 As stated earlier the system requires a process of continuing planning andimprovement. I noted towards the end of my local review that the NHS PlanningFramework for 2019-22 was published and sets out the requirements at Appendix2 to this report. This is important as it sets the direction of travel for the comingyears. The framework is available on the Welsh Government’s website.    5.4 However in reporting back on my local work I have chosen to now re-prioritisethe order of the headings, and use different section headings to reflect some ofmy thoughts around the issues that I have seen emerge from this work. 5.5 Some of the themes have remained consistent in my thinking during theproject, but the local review has stressed to me even more the importance ofissues like mental health and wellbeing, housing, resolving issues in primarycare/community settings to help ease tensions across the whole system. 5.6 I am also conscious that all aspects of the review have pointed to the almost impossible pressures and financial demands placed on a system that has now hadto operate for the best part of a decade on "austerity" budgets. I touch on thisissue later, around the competing demands for resources, in closing the report.

6. EMOTIONAL WELLBEING ANDMENTAL HEALTH THE RIGHT HELP AT THE RIGHT TIME

Talk To Me 2workshop at Merthyr

town FC.

6.1 During this local review I have been particularly struck by how frequently issuesaround the emotional wellbeing and mental health of people have arisen. I cameacross these issues in all settings: - from general concerns about aspects of behaviour in public spaces/substancemisuse, - increasing willingness of people to speak about mental health, - concerns about the emotional wellbeing of our young people and school children, - the prevalence of mental health issues in the housing sector, to the experiences of people needing support in crisis and more complex situationslike policing and custody. 6.2 Mental health legislation and associated strategies have evolved significantly overthe last decade, and progress is being made in terms of raising awareness andtackling stigma – “Time to Change Wales” campaign etc. Many organisations nowprovide good online guidance to mental health legislation, guidance and support. 6.3 As a member of this fifth National Assembly, and sitting on the Assembly’s Healthetc Committee, I have also become acutely aware of the issues and advice availablearound suicide prevention e.g. 'Working With Compassion'. I attended the recent‘Talk To Me 2’ workshop at Merthyr Town FC as we sadly know that the suicide rate inCwm Taf was 14.1 per 1,000 of population (the highest rate in Wales). Given thenumber of people who continue to take their own lives in the Cwm Taf area we needto keep improving our work on suicide prevention. 

Yet it strikes me very clearly that underlying even the most critical ofsituations there is a more general picture relating to the emotional wellbeingof people. 6.4 I realised that in many of my advice surgeries I deal with many practicalproblems around housing, welfare and benefits or an individual’s relationships withpublic bodies. Yet beneath the surface of these daily practical problems often lieissues around the emotional challenges and mental health issues that many peopleface. Conversations with other elected representatives suggest they have similarexperiences. So I believe we need to keep building personal resilience in ourcommunities and that must increasingly begin with our children and young people. 6.5 There has been a recent and significant Assembly Inquiry by the Children, YoungPeople and Education Committee in to the emotional wellbeing and mental healthof young people in Wales called 'Mind Over Matter', and in September 2018 theWelsh Government announced a Task Force to help deliver a step change in thesupport for mental health in schools. 6.6 Tools such as MIND’s big mental health survey are useful to help gather freshlessons and to help gather evidence to keep strategies up to date, but based on myrecent work I suspect we already know many of the lessons. We must keep turningthe lessons we learn in to practical actions and improved interventions. 6.7 In taking these strategies forwards it is clear to me that (a) supporting theemotional wellbeing of the population by strengthening low level interventions, and(b) improving timely access to support services are key. In transforming our serviceswe must deliver an ever improving quality of support for emotional wellbeing andmental health interventions in the community. This means maximising awarenessacross all organisations to increase the number of timely interventions, andpreventing problems from escalating. I was struck by the important work of housingsupport and community development staff in this respect. 6.8 The example of work like Valleys Steps is encouraging in helping people acrossour communities to build personal resilience in order to improve everyday well-being. The free to access classes include stress management and mindfulness. Thework of Valleys Steps is a good example of providing early interventions to try andprevent problems from accumulating and escalating.   6.9 As Cymorth Cymru recently stated:  “People living with mental illness are not ahomogeneous group, so it’s important to have a range of services available to meetdifferent people’s needs”. I thought about this as I discussed mental health health inPolice and Custody settings. I will consider this issue further with colleagues GeraldJones MP and the Police and Crime Commissioners. The Asst Chief Constable ofSouth Wales Police recently told the Health Committee that 12% of all Policeincidents are directly related to people in mental health crisis. 

7. HOUSING AND HEALTH7.1 The 70th anniversary of our NHS also reminded me that after the 1945 electionNye Bevan was the Minister for Health and Housing. That simple fact in a waymirrors my own interest in housing issues. It is also why I am willing to add my voiceto housing related campaigns as happened with Supporting People funding duringthe time of this project. I hold to a simple belief that if people do not have a homethat can provide a safe, warm environment then other aspects of life can be madefar more difficult and complex. This at its most serious for those in our communitieswho are threatened with, or have become victims of, homelessness. In early OctoberI was struck by a piece by John Bird founder of the Big Issue: “Street living and homelessness are human rights abuses…. Poverty is an abuse. It robsyou of all that makes you human” (Big Issue w/c 15.10.18) 7.2 I held a housing and health roundtable with local housing associations to explorelocal issues and experiences. As background to that discussion I circulated the papertitled “The vital contribution of housing to improving health outcomes for Wales” asit sets a good context for this part of the project. 7.3 There was an acknowledgement that a significant proportion of tenants havehigh levels of illness or ill health which can lead to complex and burdensome caringsituations for the families of tenants. These comments reinforced for me the generalcontext of health and care issues already established for the constituency. 7.4 It was therefore very pleasing to hear about the work of these housingorganisations in providing a range of interventions, not only in relation to housingand tenancy, but a wide range of other wellbeing issues including interventions forsome tenants with mental health issues.    

Housing, health and careroundtable discussion withlocal housing associations.

7.5 I discuss how we measure performance of services in section 14 of this report. Iwas struck by a part of the discussion around housing on how we can best measurethe benefits of the early intervention made through housing support services?.While few would challenge the benefits of a safe, warm home to physical and mentalhealth it can be difficult to measure the value of low level interventions relative to,say, medical interventions.  7.6 Housing Associations told me about how the wellbeing agenda is now woventhrough their corporate plans and reflected in the structure of their staff teams andthe interventions they make. It was made clear to me that the austerity and relatedpoverty agenda has grown over the last decade with all the associatedconsequences for individuals and the wellbeing of their families. It was felt suchissues were currently intense in the housing association sector as their tenants areoften those people in greatest need and having the highest levels of priority. OneAssociation described their tenancy welfare service and that across 1,000 tenantsthey had identified a need for intervention in 38% of cases. Such demands thenplace consequent demands on other services. Doubt was expressed if the necessarysupport had been fully available across the range of issues that tenants had raised. 7.7 The Associations described to me extensive staff training initiatives aroundidentifying risk, using trauma informed approaches, the ACEs agenda, vulnerableadults and children. It was clear to me that the housing sector now contains asignificant number of people able to make low level (and other) interventions, and torefer cases for more significant support where appropriate.  Perhaps a moredetailed conversation is required with other partners about the role of housingservices in triaging demands to help secure speedier responses. I have learnt thatmental health support is now based in the control room of Gwent's emergencyservices. So is it time to think about strengthening mental health services in thefront line of housing services rather than on referral? This would build a moreholistic service philosophy at a regular point of contact. Though it would need to beexamined as an intervention, and not a service which was an additional 'cost' totenants.  7.8 However it might be particularly useful in dealing with those tenants who areheavy users of other support services and more effective interventions might beachieved. It was pointed out that on one large local estate the residents have noimmediate access to a GP surgery and the question was asked whether that makespeople less likely to seek medical advice? I would need to explore this further as GPsare often the gatekeepers to support and are key to community basedprevention.However particular fears were expressed for people who are morevulnerable in the private rented sector who do not benefit from these types ofsupport services and are vulnerable to exploitation. Given a lack of accommodationfor some client groups - especially young single people - there is extensive(excessive?) use of hotels and B&Bs for emergency housing responses. I fear noteveryone sees such housing situations as a political priority.

8. CARE - THE UNDERVALUEDPARTNER?8.1 Many of the reports I have read during this project highlight the need for a 'wholesystem' response to the demands on our health and care services. In both primaryand secondary settings I have heard conversations about the importance of providingadequate social care to alleviate the pressures on the whole system. 8.2 My local work leads to me the view that I need to consider in more detail thesituation around social care services in the constituency. There is some suggestion inmy survey that people do not receive the social care they wish for – though I amtreating that feedback with significant caution pending further work as the surveyprovides limited evidence from users. However even on straightforward indicatorslike the speed of response in the adaptations service there are worrying signals aboutthe capacity to make sufficiently speedy responses. 8.3 In preparing for, and reacting to, the recent draft Welsh Budget the members ofthe WLGA made clear their view about the stress on council funding and theincreasing demands on social care budgets. This case was also made to me in ameeting with the leader of Caerphilly CBC and in a meeting with the portfolio holderin Merthyr Tydfil CBC. The Future Generations Commissioner recently bloggedaround this issue stressing the importance of preventative spending and not simplyfunding increases in ill health care. I have raised these matters with the CabinetSecretary.  8.4 Two areas of immediate cost pressures were identified in Merthyr Tydfil : (a)increasing costs for looked after children, and (b) domiciliary care packages that helpfacilitate early discharge from hospital. Part of the challenge for seamless services isthat moving people out of hospital is good news. It is to be encouraged as it createsthe space for more activity in the NHS But this is not actually a cost saving as NHSbeds are taken up by newer patients. The shift however increases costs on localauthority social services, but that extra cost is not funded by the NHS. (I will pursuethe accommodation needs of looked after children, and young single people,separately as there are issues to address in meeting statutory requirements). 8.5 The Welsh Government confirmed that in 2019/20 that £180 million would beinvested in “targeted action across the health and social care system, to reflect theintegrated approach we are promoting towards the development of seamless modelsof care.” “Ministers also confirmed local authority social care services will receive £50m next year –£20m will be provided as part of the local government revenue support grant and afurther £30m as a specific grant from the health and social services budget”. 

8.7 It is important that the money we invest at a primary and social care level helps toreshape services in order to reduce pressures on the more acute parts of the service.This will help to improve the experience for users. However I see no easy solution tothis given the pressures on all parts of the system. It requires an even more of amind-set which sees shared budget decisions as the norm. It must lead to an evermore relaxed and constructive outlook about 'boundaries', in order to ensure thatmoney can move across organisational boundaries as is required in either health orcare. Such an approach will help to continually improve the responses to increasedcare demands at peak times of demand on the NHS e.g. winter flows. The RegionalPartnership Boards have a key role in delivering this change. 8.8 As an aside it is also interesting to consider whether it is the tightening of budgetsthat has driven this welcome shift towards more closely integrating services? Perhapstighter budgets have driven a change of culture, as there is no other choice? I can only wonder whether this would have happened to the same extent if budgets hadnot been under pressure?.  8.9 The success of projects like “Stay Well At Home” in Cwm Taf which was funded byIntegrated Care Fund monies provide building blocks that the new transformationfunds can build upon. It strengthens the support available around the home so thatpeople, where possible, avoid the need to enter hospital.   8.10 The advice I have read from bodies like the BMA / Royal College of EmergencyMedicine stress that the care system must be in a position to share the whole systemresponse to challenges like Winter pressures as delayed transfers of care can pose aserious problem to A+E units, and other parts of the service. 8.11 I understand the invaluable role of carers across our communities and the needto consider their wellbeing, alongside those who they care for.   8.12 I have not however written at length about carers in this particular report as theAssembly Health, Social Care and Sport Committee is currently conducting an Inquiryabout the experience of carers under the Social Services and Wellbeing Act.  I am sure the evidence being presented to that inquiry will provide sufficient food forthought especially as regards access to carers assessments.  

Carers

9. CONDITIONS9.1 I thank those groups, patients and their representative bodies who invite me totheir local group meetings or who meet me in the constituency office (Parkinson’s,Epilepsy, Dementia awareness, Merthyr Cancer Aid, Stroke Groups, Autism etc), andwho themselves often attend the Assembly itself to update AMs on their needs,campaigns and funding bids. In a report of this nature it is not possible to respond toall the requests I have heard, indeed neither is it appropriate in this report. 9.2 The clear impression that I picked up was that: (a) by and large, people are generally satisfied with the support they receive when theyaccess a service/treatment for their condition, but (b) the wait to receive treatment sometimes takes much longer than they wish. 9.3 That is a view also stated by Community Health Councils in their reviews. I reachthe view that we should focus even more on the pathway from the speed of diagnosisto treatment. It is clear that securing early diagnosis is very important in manyconditions. So I believe that we should recognise even more that in some conditionsthe speed of diagnosis can be critical. We can do this while also ensuring that  weexamine the best way of measuring whole treatment pathways in order to achieve thebest outcomes. 9.4 In some cases I heard evidence that local services can prove to be fragile, and aswith local maternity and specialist ophthalmic services, I heard about issues that arisewhen limited and skilled resources are lost because staff change jobs or moveemployers. In some of these cases the moves to strengthen workforce planning, andmore success in recruitment can help. Improving staff skills and advances intechnology will allow treatments to be provided by members of the health team otherthan GPs. It is also why I support the process of reorganising some of our healthservices to secure more specialised centres which can more readily sustain servicesand are at less risk if, on occasion, key individuals leave the local service.          

Meeting Cwm Taf OccupationalTherapists - we need to make more andbetter use of Allied Health Professionalsacross our health and care systems.

9.5 It is why I was particularly encouraged to hear about the experiences with theprofessions allied to medicine (therapists etc) and the upskilling of practice nurses andnursing assistants to take on more responsible roles. For example when I met the localParkinsons group they were keen to see local nurses in primary care upskilled to providesome of their more regular treatments.            

Do the good things consistently well – always 9.6 There has been a lot of recent interest in innovation and transformation. These areimportant as no system can stand still and we must learn and move quickly.    9.7 Yet some things will always remain as the good things to do, and just need consistentapplication. Examples that come to mind are early discharge from hospital andrehabilitation after a stroke. The practice varies across Wales, but the needs of thepatient are that the fundamentals – are done well, and consistently.

10. ORAL HEALTH AND EYE CARE10.1 Earlier this year I had a chance to meet up with a local dental practice to talk aboutthe importance of oral health and dental care in our local health and social care services.We know from national and local statistics about the rates of activity and populationcovered.In spite of some significant initiatives like Designed to Smile  the rates of dentaldisease amongst local children and adults remain too high. Many of the risk factors arecommon to other conditions and can be changed by behaviour. Campaigns like 'BabyTeeth Matter' – initially launched in Merthyr Tydfil – are important. 10.2 This visit emphasised to me the importance of preventative work, from early in life,and the action we can all take to improve oral health. The conversation also pointed tothe importance of directing our funds towards this preventative agenda and not justfocusing on payment for activity rates. Yet again it is an example of the clear need tofocus our resources on outcomes – improved oral care- and not just for activity outputs.Team members can take on enhanced roles to promote oral health if we reward the rightactivities. 10.3 So I took a keen interest in the publication of “The oral and dental services response”in July 2018 as part of  A Healthier Wales – the new plan for Health and Social Care inWales. As a member of the Health Committee we have just undertaken a one day inquiryinto dental services in Wales which will soon report. 10.4 The new strategy recognises that the contract needs to reform more quickly so thatother members of the dental team can deliver the preventative interventions required inour communities. Our NHS primary dental care services will strengthen their work indelivering evidence-informed personalised preventative-led care.

Learning more about theimportance of registering with adentist and good oral healthcare.

10.5 So for the 2018-2021 period the Welsh Government say that success in dentistrywill have five key features: • Timely access to prevention focussed NHS dental care, • Sustained and whole system change underpinned by contract reform, • Teams that are trained, supported and delivering, • Oral health intelligence and evidence driving improvement, • Improve population health and well-being.

Eye Health

10.6 I heard similar messages when earlier this year I visited the optometry servicesin the integrated health and care centre in Rhymney and then Specsavers MerthyrTydfil as part of national eye health week 2018. Both services explained to me thattheir existing contract is outdated and probably places an emphasis on payment forthe wrong type of activity. They believe that the focus of a contract should be makingbest use of the advances in technology which mean they can deal with a far widerrange of activities and in placing a greater emphasis on outcomes i.e. improved eyehealth. 10.7 This was very marked with the range of more specialised equipment that I sawis now available in these highly accessible, community based services. This meansreferrals can be taken from secondary services and treatment moved back in totown centres and locations more accessible to people. 10.8 These are both examples of important preventative and treatment services thatare on a journey of reform and I for one welcome an increasing emphasis onoutcomes – better oral and eye care.

Technology is making better eye health more accessible in our communities -butremember that everyone needs their regular eye test. 

11. "BOUNDARIES"  SHOULD NOTBE BARRIERS 11.1 There are mixed fortunes for me in having a constituency that covers severaladministrative areas. It can be viewed as both a ‘bit of a headache’ but also anopportunity. It can make my work a little more complex, for example on casework andcorrespondence which has to be directed via the appropriate council (2), Police Force(2) or LHB (2) Voluntary councils (2) etc etc. However the advantages this situationoffers includes the ability to compare and contrast experiences both between the twolocal authorities but also the LHBs (and Police forces), Regional Partnership Boardsand Public Service Boards whose areas of operation also cover the constituency and,often, a larger geographical area. 11.2 One point which clearly emerges for me from these experiences however is that"boundaries", especially administrative boundaries, are not, and should never be anexcuse or a barrier to adopting, adapting, spreading and maximising the opportunitiesfor best practice. Likewise for organisational and professional boundaries. 11.3 In the ‘Introduction’ to the NHS Wales Planning Framework 2019/22 it states: “….Wales must continue to break down the barriers that prevent health and social careservices and their wider partners from operating across the whole system, deliveringseamless care to the people of Wales”. This is as important for organisations andprofessionals.

11.4 There is clear evidence that I see as an AM that practice can vary by geography, andeven when best practice is identified in one place it can sometimes struggle to make itacross to neighbouring areas. While I accept 'one size does not fit all' I feel there can belittle excuse if the practice in one part of our NHS or care services is proving effective, butthose lessons are not being adopted elsewhere. That is why I believe strengtheningplanning at a Regional Partnership Board level should help deliver better outcomes. So itwas good to see the Cwm Taf plan published in Spring 2018 as was the plan for Gwent. 11.5 Arising from this partnership work in Gwent we have seen the development ofNeighbourhood Care Networks including: “The Gwent Neighbourhood Care Network Model (NCN) NCN’s have been established withinlocalities, comprising primary care, health and social care community providers, public healthprofessionals and representatives of the third sector.    Through a ‘wellbeing workforce’ they will deliver integrated services across the community. This year has seen the development of the NCN wellbeing workforce with the appointmentof: - Practice based pharmacists. - Practice based physiotherapists. - Appointment of Practice based social workers. - Development and purchase of a Dementia Road Map across all NCN’s. - Development of 24/7 community nursing. - Anticipatory care planning – working with care homes 11.6 In Cwm Taf the plan appears more thematic but does set out the development of‘Community Zones’ starting with the Gurnos and Ferndale. I await to see how theseprojects are prioritised by partners from within their budgets so that together theyimprove service delivery in these communities.   11.7 I was pleased to note that the Upper Rhymney valley will be part of the next phase ofwork in Aneurin Bevan/Caerphilly by reviewing and strengthening community basedservices including those provided through the Integrated centre in Rhymney.   11.8 Yet achieving the practical and behavioural change we need is difficult and the PublicPolicy Institute for Wales recently reported on “Behaviour change in the Welsh NHS:insights from three programmes” in reviewing: Making Every Contact Count, ChoosingWisely Wales and Social Prescribing. 11.9 The emphasis I placed earlier on mental health (section 6) reflects another strand ofthought about organisational/ professional and other boundaries that too easily infiltrateservices. These potential barriers take a number of forms and we must continue to reducethem in delivering the outcomes people require.

Behavioural change

11.10 I came across some simple examples during my visits including staff having tooperate on separate IT systems (local government/NHS), or a delay in transferringrecords from a health to another setting. Everyone was focussed on the best outcomefor the user of the service but systems are not integrated. While we are all aware ofdata protection etc it seems strange to me that we face these issues in 2018. I refer tosome of the digital and technology issues in section 12. 11.11 With some of the more recent innovations in practice that I have seen it wasinteresting to read this evaluation by the Wales Centre for Public Policy about thebarriers to effective roll out and implementation of new initiatives: “The evidence base for the efficacy of the programmes suggests that they have thepotential to contribute to the achievement of these aims. However, for them to do so, andat scale, requires addressing significant barriers to change; particularly the structural andcultural factors that reinforce current behaviours in the system. Such factors, from the timeand resource constraints in the current system, to the way in which staff perceive theirroles, act as strong counter-weights to staff and patients changing their everydaybehaviour”.(my emphasis). 11.12 I read about similar challenges in an article by The Health Foundation about theNHS and behavioural change.   Public health- a key arm of a wellbeing service for Wales11.13 This need for overarching change is why we need to continue strengtheningthe effectiveness of our public health work. There is a lot to be said for Wales havinga single body that can oversee public health initiatives across the nation. This isespecially true and effective in responding to issues around infection control anddiseases. 11.14 Yet we should also consider how that capacity for national response can becombined with more proactive and localised activity to help tackle some of majorhealth issues of our time: obesity, diabetes and screening (in which take up ratesand/or responses are  too low, especially in the constituency). 11.15 Even on straight forwards public health issues like the flu we find: “With autumn approaching, the NHS is again planning to prevent as many influenza (flu)cases as possible though vaccination. Typically in Wales each year flu causes hundreds ofthousands of cases, thousands of hospital admissions and hundreds of deaths, adding tothe burden on health services. This impact can be reduced through vaccination. But onaverage over half of individuals in high-risk groups aged under 65, and 4 in 10 NHS Walesstaff, are not vaccinated against flu”.  

11.16 In England the public health role was given to councils but then allowed to witheron the vine due to funding cuts. Wales has thankfully not made that mistake. Yet ourpublic health messages, especially around exercise and wellbeing, need the localfacilities and the local facilitators to help turn the message in to better outcomes. Butagain, no one is a bystander and everyone is an ally in making these changes. 11.17 Perhaps transformation funding could be directed at this issue so that PublicHealth Wales and local government/leisure trusts can more easily reach concordatsand funding agreements on the delivery of local messages about wellbeing and activityservices.

Co-location and/or Integration  

11.18 In thinking about potential barriers I have seen examples of services being co-located in a number of places e.g. Rhymney Integrated Health and Care centre, butthat remains a step from a truly integrated service. I do know however that co-location and the move towards integration can take a number of forms and there areprofessional, cultural and organisational issues to address, not least for theworkforce. I have also heard calls for health and care to be in a single organisation,but that is not the current policy of government. 11.19 Trade union representatives spoke to me about the perceived barriers and thatstructures can create 'empires' that people then feel the need to defend againstchange. They also felt that we lack a shared definition of what organisations mean byintegration, and people therefore perceive it to mean different things in differentplaces.     11.20 The other activities that can be helped by minimising barriers is the planning forWinter pressures. 2017/18 was a particularly tough year and as a member of theAssembly Health Committee we undertook scrutiny of plans at an earlier stage thisyear, and the Welsh Government and NHS Wales have now published their review andset out resilience plans for the months ahead. 11.21 This also leads me to think about the financial arrangements that support anymove to 'integration'. If a system is to be patient/client focussed then it willincreasingly depend upon budget management being shared so that finance followsthe patient/client. To me this implies further strengthening of decision making byPartnership Boards to break down what, almost understandably, become defensivesilos within single organisations under Budget pressure.

12. TECHNOLOGY IS AN ASSET12.1 As part of my review I read about technologies, emerging technologies, the impactof digital services and looked for opportunities to see technology in action locally. 12.2 It is clear that ‘technology’ has now moved from the world of the ‘innovator’ and isimpacting directly upon treatments, service delivery and patient/user experience. NHSEngland produced an interesting report providing an overview with some interestinginsights to the complexity of scale of AI in health and care. There are now regular piecesin journals about advances in digital tech and AI. Perhaps the current generation wouldbe comfortable to have an initial ‘GP’ diagnosis via AI as exampled here? “When the app started giving advice on ways to self-treat, half of patients stopped asking foran appointment, realizing they didn’t need one” (MT Technology Review). 12.3 NHS England recently published guidance about the vision for this issue and itshows that Wales is not alone in the nature of the changes required. 12.4 At a more detailed level it was also interesting to read about developments like"smart bandages - this intelligent bandage continuously monitors chronic wounds anddelivers targeted drugs to speed up the healing process", or emerging technology like"Robo-bots" which means "nurses will be assisted by smart robots who will take on a thirdof the current workload issues which faces NHS staff". 12.5 Wherever this journey eventually takes us I am somehow reminded of the old TVseries "Tomorrow's World" and what seemed fanciful back then, is in fact often now areality today, or even appears outdated!. 12.6 The Morgan Academy at Swansea University ran a symposium on digital futures inhealth and wellbeing which is reported here which reported that more needs to bespent on digital technologies and be quicker to assess the cost effectiveness of newtechnologies. 12.7 Whether in digital developments, robotics, voice activated technologies or forms ofArtificial Intelligence these are all the changes we are currently witnessing and that canform part of the step change in ‘productivity’ we all require from our NHS and caresystems. The rate of progress was however recently criticised by an AssemblyCommittee  and calls made for more rapid progress in technology. 12.8 I noted that the NHS Planning Framework for 2019/22 already states that mediumterm plans must “demonstrate how clinical and care services will be increasingly datadriven and how informatics will support this”. 

Digital present and future

12.9 I met with staff in Cwm Taf to see how technology is changing some of  theservices that are provided to patients and for staff. It was useful to see some practicallocal examples that can enhance patient experience and boost the effectiveness ofservices. 12.10 I had a conversation about an emerging electronic healthcare administrationservice (CHAI stands for Connected Healthcare Administration Interface) which hasbeen piloted in paediatric services at Cwm Taf and after this initial evaluation it isintended that it will 'go live' and then be extended across other service areas. 12.11 From the picture below (which are not real records!) you can see that CHAI iscapturing patient data via ipads/tablets information and the records that will then beavailable across the system, which is important in a patient pathway across our NHS.The online system can also prioritise patient information and generate prompts andreminders about treatments.

12.12 As the system is held in online it can also prompt queries of staff aboutpossible conditions. In the photo below the system prompts staff to think aboutpossible cases of Sepsis, this caught my eye as being a useful supplement toprofessional observation.

Practical local examples

12.13 The system allows the documentation of admissions, discharges, transfers,assessments and observations and stores care plans and will replace paper records.Following pilot, and approval for the Welsh Clinical Portal, then the system will berolled out. 12.14 I welcome this as one of the issues I have picked up during my review ispatients moving between hospitals/LHBs for services and the new staff they meet notbeing up to speed on their medical history. This type of initiative could help changethat experience. The system also allows for monitoring and managing the quality ofcare, as records can be checked by others, even those not on the ward/site.  Mythanks to Helen and Alan for talking to me about this development. 12.15 What types of barriers might exist for such changes? Well any such changeneeds the active support of staff as they move from paper records to electronicrecords. It takes time to develop and adapt systems, but I feel there must be a big winin terms of effectiveness. In a recent report by The Health Foundation, IFS, King'sFund and Nuffied Trust they stated: "Technology has the potential to deliver significant savings for the NHS but the service doesnot have a strong track record in implementing it at a scale and needs to get better atassessing the benefits, feasibility and challenge of implementing new technology", and  "New technology could fundamentally change the way that NHS staff work - in some casesrequiring entirely new roles to be created. The impact of these changes should not beunderestimated".

BABI/BadgerNet12.16 The second conversation was about BABI and BadgerNet baby diary, bothbased in the maternity services. BABI helps new Mums bond with their new-borns.Previously Mums who were separated from their babies and unable to visit theneonatal unit would rely on a family member to tell them how their baby wasprogressing. Now a newly designed ipad cart can be used to give the Mum 'face time'and receive updates on baby's progress. Staff Nurse Leona Coleman told me aboutthe benefits of this technology. 12.17 BadgerNet baby diary has been designed to provide parents/guardians andtheir family and friends with secure, real time access to photos of their baby duringtheir baby's stay in a neonatal unit.

BABI -the advantagesfor parents from usingtechnology was met withenthusiasm.

12.18 I was also told by Consultant neonatal paediatrician Iyad Al-Muzaffar about howmusical therapy is being introduced to baby incubators to help improve the care ofbabies. These technologies will be used in the new maternity services opening in PrinceCharles next Spring.

Musical therapy beingintroduced to baby incubators

Musical units for premature babyincubators

12.19 It is clear that technology is, and will continue to impact on our NHS and Caresystems in a wide variety of ways. Some changes will present financial challenges,others will improve effectiveness and quality of care. In all scenarios it is clear to methat our NHS and care systems will require the 'future thinkers' who can identify thetechnologies, the opportunities and help to deliver the changes.

Digital platform

12.20 Aside from this visit I noted that at a daily level we need to make more progresswith “My Health Online” which makes life easier for patients as we move towards afully integrated national digital platform for Wales. The Welsh Community CareInformation System should give “community nurses, mental health teams, social workersand therapists the digital tools they need to work better together”. We know that thesestaff work in different organisations, which traditionally means different IT systems(as I saw during my local constituency visits), so the sooner we operate thesecommon digital improvements the better for patients. “The Welsh Community Care Information System overcomes this by integrating informationin a single national system that makes it possible - on a need to know basis - forinformation to be shared securely between health and social care services". 12.21 I discussed with a GP in the Treharris Primary care centre how, for example,technology now assist in adding value to the analysis of a range of standard tests (e.g.a single blood test). The system now provides the patient and doctor with screeningdata across a wider range of health issues. 12.22 We also know progress is being made with Integrating Care Electronically whichbrings efficiency and effectiveness savings. Future proofing these changes in a vasthealth and care system is always a challenge.

12.23 So from making sure people can book appointments online, securing moreseamless IT between health and local government etc, to the emergence of moresophisticated technologies, we must ensure technology tackles barriers. 12.24 I claim no great expertise in detailed issues around digital services andtechnologies. I am a user not an expert. But as a user I am very aware that roles andservices can be quickly displaced, technologies can enhance services and the rate ofprogress is only likely to accelerate. Many of us demand it in our personal lives – justthink of that feeling when your personal tablet malfunctions – but we increasinglyexpect to see it in used in our health and care. 

12. WHO GETS THE BEST SLICE OFTHE CAKE?13.1 2018 saw the passing of Julian Tudor-Hart, a pioneering GP who contributedgreatly to shaping our knowledge of the invaluable impact of primary care practice.His research work promoted the concept of the inverse health law (1971), it states: “The availability of good medical care tends to vary inversely with the need for it in thepopulation served. This inverse care law operates more completely where medical care ismost exposed to market forces, and less so where such exposure is reduced.” 13.2 More latterly I was struck by a paper published in 2016 by the, then acting, ChiefMedical Officer Prof Chris Jones about Rebalancing healthcare and the social gradientaround the inequalities of health. This report stated: “The social gradient in health refers to the fact that inequalities in population healthoutcomes are associated with the socioeconomic status of individuals”. Health inequalities cost Wales billions but major determinants are “the way asociety is organised”.  13.3 The report identifies some of the key socio-economic factors in an area –education, occupation, income and housing quality. These factors have an incrementaland cumulative impact on health and wellbeing. As a result Dr Jones stated “Simply bygrowing up in a poor area of Wales, a child is more likely to have poorer health that willimpact the rest of their lives”. 13.4 In his report Dr Jones cites the example of the “clear correlation between levels ofdeprivation and rates of overweight or obesity………. One in seven children (14.7%) living inMerthyr Tydfil is obese, compared with just 1 in 14 children (7.3%) living in the Vale ofGlamorgan. Similar gradients exist for childhood injuries and tooth decay”. 

13.5 The author also states that “These examples do make the separate point though thatpoverty or low socio-economic status does not necessarily mean ill health. Despite the clearsocio-economic gradient for the risk of obesity, most children in the most deprived areasare not obese. This shows that deprivation is not a certain path; we need to understandbetter why it affects some people and not others”. 13.6 Dr Jones cited the work of Public Health Wales on adverse childhood experienceswhich has shaped many recent, and ongoing policy interventions. “Rebalancinghealthcare” cites a range of examples from flu, screening programmes and smokingprevalence that should be better targeted to offset the social gradient. The reportconcludes that “the NHS needs to be sensitive to the life circumstances of the people itserves”. 13.7 The NHS Wales Planning Framework states that “addressing the inverse care lawwill also have a significant role to play in reducing health inequalities and inform localdelivery”. 13.8 There will be a constant political debate about the ‘size’ of the cake (total budget)given to health or social care in Wales, but we should also wonder whether it is toouncomfortable to think in more detail about what is, mostly, the social determinantsthat shape the health outcomes of the people Merthyr Tydfil and Rhymney. Forexample there will be a linkage between the current welfare reform programme andthe health and wellbeing of local communities. 13.9 The eight recommendations made in 2016 are reproduced at Appendix 3 as theyare worth repeating in the context of the new health and care strategy for Wales. “Addressing the social gradient throughout a person’s life will not only help to improve anindividual’s health and wellbeing, it will also help to reduce the overall demand forhealthcare services in Wales”. 13.10 It is good to see that Cwm Taf students at the Keir Hardie health park arestudying health inequalities. It is why I am also very pleased to see the BevanFoundation are currently taking a closer look at health inequalities and look forwardsto reading their findings in due course.