NO ONE IS ABYSTANDER -EVERYONE IS ANALLY

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

Add subheading

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 whohelped me with this piece of work, whether by hostingvisits, giving of their time to hold conversations (includingthose people 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 to me as partof this detailed look at local health and social careservices.   Thanks also to my team of staff for helping me to preparethis pamphlet, for their support with the online surveyand with a lot of the background work for my Summerand Autumn of intense and detailed work on local healthand care services. This is the final version. Since the draft report was issued Ihave added some material to the section on MentalHealth and Wellbeing as regards the "Social Determinantsof Mental Health", strengthened the reference to thevoluntary sector as brokers of services and made factualcorrections to place names etc.  I now hope the report canform part of a continuing conversation.  

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

Merthyr Tydfil & Rhymney - December 2018

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 UniversityHealth Park in Merthyr Tydfil. I also hosted a celebratory coffee morning in theconstituency. I witnessed, at first hand, the affection of staff, patients and the widercommunity for this unique, “made in Wales” response to the health needs of ourpopulation. 1.2 However as we celebrated this landmark event I was also very conscious of 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 theseservices remain ready to meet the challenges of the years ahead.   1.4 Following a major Parliamentary Review of Health and Social Care in Wales theWelsh Government has published its strategy for health and care in the years aheadbased on:    • 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. My drill down will help me to assess and understand the impact of this new strategy.

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” into the local experiences of these services and speak to the users and providers ofthese vital services in order to learn more. It has proven to be a busy and fruitfulperiod of activity. 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 Sport Committee.As a member of that Committee I frequently have the opportunity to question seniorleaders of our health and social care services about national policy, budget pressures,financial management, access to conditions and treatments, service deliveryarrangements, system design, workforce planning, recruitment and retention issuesetc.    2.3 I am however very aware that while sitting in the Assembly discussing the'national' and 'regional' picture that could so easily mask the local experiences inthese health and care services. So I want this report to reflect on the breadth of theissues I have recently looked at, and thought about, during my local ‘drill down’. But Ialso try to set this ’local’ view in an appropriate regional and national context as thatoften sets the overall direction for our local services. I am however grateful that all ofthe activities I have recently undertaken mean that as a constituency AM I can nowmore easily compare what I hear about in Assembly Committees with practical localexperiences.  

Presenting a 70th anniversary cardto NHS 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 both our NHS and care services as we move forwards. That inturn will mean we give these services the best opportunity to meet all of thechallenges which arise from the significant determinants of physical and mentalhealth that affect the constituency of Merthyr Tydfil and Rhymney. 3.1 In addition to the work that I cover in this report it is important for me to be clearon 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 that I have carried out. This includes all thework that 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 they areincluded in this final report.

3. WHAT IT IS NOT!

4.1 I am going to start my story on a Wednesday morning in Merthyr Leisure centre. Ipaid a visit to the National Exercise Referral Scheme (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. This in turn help the NHS and socialcare systems by reducing demands at source: - Stop smoking, - Drink less alcohol, - Eat well and - Take exercise. 4.7 Public Health Wales report on these issues - health and its determinants - forthe whole of Wales. Indeed the existing evidence about issues like obesity for thehealth our future generations is stark. Over 36% of children in Wales areunhealthily overweight. I also noted that in Merthyr in 2003/4 58.1% of personsaged 16+ were reported to be overweight or obese which rose to 66.7% in 2017and is projected to be 73.3% in 2025. This is a 15% rise over some 20 years. This willalso 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'Stay Well in Wales'.  This awareness in many ways reflects the 10 key evidence-based ways to make a difference to levels of ill health and inequalities set out in thereport '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 this work.Across a range of determinants the general health of people in Merthyr Tydfiland Rhymney is a source of worry. We also know from the recent “Futures forWales” report how our local data sits in a national Welsh picture, the widercontext of our societal trends and what this could mean at a national level ifwe don’t correct some of these factors. Also in “Is Wales Fairer” the Equalityand Human Rights Commission Cymru also recently reported on a range ofdeterminants of health and social care in assessing whether Wales isbecoming 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 the future.It was a number of the topics/ 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. I noted that the Health Foundation argue that "as little as 10% of apopulation's health and wellbeing is linked to access to health care". They argue thecase for looking at the "bigger picture", echoing the work of the World HealthOrganisation.     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.  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. So "we need to think more about a person's situation andcircumstances - their story" (Psychologists for Social Change) in a whole systemapproach. 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 for 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. 

6.4 The World Health Organisation write about the "Social Determinants of MentalHealth" stating it is "shaped to a great extent by the social, economic and physicalenvironments in which people live".  They make the case for universal butproportionate action to "improve the conditions of everyday life". I realised that inmany of my advice surgeries I deal with many practical problems around housing,welfare and benefits or an individual’s relationships with public bodies. Yet beneaththe surface of these daily practical problems often lie issues around the emotionalchallenges and mental health triggered by these issues. Conversations with otherelected representatives suggest they have similar experiences. So I believe we needto keep building personal resilience in our communities and that must increasinglybegin with our children and young people. 6.5 There has been a significant Assembly Inquiry by the Children, Young Peopleand Education Committee in to the emotional wellbeing and mental health of youngpeople in Wales called 'Mind Over Matter', and in September 2018 the WelshGovernment announced a Task Force to help deliver a step change in the supportfor mental health in schools. "Everybody's Business" the Assembly Health etcCommittee report on suicide prevention was published on 5th December 2018. 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 turningthese lessons in to practical actions and to deliver improved interventions. In takingthese strategies forwards it is clear to me that (a) supporting low level interventionsto support the general emotional wellbeing of the population, and (b) improvingtimely access to support services are key. In transforming our services we mustdeliver an ever improving quality of support in the community. This meansmaximising awareness across all organisations to increase the number of timelyinterventions, and preventing problems from escalating. I was struck by theimportant work of housing support and community development staff in thisrespect. 6.7 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.    6.8 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 Assembly Health Committee that 12% of allPolice incidents 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 are made farmore 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 aspect 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 theevidence established about the general determinants of health and care in theconstituency. 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 by housingservice staff 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'whole system' response to the demands on our health and care services. In bothprimary and secondary settings I have heard conversations about the importance ofproviding adequate 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 signalsabout the 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 for Health, Social Care and Sport.  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 seamlessmodels of 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”. 

8.6 It is important that the money we invest at a primary and social care level helpsto reshape services in order to reduce pressures on the more acute parts of theservice. This will help to improve the experience for users. However I see no easysolution to this given the pressures on all parts of the system. It requires an evenstronger mind-set to see shared budget decisions as the norm. It must lead to anever more relaxed and constructive outlook about 'boundaries', in order to ensurethat money can move across organisational boundaries as is required in eitherhealth or care. Such an approach will help to continually improve the responses toincreased care demands at peak times of demand on the NHS e.g. winter flows. TheRegional Partnership Boards have a key role in delivering this change. 8.7 As an aside it is also interesting to consider whether it is the tightening ofbudgets that has driven this welcome shift towards more closely integratingservices? Perhaps tighter budgets have driven a change of culture, as there is noother choice? I can  only wonder whether this welcome change would havehappened to the same extent if budgets had not been under pressure?.  8.8 The success of projects like “Stay Well@Home” in Cwm Taf which was funded byIntegrated Care Fund monies provides building blocks that the new transformationfunds can build upon. This award winning service strengthens the support availablearound the home so that people, where possible, avoid the need to enter hospital.   8.9 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 wholesystem response to challenges like Winter pressures as delayed transfers of carecan pose a serious problem to A&E units, and other parts of the service. Thecurrent Task and Finish Group on critical care will bring forward recommendationson this area of work next Spring.  8.10 I understand the invaluable role of carers across our communities and theneed to consider their wellbeing, alongside those who they care for.   8.11 I have not however written at length about carers in this particular report asthe Assembly Health, Social Care and Sport Committee is currently conducting anInquiry about the experience of carers under the Social Services and Wellbeing Act. 8.12 I am sure the evidence being presented to that inquiry will provide sufficientfood for thought especially as regards the knowledge of, and access, to carersassessments and other issues.

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 respondto all the requests I have heard, indeed neither is it appropriate in this context. 9.2 The clear impression that I picked up was that: (a) by and large, people are generally satisfied with the support they receive whenthey access 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 ofdiagnosis to treatment. It is clear that securing early diagnosis is very important inmany conditions. So I believe that we should recognise even more that in someconditions the speed of diagnosis can be critical. We can do this while also ensuringthat  we examine the best way of improving whole treatment pathways in order toachieve the best 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 thatarise when limited and skilled resources are lost because staff change jobs or moveemployers. In some of these cases the moves to strengthen workforce planning,and more success in recruitment can help. Improving staff skills and advances intechnology will allow treatments to be provided by members of the health teamother than GPs. It is also why I support the process of reorganising some of ourhealth services to secure more specialised centres which can more readily sustainservices and are at less risk if, on occasion, key individuals leave the local service.          

Meeting Cwm Taf OccupationalTherapists - we need to make moreand better use of Allied HealthProfessionals across our health andcare 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 toprovide some 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 needconsistent application. Examples that come to mind are early discharge from hospitaland rehabilitation 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 talkabout the importance of oral health and dental care in our local health and social careservices. We know from national and local statistics about the rates of activity andpopulation covered.In spite of some significant initiatives like Designed to Smile  therates of dental disease amongst local children and adults remain too high. Many of therisk factors are common to other conditions and can be changed by behaviour.Campaigns like 'Baby Teeth Do Matter' – initially launched in Merthyr Tydfil – areimportant. 10.2 This visit emphasised to me the importance of preventative work, from early inlife, and the action we can all take to improve oral health. The conversation alsopointed to the importance of directing our funds towards this preventative agenda andnot just focusing on payment for activity rates. Yet again it is an example of the clearneed to focus our resources on outcomes – improved oral care- and not just for activityoutputs. Team members can take on enhanced roles to promote oral health if wereward the right activities. 10.3 So I took a keen interest in the publication of “The oral and dental servicesresponse” in July 2018 as part of  A Healthier Wales – the new plan for Health andSocial Care in Wales. As a member of the Health Committee we have just undertaken aone day inquiry into dental services in Wales which will soon report. 10.4 The new strategy recognises that the contract needs to reform more quickly sothat other members of the dental team can deliver the preventative interventionsrequired in our communities. Our NHS primary dental care services will strengthentheir work in delivering 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 too much emphasis onpayment for the wrong type of activity. They believe that the focus of a contractshould be making best use of the advances in technology which mean they can dealwith a far wider range of activities and in placing a greater emphasis on outcomesi.e. improved eye health. 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 Local Health Board (2) Voluntary councils (2) etc etc. However the advantagesthis situation offers includes the ability to compare and contrast experiences, bothbetween the two local authorities, but also the LHBs (and Police forces), RegionalPartnership Boards and Public Service Boards whose areas of operation also cover theconstituency 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 of practice varying 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 So arising from this partnership work we have seen the development ofNeighbourhood Care Networks in Gwent: “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’ theywill deliver integrated services across the community. 11.6 This year has seen the development of the NCN wellbeing workforce with theappointment of: - 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 11.7 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.   11.8 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.   11.9 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. 11.10 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 toreduce them in delivering the outcomes people require.

Behavioural change

11.11 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 still face these issues to this extentin 2018. I refer to some of the digital and technology issues in section 12. 11.12 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 the potentialto contribute to the achievement of these aims. However, for them to do so, and at scale,requires addressing significant barriers to change; particularly the structural and culturalfactors that reinforce current behaviours in the system. Such factors, from the time andresource constraints in the current system, to the way in which staff perceive their roles, actas strong counter-weights to staff and patients changing their everyday behaviour”. (myemphasis). 11.13 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 Wales11.14 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. 11.15 Yet we should also consider how that capacity for a national response can becombined with more proactive and localised activity to help tackle some of majorhealth issues of our time: obesity, diabetes and screening (for which take up ratesand/or responses are  too low, especially in my constituency). 11.16 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”.  

11.17 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. 11.18 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  

11.19 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. 11.20 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.     11.21 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. 11.22 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 mobile phone generationwould be more 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 to the patient's pathway across ourNHS. The online system can also prioritise patient information and generate promptsand reminders about treatments.

12.12 As the system is held online it can also prompt queries of staff aboutpossible conditions. In the photo over the page the system prompts staff to thinkabout possible cases of Sepsis given the existence of other indicators in therecord. This caught my eye as being a useful way for technology to supplement professional observation.

Practical local examples

12.13 The system allows the documentation of admissions, discharges, transfers,assessments, observations and stores care plans. This will replace paper records.Following pilot, and approval for the Welsh Clinical Portal, then the system will berolled out. 12.14 I welcome this change 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 Bonding After Birth Initiative (BABI) andthe BadgerNet baby diary, both based in the maternity services in Cwm Taf. BABIhelps new Mums bond with their newborn child. Previously Mums who wereseparated from their babies and unable to visit the neonatal unit would rely on afamily member to tell them how their baby was progressing. Now a newly designedipad cart can be used to give the Mum 'face time' and receive updates on baby'sprogress. Staff Nurse Leona Coleman told me about the 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 metwith enthusiasm.

12.18 I was also told by Consultant neonatal paediatrician Dr Iyad Al-Muzaffar abouthow musical therapy is being introduced to baby incubators to help improve the careof babies. These technologies will be used in the new maternity services opening inPrince Charles Hospital 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 existing barriers. 12.24 I claim no great expertise in the detailed issues around expanding the use ofdigital services and technologies. I am a user not an expert. But as a user I am veryaware that roles and services can be quickly displaced, technologies can enhanceservices and the rate of progress is only likely to accelerate. Many of us demand it inour personal lives – e.g. just think of that feeling when your personal tabletmalfunctions – but we also, and increasingly, expect to see it in used in our health andcare. 

13. 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 a society isorganised”.  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 that poverty or low socio-economicstatus does not necessarily mean ill health. Despite the clear socio-economic gradient forthe risk of obesity, most children in the most deprived areas are not obese. This shows thatdeprivation is not a certain path; we need to understand better why it affects some peopleand 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 our 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 University Health Parkare studying health inequalities. It is also why I am also very pleased to see that theBevan Foundation are currently taking a closer look at health inequalities and lookforwards to reading their findings in due course.