ABPI CYMRU WALES

• Introduction

• NHS Cymru Wales

• ABPI Cymru Wales Links

• ABPI Cymru Wales Publications
  

The NHS in Wales

Structure of the Welsh Department of Health and Social Services

Welsh Government
The National Assembly for Wales is the 60 Assembly Members (AMs) elected by the people of Wales. It has delegated its executive powers to nine Cabinet Ministers, including a First Minister, who together form the Welsh Assembly Government.

The Welsh Assembly Government is responsible for most of the issues of day-to-day concern to the people of Wales, including the economy, health, education, and local government.

In 2006 the Welsh Assembly gained the ability to make its own legislation on devolved matters such as health, education, social service and local government. These are now a new category of Welsh laws called Assembly Measures.

Following the Welsh Assembly elections in May 2007, the Labour Party had 26 seats, 5 short of an overall majority. After numerous discussions amongst the parties, including talk of a Plaid Cymru led rainbow coalition with the Liberal Democrats and the Conservatives, Labour leader Rhodri Morgan was confirmed as the First Minister for Wales and on 27 June 2007 Labour and Plaid Cymru agreed to form a coalition Welsh Assembly Government.

The Department for Health and Social Services
The Department for Health and Social Services (DHSS) is responsible for:

• advising the Welsh Assembly Government in setting policies and strategies for health and social care in Wales
• contributing to making legislation in the field of health and social care
• providing funding for the NHS and other health and social care bodies
• managing and supporting the delivery of health and social care services
• monitoring and promoting improvements in service delivery

The Department consists of the following directorates and units:

• Community, Primary Care and Health Service Directorate
• Quality, Standards and Safety Improvement Directorate
• Resource Directorate
• Children’s Health and Social Services Directorate
• Older People and Long-term Care Policy Directorate
• Performance and Operations Directorate
• Strategy Unit
• Health and Social Services Human Resources
• Children and Family Court Advisory and Support Service in Wales (CAFCASS Cymru)

and has four regional offices in South East Wales, Mid and West Wales and North Wales.

The Public Health and Health Professions Department
Sitting alongside the DHSS and reporting in to the Minister for Health and Social Care, the Public Health and Health Professions Department (PHHPD) leads on public health strategy and programmes, with the aim of protecting and improving health and reducing health inequalities. It was formed in the 1 April 2007 when the Office of the Chief Medical Officer and the Office of the Chief Nursing Officer were merged together.

Dr Tony Jewell has been the Chief Medical Officer (CMO) in Wales since April 2006. It is the responsibility of the CMO to lead public health policy in Wales, with the aim of reducing health inequalities, to lead the medical profession in Wales, and to maintain appropriate UK and international links with other Government health leaders and organisations.

As Chief Nursing Officer, Rosemary Kennedy is head of profession for the largest single group of health professionals within the NHS in Wales and offers advice and support to nursing professionals employed outside the NHS in other public and private sectors, industry and commerce.

All Wales Medicines Strategy Group (AWMSG)
The All Wales Medicines Strategy Group, established in 2002, provides advice to the Minister for Health in terms of both medicine appraisal and strategy, including the development of a prescribing strategy. NICE continues to cover England and Wales and all decisions made by NICE take precedence over the decisions of AWMSG. However, AWMSG is able to provide interim advice, which once ratified by the Minister, takes precedence over local decision-making in terms of funding arrangements.

Healthcare Inspectorate Wales
Healthcare Inspectorate Wales (HIW) was established in 2004 to promote improvement in the quality and safety of patient care within NHS Wales. In April 2006 the remit was expanded and HIW became the regulator of independent healthcare.

HIW inspects NHS bodies and services, which include the 14 NHS trusts, 22 local health boards (LHBs), the Cancer and Coronary Heart Disease Networks, the National Public Health Service (NPHS) and screening services, NHS Direct in Wales and the Welsh Blood Service. Organisations are inspected against national standards, and also assessed are the management arrangements in place to deliver clinical and NHS service and the quality of NHS services provided.

Health Policy in Wales
The coalition government in Wales is based on the document ‘One Wales’ which outlines their key policy pledges.

For health, the One Wales document commits to deliver a programme of government over the next four years that includes:

• Reviewing NHS reconfiguration
• Strengthening NHS finance and management
• Developing and improving Wales' health services
• Ensuring access to healthcare
• Improving patients' experience
• Supporting social care

The work of the DHSS is guided by the Welsh Assembly’s twin ten-year strategies for health and social services; ‘Designed for Life’ and ‘Fulfilled Lives, Supportive Communities’. Launched in May 2005, this new vision was produced to update ‘Improving Health in Wales’ and describe what kind of health and social care services the people of Wales can expect by 2015.

In particular, the vision aims to:

• improve health and reduce, and where possible eliminate, inequalities in health
• support the role of citizens in promoting their health, individually and collectively
• develop the role of local communities in creating and sustaining health
• promote independence, service user involvement and clinical and professional leadership
• re-cast the role of all elements of health and social care so that the citizen will be seen and treated by high quality staff at home or locally - or passed quickly to excellent specialist care, where this is needed
• provide quality assured clinical treatment and care appropriate to need and based on evidence
• strengthen accountability, developing a more corporate approach in NHS Wales so that organisations work together rather than separately
• ensure full public health engagement at both local and national levels.

Progress towards this vision is to be reviewed in 2008 and in 2011. Each review will inform the development of a new strategic framework to guide activity for the following three years.

NHS Wales

The NHS is Wales' largest employer, with approximately 91,000 staff which equates to approximately 5% of the working-age population of Wales. For 2006-07 the NHS Wales budget was £4.8billion.

NHS Wales undertakes;

• more than 700,000 first out-patient appointments every year
• more than 600,000 inpatient and day-case treated each year
• more than 1,059,000 people seen in A&E every year
• more than 53,900,000 items prescribed each year
• more than 655,000 eye tests each year

The NHS delivers services through Local Health Boards (LHBs) and NHS Trusts across Wales at four levels:

• Primary care is provided by general practitioners (GPs) and other health care professionals in health centres and surgeries across Wales
• Secondary care is delivered through hospital and ambulance services
• Tertiary care is provided by hospitals which treat particular types of illness such as cancer.
• Community care services are usually provided in partnership with local social services, and delivered to patients in their own homes.

In addition, the NHS provides specialist services that support medical diagnosis and treatment and disease prevention, such as screening services.

Primary care
There are over 1,900 family doctors in Wales, over 1,000 dentists, and some 600 opticians. Family doctors are the ‘gateway’ to the NHS, referring people to hospitals for specialist treatment where necessary.

There are 22 Local Health Boards, which assess the health services their populations need and then pay hospital trusts, family doctors, dentist and so on to provide these services.

Each Local Health Board has a decision-making board made up of local doctors, a nurse, other health professionals, members of the local council, voluntary organisations, and other to represent the voice of patients on a truly local basis. They also have a small executive team to put the decisions into action and provide services for the public.

Secondary Care
There are 14 NHS Trusts in Wales, including one all-Wales ambulance trust, which between them manage 135 hospitals and more than 15,000 hospital beds.

Hospitals across Wales provide a range of services with a balance between District General Hospitals providing care on an outpatient, inpatient and day case basis, and Community Hospitals, which provide a more limited range of services.

Tertiary Care
Although Local Health Boards plan and pay for most hospital and family health services, there are a few specialised services to treat illnesses such as cancer which are better planned across the whole of Wales. These are the responsibility of a new organisation, the Health Commission Wales (Specialised Services) which was created on 1 April 2003.

Community Care
Healthcare professionals working in the community include health visitors, midwives, community nurses, physiotherapists, occupational and speech therapists.

The Local Health Boards cover exactly the same areas as the 22 local authorities in Wales which allows for close working between the NHS and the local council. Indeed the Local Health Boards and local councils have a statutory duty to work together in partnership with other local organisations to produce strategies for improving health and social care for the people living in their area.

A single organisation covering the whole of Wales, the National Public Health Service, along with the Wales Centre for Health gives advice and guidance to Local Health Boards on a range of issues such as disease protection and control, and child protection.

Informing Healthcare
Informing Healthcare is a Welsh National Programme to develop new methods, tools and information technologies to improve health services for the people of Wales. Its aim is to modernise health service delivery, promoting new ways of working through better access to information and knowledge for shared decision making. Informing Healthcare has developed a series of healthcare service improvement projects and has invested in information communication technologies to achieve its overall aim of enabling health information to be securely shared between the NHS and social care.

Proposals to change the structure of the NHS in Wales: Consultation Paper

In 2008, the Minister for Health and Social Services in Wales, Ms Edwina Hart, MBE, AM announced a major consultation on the structure of the NHS in Wales. Information pertaining to this can be found at:

http://new.wales.gov.uk/consultations/closed/healandsoccarecloscons/nhswales/?lang=en

ABPI Cymru Wales and the ABPI Cymru Wales Industry Group submitted a response to this consultation, which follows.

“Please find below a summary of the response from ABPI Cymru Wales and the ABPI Cymru Wales Industry Group to the Consultation Document on Changes to the NHS Structure, which we hope you will find useful and of interest.

As you will be aware, the Association of the British Pharmaceutical Industry (ABPI) represents more than 80 pharmaceutical companies in Britain that are engaged in the research, development, manufacturing and supply of prescription medicines. The ABPI Cymru Wales Office has been working closely with the Welsh Assembly Government, the National Assembly for Wales, NHS Wales, health professionals, academia and patients since devolution to help develop policies and solutions to address the distinctive health needs of the people of Wales. And the ABPI Cymru Wales Industry Group (WIG) is made up of over 30 ABPI member companies who have a particular interest in Wales.

The pharmaceutical industry is is the longest standing independent sector partner of the NHS since 1948, and has a great deal of expertise not only in medicines and research and development, but also in management and organisational structures. Our aim in this response is to share some of our knowledge of best practice and management structures in both in the commercial sector and in other countries, with a view of helping to improve patient care and the health of the people of Wales.

Overview

• A National Board will be able to take a much needed strategic, holistic and cross budget view of health in Wales and will be able to provide much clearer leadership on the need to focus on health outcomes and expected standards
• The current organisational structure of health and social care services in Wales does not allow wider economic (e.g., long term care costs) and societal (e.g. quality of life, continued economic activity) factors to be fully considered when funding decisions are made in relation to individual medicines and therapies
• LHBs have been reluctant to invest in medicines and therapies that would lead to significant long term savings for secondary and social care providers because they are focusing too narrowly on balancing their own annual budgets
• This short term, silo budget approach has created a perverse incentive for organisations to delay or refuse funding for clinically and cost effective treatments
• The National Board should be made accountable for setting clinical standards and performance managing the delivery of health policy in addition to planning and funding services, in order to avoid the postcode lottery of service provision and patient outcomes
• Local Health Communities should be held accountable for the delivery of holistic and seamless healthcare services to agreed clinical outcome standards

National Board – Structure & Membership

• The new structure needs to be transparent and open to external views and influence. Advisory Boards should be established to ensure the views of a broad range of stakeholders, including the commercial sector, are considered by the Board
• The planning and contracting services should be undertaken independently at arms length from government in line with the findings of the recent review of HCW by Prof. Mansel Aylward. Option 1 (Special Health Authority) is the option that best meets this criteria

Integrated Health Communities

• We accept the need to reduce the number of LHBs as they have been too small to develop an expertise in all therapy areas and led to unnecessary duplication of roles and work in relatively small geographic and population areas
• Reducing the number of LHBs should lead to cost savings through economies of scale that can in turn be redirected to front line services.
• It will be easier for partner organisations such as professional organisations, patient groups and commercial organisations to communicate with fewer bodies
• We propose the establishment of an integrated holistic approach to the local delivery of services through Integrated Health Communities. These should be accountable for delivery of holistic health services for their defined population including primary, community, secondary and tertiary care needs.

Community Services

• Transferring the responsibility for managing and providing community services from NHS Trusts to LHBs could create new organisational barriers, confusion over who funds different elements of care, and competition for resources and patients in the same geographic area
• One integrated organisation for secondary, primary and community care should be established for each of the proposed Health Communities in order to provide seamless care, improve transfers of care, improve the management of chronic conditions and eliminate silo budgeting and organisational ‘buck passing’
• Such an approach would overcome the tendency for budget protectionism, reduce internal “local” competition between service providers and introduce a new ‘population needs’ led approach to holistic health care provision

Localism

• No new structure or tier should be created below the new LHBs / Integrated Health Communities as this would create duplication, bureaucracy and could lead to confusion for patients about who is responsible for making decisions about their care
• The new Health Communities should draw on the detailed local knowledge of GPs, Nurses, Community Pharmacists and other primary care providers, who in turn should be given a louder voice and responsibility for managing patient care pathways and freedom to design individual care packages based on the needs of individual patients

Community Health Councils

• CHC's need co-ordinated support nationally and additional human and financial resources locally in order to fulfil their core scrutiny and advocacy roles effectively
• CHC’s should work more closely with, and draw on the knowledge and expertise of, patient advocacy groups and other third sector organisations that represent patients and carers.

Membership of Local Boards

• Stakeholder and Citizen Advisory Groups should be established to ensure that the new Health Communities draw on the knowledge and expertise of local populations, local government, healthcare professionals, the voluntary sector, patient groups and the commercial sector
• These Stakeholder and Citizen Advisory Groups need to have real influence on Board deliberations and decisions if they are to gain the trust, support and respect of local communities, health care professionals and partner organisations

Local Service Boards & Local Government

• Wales needs to move away from silo budgeting and arguments over who funds different elements of care to a more holistic model where patients are provided with fully integrated care packages that cross health and social care
• It would be logical for the Local Service Boards to be reorganised so that they are coterminous with the new Health Communities to ensure that NHS organisations remain fully engaged and to help deliver the ambition of closer joint working outlined in Making the Connections

Support Services

• Creating a single shared services body could help healthcare organisations to focus on the delivery of patient care and lead to economies of scale, however the roles and responsibilities of the new body should be transparent and accountable
• The shared services body needs to work closely with NHS organisations and the independent, commercial and voluntary sectors so that it does not become remote from patients and the rest of the health service
• The All Wales Medicines Strategy Group should retain an advisory role directly to the National Board and the Minister and should not be incorporated into a single shared service body as it derives significant benefits from its links with Cardiff & Vale NHS Trust and Cardiff University and has developed effective stakeholder engagement models”

It is now anticipated that a further consultation will be launched on the Ministers final proposals in the Autumn of 2008, with the implementation of the restructuring pencilled in for April 2009.