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The story in Wales

In the latest article in our latest Policy in Focus series we look at the developments in Wales over the last two years. Reports and research by Matthew Limb

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What’s happening and why?

T-shirt with Cymru WalesLike all UK governments, the Welsh Assembly Government is under pressure to reform public services. The drive is on to meet people’s rising expectations, improve levels of health and well-being, reduce inequalities and, of course, try to control ever-spiralling costs.

But the WAG is taking a different approach to its neighbours in several key areas, a reflection of the country’s size, politics, history, culture and demographics.

Wales has higher levels of social need, unemployment and chronic ill health than England. The health service’s role in reducing health inequality has long been recognised in the country and there is also a longer history of close working between the NHS and local government than in England. But critics say this has been at the expense of performance and financial control, as evidenced by deficits and stubbornly long waiting lists.

In 2006, the WAG outlined its commitment to making public services more efficient and responsive in the document Making the Connections: Delivering Beyond Boundaries.

This Welsh model puts the focus on the citizen, rather than the consumer, making a distinction with England that is meant to be more than symbolic. The aim is to value individuals’ right to express choice but not to the extent of letting competition destabilise provision and undermine the wider public good.

In June 2007, a newly elected Labour and Plaid Cymru coalition government then announced a fundamental departure from the policies of the Department of Health.

Affirming its pride in an NHS ‘born in Wales’, the WAG rejected privatisation of NHS services and the market model, and vetoed the NHS’s use of private sector hospitals.

In May 2009, after two consultations the government announced a new planning and funding system to replace the commissioning framework and internal market, and a streamlined system of integrated local health boards.

So-called 'whole-system' planning and provision will focus on developing ‘localities’, based on populations of around 30,000 to 50,000 people. The theory is that this will improve community services, ensuring more people receive effective care in the most appropriate setting. Wales has also retained community health councils and free prescriptions.

What are the challenges?

Over time there will be significant benefits for patients and staff, with better joint working, swifter access to services and more career opportunities - Paul Williams, Chief excecutive Executive, NHS Wales

Many physio teams have traditionally been based in integrated acute and community trusts, and the reforms suggest a move to more localised primary care teams, although it is not clear whether resources will move with them.

It is also unclear whether local teams in the community will manage themselves under a devolved model or be managed more centrally by health boards. Critics point to potential risks for physiotherapists operating in small groups, including loss of peer and professional support and the governance that they would receive in a large physio department.

A wider fear is of fragmented services and unequal access, a post code lottery in other words, which is easier to avoid with a centralist approach. The blurring of boundaries represents another challenge, with services being planned across organisational boundaries.

The main changes are:
  • seven local health boards will be responsible to the health minister for delivering all healthcare in their regions. They replace 22 health boards and seven NHS trusts
  • each LHB will have a director of therapies and health science, and advisory groups or committees comprising professionals and wider ‘stakeholders’. They will also have a full board member trade union representative, appointed through the public appointments process
  • each board will have a vice chair to take responsibility for primary, community and mental health services
  • a new National Advisory Board, chaired by the health minister, will oversee the health service as a whole. It will meet in public will include employer, trade union and outside expert members
  • a National Delivery Group will be responsible for day-to-day performance.
  • there will be one unified public health service for the country

How will the workforce be affected?

Physio workingHealth minister Edwina Hart has pledged there will be no compulsory redundancies as NHS structures are streamlined.

Unlike in England, there is no competitive market in Wales, so staff are not being transferred to private sector employers. However, the new system will still have implications for NHS employees.

The Welsh Partnership Forum, comprising health sector union, management and government representatives, is developing a series of all-Wales policies and procedures covering sickness absence, grievance, disciplinary issues and a revised bank staff contract.

The forum is also looking at violence against staff, including lone worker policies, and has raised the question of leadership training for allied health professions with the minister.

What are the opportunities for physiotherapists?

The focus on ‘whole-system’ planning and provision and on improving services in primary care and the community are positive moves for physiotherapy, say proponents. Physios can play a key role in integrated multiprofessional teams, treating patients and helping them to access health and social care across the entire patient journey, they claim.

Alun Morgan, head of physiotherapy services for Cardiff and Vale and CSP Welsh board Council member, says this is because physios are used to working across the continuum of health, social, acute and very specialist care.

He sees new roles for physiotherapists in the community as ‘specialist generalists’, bringing a wide expertise and managing many different clinical conditions.

‘We will still need to have physio establishments in hospital as well as out in the community, for a complex case mix of patients,’ Alan Morgan says.

There are also opportunities for physios to play a strategic role in shaping services, as LHB directors of therapies and health science and as advisers on the professional and stakeholder reference groups, says CSP policy officer for Wales Philippa Ford.

'At the moment physio services do engage with their patients but they don’t necessarily engage with citizens, with people outside of the services who have a community interest in what the LHB is delivering,’ she says. ‘So there’s an opportunity here for physiotherapy as a profession to be really engaged with the community in a way that perhaps hasn’t happened before.'

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