Features: All change for NHS Wales
25 May 2009
The NHS in Wales is undergoing wide-scale restructuring that will replace all trusts and local boards with seven new integrated health boards.
The NHS in Wales is undergoing wide-scale restructuring that will replace all trusts and local boards with seven new integrated health boards. GMCtoday asks what the changes will mean for patients, the profession and for the health service in Wales.
In April 2008 the Health Minister, Edwina Hart, announced the proposals for a major change in the structure of the NHS in Wales in order to reduce bureaucracy and improve patient care throughout the country.
The new structure follows the signing by the coalition Labour/Plaid Cymru Government of the One Wales document which contained a commitment to abolish the internal market in the Welsh NHS. A threemonth consultation period followed in which people from across Wales were invited to respond and share their views.
A second consultation on the governance arrangements for the new health service closed in February this year and it is expected that the seven new Local Health Boards will commence operation in shadow form this June.
The changes herald a unified health organisation, with executive responsibility for health being vested with the seven NHS local bodies at a national level. The new structure will be made up of two main bodies: a National Advisory Board and a National Delivery Board. Primary and secondary care (NHS Trusts and LHBs) will be merged into seven strategic Local Health Boards.
Views from Wales
Dr. Tony Jewell
Chief Medical Officer for Wales
At present, we have two distinct NHS bodies in Wales: the Local Health Board as the commissioner of services; and the Trust as the provider of those services. That means two separate teams working on the same issues but from a different perspective – this is unnecessary duplication and wasteful. We have the transactional costs of a market structure but these bodies are not operating as market-run systems.
One Wales committed the Welsh Assembly Government to ‘move purposefully to end the internal market’ in order to improve services for patients. The end of the internal market in health is part of the wider Welsh Assembly Government determination to make co-operation, rather than competition, the bedrock of public service delivery in Wales.
By reducing the numbers of NHS bodies, we are significantly slimming down these structures. We will have one NHS body with responsibility for what were previously two functions – this must improve efficiency in practice. The number of organisations will reduce from 31 to nine.
The new NHS structure has been developed around the benefits that will flow from a much simpler governance system, which provides for higher levels of integration across service sectors, and ultimately improve patient care.
This programme of work is not simply about changing organisational structures, but about ensuring that these new organisations are fit for purpose. These seven new LHBs must focus on:
- changing behaviour not structures
- collaboration not confrontation
- planning not commissioning
- whole systems not hospitals
- clinical engagement
- partnership working
- wellness not illness.
The importance of clinical engagement is reflected in the job description of the Chief Executive. The LHB model was chosen over the trust model for the new organisations to underpin partnership working. The statutory duty to formulate and deliver health, social care and well-being strategies and children and young people’s plans with local authorities will remain. In addition, the importance of working closely with the third sector in delivering services will be vital to the success of these new organisations.
One of the most important challenges and priorities is to ensure that business continuity is unaffected during the transition period. To address this, we have appointed seven Transition Directors who are now working across all organisations within the proposed new communities to ensure a fully joined-up approach to managing in-year pressures. The new Chief Executive appointments have been made and the shadow health boards will start in June.
In addition to these main changes there are also plans to create a new Public Health Trust to bring together the National Public Health Service and the Wales Centre for Health. Consultations are also under way to consult on Community Health Councils, alignment with the new LHBs and to host national specialist commissioning with one of the new LHBs.
Carol Lamyman-Jones
Director, Board of Community Health Councils
Community health councils in Wales are the statutory, independent voice of all citizens within the NHS. They are actively engaged in continuous dialogue through their communities and are one of the major conduits for gathering and cascading information from and to local communities. The confidential, independent complaints advocacy service offered to the public by CHCs provides the NHS and other bodies such as the GMC with trends in patient/public experiences of services; this includes the performance of primary and secondary care practitioners.
The NHS in Wales is going through a time of tumultuous change and it is essential that the CHCs, in holding the NHS to account, have their powers of scrutiny strengthened by the Minister for Health and Social Services.
Currently, the NHS is composed of two separate entities: Local Health Boards, as commissioner of services, and NHS Trusts as the providers. The new combined structure will make better use of resources and avoid unnecessary duplication. The CHCs in Wales will play a vital role in each community, allowing the public a voice to seek answers to questions surrounding the development of the new LHBs.
The CHCs and, in particular, the Board of CHCs, intend to work in more formal collaboration with essential regulatory bodies like the GMC to monitor and observe services so as to ensure safe, equitable practices for the citizens of Wales.
Dr Malcolm Lewis
Wales GP, Director of Postgraduate Education for General Practice and GMC Council member
There is an appealing logic in reducing the number of LHBs from 22 to seven. This should ensure greater consistency within and between LHBs. The integration of service delivery into a single system, including primary, secondary and tertiary care, makes a lot of sense in terms of working towards linear and continuous care pathways for patients.
The increasing shift of aspects of care from secondary to primary care and intermediate care, as well as a move from the traditional model of service delivery in hospitals, should all be facilitated by the reorganisation. Rationalised management structures should lead to a more equitable approach to the healthcare professions, whether employed by or contracted to the NHS.
This new environment will need to have in place robust systems of clinical governance. A priority in this context will be to ensure that the LHBs each have reliable systems of appraisal and clinical governance.
Having a reduced number of LHBs should make it easier to ensure consistency of standards and delivery across Wales. In fact, general practice in Wales has already developed single systems of practice-based clinical governance assessment (an electronic toolkit), a single system of performance management and a single web-based system of appraisal for all GPs in Wales.
The Health Minister has recognised that where strong systems are in place, these should not be lost as we move into a new NHS structure. There is also a possibility of the previously separated appraisal and clinical governance models in primary and secondary care moving closer together in a structure that should allow and encourage sharing of best practice.
In terms of regulatory oversight, Healthcare Inspectorate Wales will enjoy a simplified process of quality assurance if the new organisations are able to work to a consistent set of standards. In turn, the GMC will be able to build confidence in the recommendations to revalidate doctors as these come through in due course from local Responsible Officers or Medical Directors.
It is worth noting that we have always been in cycles of change within the NHS in Wales (in fact UK wide) and that sometimes the changes reflect political rather than purely operational motives. Let's hope that this latest set of proposals are given adequate time to bed down and deliver an improved NHS in Wales.