The Welsh Liberal Democrat Assembly Group’s Response to “Improving Health in Wales – Structural Change in the NHS in Wales: A Consultation Document”
This
is a response to the Consultation Document by the Welsh Liberal Democrat
Assembly Group.
We
welcome the opportunity to respond to the document and have consulted widely in
drafting this response. The right NHS
structures are essential to enable the improved delivery of health care in
Wales.
We
trust that the Minister for Health and Social Services will take into account
the views presented to her.
It
is the hope of the Welsh Liberal Democrat Group that the Minister will publish
the responses to the consultation document to ensure that a full and public
debate is possible with all the evidence readily available.
We
support the guiding principles articulated by the Structures Task and Finish
Group at their first meeting:
Simplicity
– the new structures must be easy for all who have contact with the system to
understand;
Democracy
– the new structures must be more open
and transparent for all those who wish to participate in or scrutinise the
system;
Accountability
– the system needs to be one which enables all to know what is expected of them
and lines of accountability must be clear and capable of being monitored.
In
addition we believe that the principles guiding change should include
effectiveness, efficiency and partnership.
Also, change should be clinically-driven and patient-focused.
The
Welsh Liberal Democrats’ support for restructuring depends on structural
changes delivering improved quality of care and services for the patients of
Wales and on allowing all NHS Wales staff to work in an atmosphere that values
their contribution and enables them to utilise their skills to their full
potential.
We
believe that one health authority responsible for the strategic commissioning
of key services should be created to develop into a Health Commission for
Wales. This body would be responsible for commissioning tertiary services and
providing All Wales strategic management and would be at arms length from the
Assembly but accountable to it and scrutinised by it.
The
time-scale for structural change is a matter for concern and we have doubts
regarding whether it is achievable. The
implementation date of April 2003 appears unrealistic. Linked to this, structural change must take
account of the need for stability in regard of services and the
work-force. Care must be taken not to jeopardise
other policies designed to improve the quality of care by making key staff take
their eye off the ball. We suggest that
slowing the pace of change will allow for greater stability.
Currently
Health Authorities make resource allocation decisions in public at meetings
open all. Under the proposals set out
in the consultation document the NHS Directorate Health Economy teams would
arbitrate “…in disputes between members of the Consortia in the content, range
and resourcing of service level agreements and in disputes between the
Consortia and their providers.” As the
NHS Directorate is not directly publicly accountable and presumably the
arbitration would take place behind closed doors then this represents a
potential lessening of Democracy within NHS Wales.
The
strengthening of LHGs into Local Health Boards (LHBs) in order to ensure better
local input, local solutions to local problems and more local democratic
accountability and openness is a proposal we welcome. We also welcome the coterminosity of the proposed LHBs with the
22 local authorities – we see this as key in terms of joint working with social
services. We are in favour of the
proposal for a new statutory duty to be placed on LHBs and local authorities to
work together in order to develop and implement Strategic Partnerships for
Health and Wellbeing.
Do you have
any other suggestions for a title?
Local
Health Board conveys the right message of responsibility for the local health
service but the word “Board” sounds old-fashioned.
Do you think the
above accountabilities are appropriate for the new Local Health Boards?
In
principle we would agree that the accountabilities are appropriate. As LHBs will be locally rooted they should
be more responsive to local health needs and therefore be the best agency to
deliver a local health service.
What is your view
about the role of LHBs in the provision of community health services?
Whilst
supporting Option Three we recognise that in doing away with the
purchaser/provider split in the community setting we have to ensure that there
are mechanisms in place to ensure quality levels and improvements.
What is your view
about the commissioning and provision of mental health services at local level.
There
is concern especially amongst users that mental health will not be given the
prominence and attention that it needs.
Whatever is decided, mental health services need to have a high profile
and must be adequately funded.
How do you
think the strategic partnerships should be structured?
There
would have to be more detailed consultation on this involving the input of
Local Health Groups, Local Authorities, Local Health Alliances, the voluntary
sector and community groups.
Do you have
views on the commissioning of secondary care services by LHBs?
It
would be appropriate for some secondary services to be commissioned by LHBs.
Do you have
views on the proposed consortia arrangements and the arrangements for securing
high quality support services for LHBs?
We
are uneasy about the role proposed for Consortia for a number of reasons.
As
the proposed Local Health Board Consortia will not have statutory powers how
can it be ensured that they perform their role effectively? If they are given statutory powers then
Health Authorities would be reinvented.
LHBs
may also end up in Consortia to which they believe it is inappropriate for them
to belong. For example Powys could end
up in the Mid and West Wales Consortia which would not make sense when you take
into account that the majority of patient flow is to District General Hospitals
across the border in England or to Nevill Hall Hospital in Abergavenny and
hospitals in Newport and Cardiff.
If,
as proposed, one LHB in each consortia is responsible for managing one of the
shared services (Financial Support Services, Planning, Information Services,
Public Health, Professional Advisers, Corporate Support, Human Resources and
Estate Management) how will it be decided which LHB is responsible for which shared
service?
Financial
accountability is a matter for concern.
Current financial control over the £3 billion health budget in Wales
rests with the Health Authorities. It
is important during the proposed structural changes, to maintain strict control
of expenditure and to establish robust audit trails to ensure budgets are kept
within and that budget deficits do not occur.
We
feel that the creation of one Health Authority to develop into a Health
Commission for Wales as outlined in our General Comments section would be the
best way to dispense with the need for Consortia and the problems associated
with them.
What would you
suggest as the upper limit on the number of Board members if Boards are to
function effectively?
The
number of Board members would have to be representative of the different NHS
professions, the public and the voluntary and community sectors as well as
include a number of local councillors.
For
the Board to be truly representative of all interests it could have around 16
to 20 members. Obviously this would be
too large to provide effective, decision-making local leadership. Therefore, there is perhaps a case for a
larger council or forum that the Board would consult.
What would you
suggest as a balanced and appropriate membership for Local Health Boards?
Local
Government should be represented on LHBs at officer and councillor level.
In
light of the make-up of the Local Health Group (LHG) Executives it should be
ensured that there is a place for a nurse and a PAMs representative on each LHB
Executive.
It
is also important to ensure that proper training, support and induction
services are available to those members who may feel intimidated by the
expertise of clinical professionals.
Do you suggest
any specific mechanisms for the election of non-local government members of
LHBs?
Election
mechanisms should be open and transparent allowing the maximum number of people
to put themselves forward and to vote.
Do you have
views or suggestions on the role and organisation of the NHS Directorate and
its relationships with LHBs and NHS Trusts?
The
NHS Directorate should remain responsible for policy and it should be made
clear that there is no management role for them. All Wales strategic management should be under-taken by a Health
Commission for Wales.
What are your
views on the organisation development programme and the issues it should
address?
The
key is to ensure that stability and services are maintained and not
disrupted. The anxiety and concern
about structural change felt by many who work in NHS Wales must be recognised
and the pace of change must be gradual and of a consultative consensus in order
to take account of this.