A personal reflection on the structural changes in health and social care in Wales

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

This week’s blog is by another long-term friend of WIHSC, Tony Garthwaite, Senior Fellow at the Institute. Many readers will remember Tony as a leading figure in Wales’ Social Services, when he was Director of Social Services and a Corporate Director in Bridgend, and led a fundamental review of the future workforce needs of Social Services in Wales. This week he looks at what is needed to effect a similarly fundamental reconfiguration of health and social care here, and does not seek to avoid controversy. Tony will be speaking at WIHSC’s 20th anniversary debate in Cardiff City Hall on 26th November.

A personal reflection on the structural changes in health and social care in Wales

WIHSC’s 20th anniversary provides a timely opportunity to offer some personal reflection on the history and impact of structural changes in health and social care in Wales since 1995.

There seemed to have barely been time for the changes of the 1990 NHS and Community Care Act to have bedded in when in 1996 along came local government reorganisation and the creation of 5 strategic area health authorities. Health partners wondered how they would manage different relationships with multiple smaller authorities having previously enjoyed the relative convenience of co-terminosity on social services issues with the 8 Welsh counties. Social Services directors bemoaned the loss of scale in their strategic capacity brought about by the creation of 22 councils and wondered what risks the advent of relatively unproven unitary status would bring. The latter proved to be surprisingly beneficial in most cases as services like housing and environmental health were able to engage with social services under one organisational umbrella. The capacity issue, however, remained a problem as authorities competed for staff and lost much of their ability to appoint single specialist staff. Multi-tasking soon became the norm at the individual and organisational levels; not an entirely negative notion but dependent on logic prevailing over expediency when the combinations of functions were determined.

Along came devolution and co-terminosity returned to the central stage with the replacement of the health authorities by local health boards in 2001. Suddenly, far from being the problem, 22 was now the magic number. Trusts remained unaffected and new relationships had to be formed, accompanied by different platforms of power and influence. The commissioner/provider split was still there but in reality with very blurred edges. Derek Wanless’s reports helped galvanise thinking that prevention was better than cure as a strategic objective but the ramifications of any collective organisational change for health and social services were mostly treated with scepticism and fear.

Clear red water then flowed and the market split in health was subsequently abandoned in favour of the current 6 integrated health boards. Currently, a Local Government Bill opens the opportunity for mergers of local authorities while disagreements about the right number dominate the debate.

Through all of this change and uncertainty, health and social services leaders have been expected to navigate a path to ever greater integration. I’m not a fan of structural solutions to problems, and the research generally supports my position, but if we are to find a sensible way to achieve integration at scale and pace

maybe the time is right for health and local government to be organised on the basis that has some logic and rationale. The ingredients for this appear to be coterminosity and a scale which can provide a sustainable strategic response to the huge challenges ahead. This would suggest a reorganisation of local government on the NHS footprint – as controversial an idea as any other configuration but at least one that we can all understand.

By Tony Garthwaite, Senior Fellow, WIHSC


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