14. MEASURING WHAT MATTERS14.1 Politics can sometimes be dominated by political ping pong on the release of anew batch of health or social care statistics. Does the latest data indicate performanceis up or down on the previous month, is the change shown a “scandal” (a term usedfar too frequently), or is it an indication of a seasonal/temporary blip in service or acontested debate on whether the latest change really reflect a real concern at theoverall direction of travel? 14.2 The need for, and purpose behind the data we capture is important in that itshapes the political and public perception about the performance of services. It canhelp to provide critical indicators about the state of our services, but I believe we mustalso avoid perverse impacts. Our focus must always be on the right outcomes.So if wewish to reshape services, with a focus on wellbeing and not ill health, I believe weneed to more sharply focus on the right units of measurement. For example I notedthe ideas of the Stroke Association around emergency responses to stroke that focuson ensuring “the right vehicle takes patients to the right hospital for the right treatment inthe quickest possible time”. As a football fan it reminded me of the experience ofFrabrice Muamba who, following heart failure, was not taken to the closest hospital,but the centre that could deal with him best. 14.3 The Stroke Association in their paper explain how the current measure ofperformance is not best and they make the case for the emergency responsepathway. Counterintuitively they argue that stroke calls need not be ‘red category’ assending a vehicle as quickly as possible means an unsuitable vehicle may be sentwhich cannot take a patient to hospital. Such a debate, and the recognition of smartermeasures needs to be encouraged far more across health and social care. Gettingthe right response, to the right place, by the right people as soon as possible..Itunderpinned the recently published review of Amber Care in the Ambulance Service.   

Use the right measure14.4 In October 2017 Cabinet Secretary Vaughan Gething issued a Written Statement: “The NHS and social services across Wales gathers a wide range of data that is essential toprovide safe, effective health and care services. This vast collection of data means that it isimportant that we not only ensure that there are robust systems in place to manage datasecurely, but also make better use of data to improve decision making, plan change anddrive improvements in quality and performance”. The Statement of Intent is available on the Welsh Government website. (my emphasis in bold type above to stress this is a ‘vast’ activity but it must impact on‘quality and performance’ improvements – otherwise why do it?).

14.5 As the Statement of Intent says: “By making better use of available data we can improve decision making, plan changeand drive improvements in quality and performance. Beyond supporting the immediatecare of individuals, the sharing and use of data is essential as the basis for creatinginformation and intelligence to help those commissioning and delivering health and careservices to learn from what has happened in the past, understand what is happeningtoday, and to plan for the future”.

Data driving improvement

14.6 On 25th June 2018 the Welsh Government published a “Welsh health and carestatistics mapping tool”. It is an attempt to open up the availability of data bydifferent geographies and subjects. This is no bad thing given the ‘vast’ resource thatis used in assembling this data. 14.7 Yet as a member of the Assembly’s Health, Social Care and Sports Committee Ialso ask myself whether we actually spend sufficient time measuring and discussingwhat matters to patients? So the progress being made to produce a “national set ofgeneral experience and health outcome questions” which provide data to measurethe success of treatments and whether “outcomes are in line with what patientsshould expect to receive”. These patient reported outcome measures (PROMs) andpatient- reported experienced measures (PREMs) are a welcome next step: “What are PROMs? Patient Reported Outcome Measures (PROMs) are a systematic way for you to tell usabout your care, experience and health status. They help us monitor your progress andprovide strong evidence on the effectiveness of care and treatment. They can also be usedto: a. Help you and your clinical team decide what care is best for you; b. Compare performance across hospitals and health boards; c. Help us plan future service developments”. 14.8 To be clear this question about the measurement of quality applies across arange of activity in the public and private sector, not just health and care. 14.9 I also recognise that a journey is already underway and perhaps the politicaldiscourse needs to mature to reflect this. Just for example I was also contacted by alocal teacher about the measurement of success in schools and performancemeasures is often a contested area of discussion. The data we gather, and how it isgathered, is critical. But how we use it is as important. 

14.10 It can be clearly evidenced how this data relates to key “targets” e.g. waitingtimes for specific treatments or to frame a view on the performance of elements ofthe service e.g. ambulance response times. 14.11 For me this whole thought process stems back to an earlier experience inwhich I was involved in debating ambulance response times. At that point, some fiveyears ago, I was a trade union official and we could see that the, then, measure of“success” (then the 8 minute response time target) was a blunt instrument thatcould act as a disincentive. It was in fact having a demoralising impact on hardworking front line staff. That was what I call a perverse effect. The key measuremade little sense and it was in fact hindering important discussions aboutdeveloping a modernised and more responsive ambulance service. That specificdebate is now well rehearsed and was part of the move to the change in how wedeliver the ambulance service, and how we measure performance. It is a modelother countries are broadly following. The recent review of Amber calls has upheldthe model as an improvement.  14.12 Of course this change does not remove the challenges facing the service, andthe nature of the critical decision now to be made about categorising incoming calls.However in refining the performance measurement, we have helpfully movedbeyond a rather blunt measure to something more meaningful that seeks to helpget the right response, to the right place as soon as possible. 14.13 As a result of the new social services legislation there has been a widespreadreview of the “Performance management framework for local authorities” with apurpose that includes to “enable people to understand the quality of socialservices”. “Well-being is to be measured nationally by the national outcomes framework for peoplewho need care and support and carers who need support[1]. This will contain nationaloutcome indicators of well-being that all services and people themselves will contributeto. These national outcome indicators will be reported on by the Welsh Government andwill provide greater transparency on whether care and support services are improvingnational well-being outcomes for people in Wales”. “In relation to social services, qualitative data will detail a person’s experience, includingtheir satisfaction with care and support. The measures developed include asking peopleabout their experience of social services and whether this has contributed to improvingtheir well-being”.

Social care performance

Inputs, Outputs and Outcomes

14.14 We gather data to help inform our decisions and assess progress/changeover time. Data gathering can take many forms but in my experience the politicaldebate has traditionally tended to primarily focus on ‘inputs’ and ‘outputs’, andonly more recently to the critical issue of 'outcomes'. The inputs and outputs haveprobably been a focus as they are critical indicators of how our money is beingspent. In a financially driven system how many nurses, carers, police, teachers etcare employed has been seen as a key indicator, and a determinant of output(number of operations performed, crimes tackled etc.) But that is less useful datain assessing the outcome from all the activity we fund. 14.14 Critically for me, if we want to build our health and care system around theprinciples of being patient/client centred then the ‘outcome’ they experience –their well-being is surely THE most critical thing. It is possibly also the mostdifficult thing to manage when the focus is squeezing activity out of restrainedbudgets.

15. WORKFORCE15.1 Everywhere I have been there are conversations around the health and careworkforce. Sometimes discussion around a simple lack of numbers, sometimes alinked discussion around the levels and costs of Agency staff time, or perhaps theappearance of a gap in a specialist service. I noted that the Association ofDirectors of Social Services highlight the problems of recruiting care workers todeliver community based services. 15.2 I also had more positive conversations about retraining, or expanding theskills base of existing staff to meet new demands or to employing different mixesof staff to expand a service. We know there has been some success with recentrecruitment campaigns in Wales and as a former trade union official I always feltmany of the solutions lay in empowering and improving the skills of existing staff.     15.3 A project like this obviously cannot set out to solve these issues. It doeshowever help to point to the critical issue of workforce planning. It highlights tome the need to invest in training and recruiting the differing mix of personnelrequired over time. 15.4 It is also why some of the ‘new’ money that comes in to our NHS and caresystems must now be used to pay and reward staff. Austerity pay freezes donothing for morale and in fact damage recruiting and retaining staff. This damagemust now slowly be undone. 

15.5 However these conversations about the workforce again reflect the title I havechosen for this report – no one is bystander and everyone is an ally. As many staffas possible across our health and care systems must be skilled up to the maximumlevel possible to use their skills and knowledge. One example that struck me indiscussion with Caerphilly CBC. The NHS provide District Nurses to visit patients athome, and the Council provide a domiciliary care. In some cases I believe some careworkers, offered more skills training, could do some of the routine ‘nursing’ type oftasks and free up the time of District Nurses for the more demanding and complexwork. 15.6 I recognise that this gives rise to all sorts of practical issues as people fromdifferent organisations, carrying out similar roles, come to be co-located/integratedand have different pay rates, terms and conditions and regulations. It is for thesocial partnership between trade unions and employers to resolve these issues. 15.7 There is no shortage of work, but we may need to change the skills mix of staffto meet the demands. I met local trade union representatives who took a verymature view of the need to integrate health and social care staff. I was howeverasked the question - "what do you mean by integration?", as it was pointed out theword is used frequently, but is far less frequently defined. If we are to integrate itleads to some tough questions about disparities in pay, conditions and workingarrangements. To often it leads to co-location of the workforce, but not trueintegration. We need talk less about hospitals and doctors - and unlock the potential ofallied health professions and other staff groups to make the system moresustainable. 15.8 Too much of our political discourse revolves around hospital services and‘doctors’. I hope they don’t take offence at this thought, but our focus – driven by thenew national strategy - has to be on running a community focussed wellbeingservice, not just a medical response to ill health. 15.9 My local survey (Appendix Four) suggests that one of the most concerns thatpeople express is the ease of access of making appointments in primary care, butwe must also accept that “seeing the doctor” is not the solution to many issues.There are a range of social situations in which the necessary support can come frompeople other than the GP. The work of allied health professions is vital to thischallenge. I was pleased to take part in a recent training day for them: OccupationalTherapists, Physiotherapists, Chiropodists, Podiatrists, Social Workers, Speech andLanguage Therapists, Pharmacists and Radiographers can all contribute more tohealth and care and we must unlock that potential.

16.1 The majority of the time we can celebrate the achievements of our Welsh NHS, forexample see the recent annual statement on quality in our Welsh NHS.  The Welsh NHSalso has significant national programmes, such as 1,000 lives, to help improve thequality of health care. Our social care system is inspected by Care Inspectorate Walesto maintain and drive up standards.   16.2 However given the scale and range of activities undertaken in our Welsh NHS andcare systems it is inevitable that some things will go wrong. It is perhaps unavoidablethat all systems driven and delivered largely by humans carry such risks. In both ourhealth and care systems we therefore need the checks and balances, whether that isthrough lines of managerial/professional accountability, or the analysis of the data wecollect, or in the role of bodies like Community Health Councils or Inspectorates. 16.3 I had a meeting with representatives of Cwm Taf CHC to discuss their approach tosecuring the patient voice in the shaping and delivery of services. It was good to hearhow CHCs across Wales have been able to develop common themes for their localreviews of services. This certainly adds value to their work. For example in the “OurLives on hold” the CHCs across Wales pooled knowledge to “capture the impact that longwait lists have had on a range of people across Wales”. The CHCs also reported on “Thefragility of GP Out of Hours services in Wales”.

16. WHAT TO DO WHEN THINGSGO WRONG

16.4 Yet in accepting that things will sometimes go wrong, whether in falling short of astandard of care expected, or in that recommended by expert bodies, or whether inproblems that occasionally lead too far more complex situations that can involvepolice and other inquiries,  there is a need to: a) Be open about the mistakes, b) Review to learn lessons, c) Apologise/compensate where that is necessary, d) Correct going forwards, e) Ensure robust follow up. 16.5 Where possible I favour a culture of 'learn and correct' rather than 'blame andlitigate'.In my experience it can sometimes be the process of litigation, that may wellinvolve insurers, which can close systems down rather than open them to earlylearning. These steps should be taken as quickly as possible. During this review I havelooked at least one situation that, due to circumstances, is continuing many yearsafter the initial events. In some cases it can prevent closure for those involved withtraumatic cases. Again we must continually work to minimise system weaknesses thatcan leave people feeling isolated and let down. We must also ensure robust follow upto recommendations for improvement.

17. THIRD SECTOR EXPERTISE17.1 During my visits I have seen the knowledge and expertise that sits withinvoluntary and third sector groups. I am not sure it is fully appreciated, but thesevaluable resources of people and knowledge in this sector have to be a key part ofimproving support in our community. There are undoubtedly stresses given theebbs and flows of funding sources e.g. lottery and EU funds. So we need tostrengthen the tripartite relationship between health, care and voluntary sectorsto make best use of their expertise and resources. 17.2 One contribution that I found of interest was the support given to empowerthe voices of patients and users of services. I believe that empowering groups inour communities is important to help tackle the social gradient written aboutelsewhere in this report. Given the significant challenge posed by the determinantsof health in the constituency we must help to raise more voices so that we avoidthe most voicefous and best organised being heard the most. 17.3 Empowering patient voices can play a part in the checks and balances werequire to help sustain patient/client centred services and in quality controls. Iread with interest the work undertaken with Big Lottery funding by GAVO on"Community Voice". For example in the Caerphilly project around People First aparticipant reports: "I now feel like I can make a difference and my opinion counts".    I was pleased to join RCT Interlink as they helped the People First group in Merthyrto reform and ensure voices are raised in terms of patient expectations andexperiences.    

Meeting the reformed PeopleFirst group at VAMT as they

discuss working with RCTInterlink

17.4 One issue I noted with the current wave of 'innovation' in NHS and care isthat there may be some overlap with existing voluntary service offers. I cameacross a range of job roles: Co-ordinators, Prescribers, Support Officers etc whoseem to be doing roles with similar objectives but from different settings. Iraised a question with the Cabinet Secretary for Health as this needs to bequickly ironed out and a reasonable degree of consistency established acrossdifferent areas. As always there is a balance to be struck between models ofinnovation and the local delivery of these services. But given the apparentsuccess of GPSOs in helping to manage pressures on GP surgeries, then weneed to ensure a deep and full engagement with existing voluntary services tohelp ensure services are planned and delivered in response. 17.5 I was clearly struck by the 'demand' from voluntary bodies to access spacein GP surgeries as this provides for ready responses, and can help to managethe problem of referrals and delays for non-medical support. There is clearly alimit of time and space, which GPSOs are partly filling so perhaps this part of thesystem: voluntary and third sector support along with staff such as GPSOs needunderstandings, even possibly short concordats, on who does what and best.     Volunteering17.6 I also recognise the enormous contribution of volunteering in a community likeMerthyr Tydfil and Rhymney. In so many ways that are too numerous to detailpeople give of their time, knowledge and energy to help make our communities abeter place to live. I thank them all. With Gerald Jones MP we run a small schemecalled 'Community Stars' I am always impressed by the record of service that manyof those recognised can show, often untold and unthanked. 18.7 We should always think about encouraging people to volunteer - and it also apositive way to deal with other issues like social isolation, mental wellbeing, return tothe labour market etc.

Volunteering at the Marie Curie shop in Merthyr Tydfil

18. FINDINGS18.1 I became apprehensive in reaching this section. I had to question myself onwhether a project such as this is able to make sensible findings across such awide range and depth of activity such as our NHS and Social Care services inMerthyr Tydfil and Rhymney. So I do not include every previous section in myfindings. 18.2 The data gathering and research for this written report was concluded on8th November so as to allow me to complete my thoughts on the key findingsfrom the work on local health and care services in Merthyr Tydfil and Rhymney.Even as the project was ending there was an Assembly Committee report whichhighlights the significant challenges facing the Welsh NHS in providing a responseto the needs of our digital age. I have little doubt that I will continue to gatherexperiences in the months ahead, but I drew the “drill down” to a close on thisdate. 18.3 Earlier this year I wrote a piece for the Welsh Fabians about Wellbeing stateof Wales, and how wellbeing might be reflected throughout Welsh Governmentpolicies. It formed part of a discussion prompted by Jeremy Miles AM about whata modern day successor to the welfare state might look like. I was interested toread a recent response which discussed wellbeing in all decisions and arguedthat “the words we use influence our thinking”.  18.4 I believe that we must still make the big cultural change from our Welsh NHSbeing seen as an ill health service to becoming ever more a wellbeing service.This is a continuous journey. Though I sometimes fear the Welsh NHS is toostrong a ‘brand’ to be able to change people’s outlook/attitudes towardsit. However given its prominence in our national psyche it needs to go evenfurther in promoting a wider message and I would suggest it is consistently sub-branded along the lines of:    NHS Wales The Wellbeing Service for Wales 18.5 There is a need to consistently reinforce the real purpose and overridingpriority of our health and care system: to promote our wellbeing and not justtreat ill-health. The direction of the new Welsh Government strategy is correct,but we must all go further to support its delivery and to reinforce the wellbeingobjectives.

a) Promoting a Wellbeing service for Wales Noone is a bystander - everyone is an ally

b) Mental health and wellbeing 18.6 Sadly too many people are taking their own lives and we must continue tostrengthen our efforts to tackle the stigma around mental health. Yet the mostimportant solutions may well lie in increasing/improving low level interventions sothat we prevent problems from escalating. The work of organisations like ValleysSteps is interesting as it helps to build personal resilience, as do the services of arange of other mental health charities and organisations. 18.7 I am very hopeful that the new 'innovation' projects like GPSOs etc can helpdirect more of the people who choose to visit the GP to more appropriatesupport. However this will rely on voluntary services and others having adequateand planned capacity. Again we are back to the need for a whole systemresponse. 18.8 I see a lot of discussion around the importance attached to the 'ring fencing'of mental health spending. However I am not much clearer on whether this fact,in itself, relates in a meaningful way to the outcomes we wish to achieve. 18.9 The mental health system in Cwm Taf provides for a 'walk in service' ifneeded at times of crisis. However the key concern is around the delays in accessto treatments, and through the Assembly Health Committee I hear the evidencearound the investment in services and the ongoing concerns such as having a better understanding of the increased demand for CAMHS services.  18.10 Mental health and wellbeing arose in so many situations that I willcontinue with my work to understand how best we can improve the wholesystem response as we go  forwards, seeking to make a reality of thepromises around parity of care betwen mental and physical health.

c) Housing and health18.11 I maintain an active interest in housing issues, especially the housing needsof people who are vulnerable and need extra support. I have a basic political valuewhich tells me homelessness is a blight on our society and we need to act to helpthose affected. Any effective intervention that we can make will also reducepressures on health, care, policing and justice systems by reducing the morechaotic situations from arising. Housing has to remain a high priority for Welshand local government and so I was pleased to play my part in the campaignaround protection for supporting people funds during the period of this project.  18.12  Yet again I have been struck of the potential available through the furtherstrengthening of low level interventions. Social landlords have direct contact withthousands of people and already signpost and support individuals. I want toexplore what further potential exists for early intervention in this sector.  

d) Social care - the undervalued partner

18.13 So much of the research around health and social care speaks to the needfor a whole system response to resolving some of the pressures we face. Thisproject has led me to the view that I need to give social care moreconsideration. There is some increasing success in providing the social carepackages that people need to get them out of hospital. While that is effective forindividuals, and probably better for their health, it does not save money as theNHS bed is filled by the next patient. It does help with waiting list pressures butthere is the cost of domiciliary care for the person who has left hospital. Truecost savings will come from social/community care that reduces the pressure ofentries to our hospitals, and there are many and various reasons for that. 18.14 So in addition to recognising the real contribution of social care it is goodto see the success of projects like the "virtual ward" and "Stay Well at Home" It iswhy we must also keep promoting schemes like "Choose Well" so that peopleuse an appropriate location for their health needs and do not just think aboutthe hospital or GP. My survey suggests we can do more to promote awarenessof "Choose Well". 18.15 Likewise it is the GP and related services in our GP clusters that must playan ever stronger role in keeping pressure off secondary services.  

e) Conditions18.16 I thank all those individuals and groups who take the time to explain theneeds relating to their conditions. This gives rise to both heartbreaking, andamazing, stories about progress and success. This along with my survey makesme reach a view that:  a) by and large people are generally satisfied with the support they receivewhen they access a service/treatment for their condition, and b) they are treated with dignity and respect, but    b) the wait to receive specialist advice/treatment sometimes takes longer thanthey wish. Some groups suggest people may stay  in hospital too long, whichcan become acute if it depends on adequate social care packages.  18.17 We must keep strengthening our focus on the whole pathway from thespeed of diagnosis to treatment. In some conditions early diagnosis isimportant so I will be looking at how this can be achieved, which includes therole of the more specialised centres which I still believe are needed to helpprovide the necessary capacity. This is often resisted but I believe furtherprogress is required.

f) Boundaries should not be barriers18.18 I suspect very few will argue with this statement and yet the complexity ofour organisations and systems means it is too often the case. We have to keepworking to make sure that boundaries are never excuses for adopting, adapting,spreading and maximising the opportunities for consistent and best practice. Thismust be increasingly true in our digital age. To see, and learn more about thenumber of different systems within different parts of our health and localgovernment systems is staggering. Yet without care I fear that it reinforcesprofessional, political and cultural barriers.  18.19 Part of the solution here lies in more clearly defining what we expect of'integration' between health and care. I find examples of services being co-located,perhaps sharing the same building, but I am not clear on the evidence about thedegree of integration. It is encouraging to see transformation funding beingdirected to this issue. In ensuring care workers, district nursing services and otherscan be truly integrated this work needs strengthening further.  g) Technology is an asset

18.20  Technology and the growth of digital services has to be simply viewed asan asset for more productive care and health services. There has very recentlybeen criticism of the pace of change in the Welsh NHS and that will be for theWelsh Government to consider. Indeed the recent criticism reflects similarconcerns expressed about the English NHS: "Technology has the potential to deliver significant savings for the NHS but the servicedoes not have a strong track record in implementing it at a scale and needs to getbetter at assessing the benefits, feasibility and challenge of implementing newtechnology".  18.21 I did however visit some local examples of the use of technology that isprogressing digital records to replace paper records, and in maternity services.Both were examples of technologies that could be spread across the wholesystem after completion of pilots and validation. 18.22 However even at a simple level, like making GP appointments, it seemsvery strange that in 2018 this cannot universally be undertaken by computer tohelp reduce frustrations of patients seeking appointments.  I find that technology is an ally to effective health and we must accelerateits use in these services whenever possible/appropriate. 

h) Measuring what matters18.23 This may seem a somewhat dry and technical issue but I find it to be veryimportant in the perception of our health and care services. If we are to trulydeliver person centred services then we must increasingly focus on measuring theoutcomes we achieve. I first become interested in this debate when I was a tradeunion official involved with negotiations about the performance of the WelshAmbulance service. It was plain to me that the wrong measures were used andafter considerable debate, and some opposition, we moved the service to a moresensible measure of success. I would now summarise this as getting the rightvehicle, with the right staff, to a person who needs it most, as soon as possible. 18.24 Yet I believe we persist with other rather less meaningful measures ofperformance e.g. 4 hour target in A+E services. I see little evidence that this targetrelates to a meaningful assessment of the role of accident and emergency inresponding to those very serious incidents, and is not just a measure relating to aroom of people who don't need A+E, but couldn't access a community service. Ourmeasures need to smarter and focussed on outcomes. I will maintain my interestin this debate.  i) Inequalities of health 18.25 Underpinning much of this local "drill down" in to local health and careservices are the undeniable forces of the health inequalities faced by communitiesin this constituency. As Dr Chris Jones said in 2016: "Simply by growing up in a poor area of Wales, a child is more likely to have poorerhealth that will impact the rest of their lives". 18.26 Chris Jones also made the point: " These examples do make the separate pointthough that poverty or low socio-economic status does not necessarily mean ill health.despite the clear socio-economic gradient for the risk of obesity, most children in themost deprived areas are not obese." As a result the Chief Medical Officer stated: "Addressing the social gradient throughout a person's life will not only help to improvean individual's health and wellbeing, it will also help to reduce the overall demand forhealthcare services in Wales". 18.27 I am pleased that the Bevan Foundation are currently looking at healthinequalities, and I will look to learn more from the studies of health inequalitiesundertaken by students at the Keir Hardie health park. As my report states we must get a better slice of the cake to tackle thedeterminants of health that we face.

19. CLOSEThank you to those who have read this far! 19.1 Our NHS and Social care services matter to so many people. They are thesubjects that are hotly contested - there are ideological tussles over the nature andform of delivery for these services. NHS Wales and NHS England are followingdifferent models though sharing many similar challenges. 19.2 The final point I reach is one of democratic decision making. In the course ofthis short project I have heard and read about the need for more resources: - in primary care to boost GP and community services, - in local government for care and social services, - in the out of hours service so we help hospitals, - in hospitals so they have more bed capacity, - in drugs for cancers and other rare conditions, - in technology to transform the system, - in community mental health care, - in workforce development, - the top issue for residents in my online survey,  - to end austerity and to make reasonable pay awards for staff. 19.3 Together they would require billions of pounds extra per year. All these callsfor extra funding are probably valid in their own terms, yet we see little prospect ofthose funds being available in the short to medium term. The real average termgrowth for health set out in the recent UK Budget (3.4%) is lower than the historicaverage (3.7%) going back to 1949 and much lower than the average increase from1997-2010 (6%).  (source IFS - "The end of austerity?")   19.4 That is why we have democratic decision making structures. It is the way inwhich we resolve all these conflicting demands, and in turn the Welsh Governmentcan be judged on the priorities chosen. That neatly takes me back to chapter oneand the importance of delivering the new health and care strategy for Wales. Thatis the priority framework on which we will be judged in the coming years.  On the following pages you will find the appendices which have been referred toearlier in this report. This includes a summary of responses to the survey completedby constituents. I chose to use the survey for "signals" about issues in which I shouldtake an interest. As I have stated at the outset this report is not an academicallyrigorous study and the survey is not sampled or stratified in any way to reflect thelocal population.

Democratic decison makng

Appendix one - activities undertakenThis schedule summaries the range of activities undertaken during my review of localhealth and social care services. Occupational Therapy services – Cwm Taf Opportunity to learn about the differentrole of OTs as part of teams driving service changes.  GP Support Officers (GPSOs) It’s not all about the GP - a trial in six surgeries acrossMerthyr Tydfil providing advice and support to patients, which helps take pressure offGPs.    Roundtable discussion with third sector organisations – VAMT. Emphasised thevalue and professionalism of the sector and its role in signposting and providingsupport in the community.  Roundtable with providers of mental health services Helped explore the range ofservices that are available and the importance of emotional wellbeing Discussion with users of mental health services Interesting insights to therecovery process.  Attended “Talk to me 2 “ workshop - Agencies in Cwm Taf working together onsuicide prevention and reduction of self-harm. ‘Fit and Fed’ scheme Visited 100 children who were enjoying the Summer schemewhich helps support healthy living and provides a meal.  National Exercise Referral Scheme (NERS) and Leisure Trust wellbeing work Visit toleisure centre and saw the variety of activities offered to improve fitness andwellbeing.  Cwm Taf CHC - Met Chief Officer and board members to discuss role of patient voicesand service reviews they undertake.   Volunteering in Marie Curie shop - Opportunity to learn about their activities andthe importance of end of life care. Parkinson’s cafe - Visit to discuss issues relating to the condition. Meetings about various conditions Epilepsy, dystonia, cystic fibrosis. Dentistry visit (Carried out before recess) Talking about changes to contracts andoral health priorities.  Optometry visits-  In Rhymney before recess and in Merthyr to considerdevelopments in optometry. Mental health – policing and custody Really interesting discussion about how thepolice deal with mental health issues, duty of care and places of safety.  Local exercise group in Rhymney - Self-organised group to talk about health andcare issues in Rhymney. Visit to Prince Charles hospital - To be shown around the over £130 million ofcapital spend and present the NHS70 cheque to the hospital.  Visit to Prince Charles physio unit -  Meet patients in rehabilitation group and learnabout future service developments.

Visit to Ty Gwaunfarren , Gurnos Stroke rehab and support/social group Visit to Primary Care centre in Treharris Learn about services offered in primarycare. Met Deputy Chief Medical Officer about ‘Patient voices’ in cancer treatment Visit to explore use of technology in health and care Three settings in Cwm TafRoyal Glamorgan hospital Met both local authorities about commissioning of care Housing sector roundtable with local housing associations To come: Gwent Police and mental health in control centre, radioogrpahy Website pieces - Mental health in police and custody settings - End of life care - Oral health - Wellbeing and nutrition - Do we measure what matters? - Power and value of volunteering - Therapists delivering transformed services - Helping people find their own voice - Commissioning social care - Challenges - Context Facebook stories - Ran the Local health and care services survey on facebook - Stroke Association and blood pressure - Organ donation - Housing and health - Caring for carers - Changing role of GPs - Technology and patients - Social inequality - Inequalities and inequities Facebook videos - GPSO visit - NERS visit - Marie Curie volunteering - Fit and Fed group

Appendix two - NHS Planning framework 2019-2022

As we enter the sixth annual planning cycle, IMTPs must continue to demonstrate atruly integrated planning approach. This approach must link population need toquality, service models, capacity requirements, workforce development and capitaland financial planning, set within the context of the organisations’ longer-term clinicalservices strategies. This NHS Wales Planning Framework sets the tone and direction for the next threeyears and focuses on the delivery of A Healthier Wales. This is therefore an importantmoment in strengthening the development of integrated planning in NHS Wales.    The overarching strategic priority remains to improve population health, focussing onprevention and reducing health inequalities based on the prudent health and carephilosophy. Primary and community care, including cluster level planning, are thebedrock of the healthcare system. People access the majority of their care in theircommunities, supported by hospital services providing more specialised treatmentsand care as and when required.    Plans should set out how health boards and trusts will work together, and with theirpartners, to continuously improve services for the people they serve. RegionalPartnership Boards (RPBs) are expected to have a strong role to play, bringingtogether a range of stakeholders, including social care, health, the third sector and theindependent sector.  IMTPs must demonstrate evidence of and an emphasis on: • Implementation of A Healthier Wales • The Well-being of Future Generations Act (with a particular focus on how IMTPs areroutinely utilising the 5 ways of working and contributing to the well-being goals) • Fully reflecting the Quadruple Aim • Quality and Safety • Prudent and Value Based Health and Care • Integration and seamless models of care (in line with the Social Services & Well-beingAct) • Collective working (including regional and once for Wales planning and betweenhealth boards, trusts and supporting organisations) • Maturity and continued improvement across all service areas 5 Key WelshGovernment delivery priorities include: • Prevention • Reducing Health Inequalities • The Primary Care Model for Wales • Timely Access to Care • Mental Health

Appendix three - Rebalancing health - tackling socialinequity

Recommendations in “Rebalancing healthcare. Working in partnership to reducesocial inequity” -  Report of the Chief Medical Officer 2016 1. NHS organisations must ensure they are working effectively with their publicsector partners to reduce the social gradient by upstream effective interventionsthroughout the life course; but with a particular focus on early years a. the first 1000 days b. adverse childhood experiences c. active lifestyles and healthy ageing 2. NHS organisations, especially Public Health Wales and health boards, shouldensure health protection interventions are delivered consistently across the socialgradient a. Vaccination b. Cancer screening c. Smoking cessation    3. Primary and community care services should work co-productively with their localcommunities to manage demand on GP services and ensure an appropriateresponse to those with the greatest needs a. Co-produce primary care b. Social prescribing c. Time banking 4. NHS organisations should ensure clinical costs, activity and outcomes are,wherever possible, monitored against socio-economic status to ensure positiveimpact on equity of outcome a. Cluster level data b. Activity and performance data c. Programme budgets 5. Welsh Government should ensure the revised planning framework requiresorganisations to plan for equitable health outcomes for their populations and tofocus on reducing demand. a. Co-production b. Life course intervention c. Health and wellbeing services d. Targeted community services e. Timely hospital responses  

6. A programme of health services delivery research should be established toevaluate new models of care designed to minimise the impact of the social gradienton health outcomes. a. Co-production for health protection b. Co-production and primary care demand c. Time banking and communities 7. Providers of healthcare education and training programmes should ensure theircourses include a focus on health equity and their intake reflects socio-economicdemographics. a. Undergraduate and postgraduate curricula b. Disadvantaged backgrounds 8. NHS organisations should have policies and monitoring and reporting processes inplace that ensure they fulfil their social responsibility to the health and wellbeing ofthe populations they serve. 

The ‘drill down’ on local health and care services was supported by a survey onmy AM facebook page using a surveymonkey questionnaire. It is important to give a context for this survey. It is not an academicallyrigorous study and no effort is made to present it as such, neither is itstructured or sampled to reflect the local population. The respondents come from both parts of the constituency, which is importantas there are two LHBs, local authorities etc. The % geographic split inrespondents is about right. I saw the survey as a means of gathering furtheropinions on services in the hope of picking up, what I am calling, signals aboutservices which may need my attention and possibly be the basis for somefuture work. Signals So in summary what broad signals do I draw from the survey: • Those who responded seem to reflect more general health patterns withsome increases in personal weight and alcohol consumption, but a significantproportion saying they drink less alcohol than 12 months earlier. • Significant percentage of respondents say they are not dealing with life’sproblems well, but most people do seem aware of their personal health andwellbeing. • People seem generally satisfied with their experience of health service andtreatments, but there are some issues around timely access (e.g. GPs) andtreatments (e.g. mental health) and including ambulance response times –though there was a much higher satisfaction expressed with the overallambulance service respondents received. • People report they are treated with respect by GPs/primary care, hospitalsand dental services. • A significant portion of respondents are not registered with a dentist, butthose who are say they receive good treatment. • Responses to mental health and social care questions give the clearest“signal” for further investigation but care is required as hardly any respondentsare direct recipients of social care.

Appendix four - local survey

Out of Hours - 25% of respondents said they had used it. - 10% said they didn’t know how to. - 80% satisfied with the out of hours service. Ambulance - 20% of respondents said they had called for an ambulance. - 80% said it was for someone else. - 50% said they were not satisfied with the response time. - But 85% satisfied or very satisfied with the ambulance service received.  Social care (caution required). - Very few people who receive personal care responded to this survey. - Over 30% of respondents provided social care and 20% said they were carers. - Just on 10% said current accommodation unsuitable. - 55% of respondents do not believe good social care is available. - Over 10% had received support from social services. - 90% said they had not received the right information about their social care. - 50% said social care had not improved their quality of life. - Over 60% not satisfied with their social care. Dentist - Over 30% of respondents said they were not registered with a dentist. - So not surprisingly about the same % had not seen a dentist in the last twelvemonths. - Over 90% of those who attended said they had been treated with respect. - Over 90% satisfied or very satisfied with treatment. Response to open question The questionnaire also offered an ‘open question’ text box in which people couldsuggest the most important improvement for local health and care services. Theseresponses were analysed by grouping them under common themes. This analysisshowed the following as the most common suggestions (all % approximate, andtotal does not make 100%): - Increased finance – 33% of responses. - Better access to GP surgeries especially ease of making appointments – 24% - Patient care issues – 12% - Assorted other issues – 11% - Mental health improvements – 5% Indeed in these responses a wish to spend more on the NHS, and better/ease ofaccess to GP surgeries stood out amongst the responses received.

Visiting refurb work at Prince Charles Supporting UNISON campaign for care standards

Meeting nurse of the year Louise Wallby

Presenting NHS coffee morning cheque

With Jules Peters promoting breat cancerawareness

Promoting bowel cancer screening

SupportingOccupationalTherapists

Blood pressure test withStroke Association / Cardiff

Uni

Original Nye Bevanbadge at NHS coffee

morning