NHS and social care: Can Wales fix its issues?

Nearly 1,800 patients were ready but unable to leave hospital just this week, health boards revealed

In a relatively slim manifesto, Welsh Labour made a very clear promise on the NHS and social care.

A "health supremo" would be appointed to "break down the barriers" between the two services in order to eliminate "wasteful 'bed blocking'".

Bed blocking is the term used for patients who are medically fit enough to leave hospital but cannot be discharged because of a lack of suitable social care closer to home which has a knock-on effect through the NHS.

It is a real issue, so you might well expect it to be included in a party's election manifesto.

In fact, it was an election promise made by Welsh Labour almost a quarter of a century ago.

Much has changed since the very first election to what was then the Welsh Assembly in 1999, but the issue of bed blocking is as bad today, if not worse, than it has ever been.

This week, with nearly 1,800 patients ready but unable to leave hospital, senior NHS staff were advised to discharge the healthiest, even without a care package in place at home or in a care home.

Even the head of the Welsh NHS described it as a policy presenting "huge dilemmas".

The NHS and social care are two sides of the same coin, but can social care be considered the poor relation?

"It is very much an undervalued service - it lives in the shadow of general hospitals," said Steve Thomas, who ran the Welsh Local Government Association for more than a decade.

Steve Thomas: "Nothing's changed. It's one of those systems that lives on a rolling crisis"

He pointed to a review of Welsh health and social care, published in 2003 by Derek Wanless, which talked of "widespread under-performance associated with systemic defects".

Mr Thomas said: "All the problems social care and the health service are facing are set out in the Wanless report in 2003.

"Nothing's changed. It's one of those systems that lives on a rolling crisis.

"It has good times but it generally has bad times," he added.

"I could plaster the floor of the Principality Stadium with the plans and the cunning ideas that political parties have had over the years to fix social care," said Mr Thomas.

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"It's like that old saying, 'to govern is to choose'.

"When it comes to social care, 'to govern is to kick the can down the road'," he said.

Kate Young, director of Wales Carers Alliance, said politicians had not fixed social care issues because "it doesn't have the same status that the NHS has".

Staffing issues, particularly regarding pay and working conditions, have been at the heart of the sector's problems.

Research by Cardiff University published in August 2020 found that fewer than half of the Welsh social care workforce were paid the Real Living Wage, calculated as the minimum salary needed to meet the cost of living.

In its manifesto for the 2021 Senedd election, Welsh Labour pledged to pay social care workers the Real Living Wage, although some workers will not receive the new rate of £10.90 an hour until June.

But even Wales' deputy social services minister has admitted the Real Living Wage is "not really enough" when the sector is competing against, for example, supermarkets who are offering higher hourly wages.

Ms Young said: "Without a well-paid and respected workforce there is no social care.

"We need to stop tinkering around the edges of funding social care workers and properly look to plan a way of getting social care wages on to a level of parity with similar roles within the NHS.

Kate Young: "If we don't fund the social care workforce now, we will see more people leave"

"We know the Welsh government is pressed for money but the reality is, if we don't fund the social care workforce now, we will see more people leave, we will see it being even more difficult to recruit new people into that system, we will see greater crises," she added.

Demand for social care is likely to increase significantly.

According to the 2021 Census, 21.3% of the Welsh population (662,000) were aged 65 years and over, up from 18.4% (562,544) in 2011.

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As part of a co-operation agreement between the Welsh Labour government and Plaid Cymru in the Senedd, the parties have been working towards the aim of creating a National Care Service, free at the point of need.

It would mark a significant departure from the current means-tested system.

But it is not a short-term solution and likely to take "at least 10 years" to achieve, according to an expert group established to consider the policy.

And a change of system would not necessarily result in better outcomes.

Ms Young, joint chair of the expert group, said: "I think if you change the model to be more preventative... it will make a difference to the outcomes people receive.

"But if you just create an office, if we just create a National Care Service but nothing underneath it changes, will it change outcomes?

"No, it will just have a title," she added.

Fewer than half of Welsh social care workforce were paid the Real Living Wage in 2020, a Cardiff University study found

To illustrate the point, the expert group pointed to a social services law passed in Wales in 2014, hailed at the time as an "historic" and "landmark" act.

Almost a decade later, the expert group found "that the consistent translation of the act into practice has fallen short of its ambition".

If Wales was to move towards a National Care Service that delivers on its promises, Ms Young said: "The reality is, unless you pump-prime quite a considerable amount of extra resource it will be difficult to see some of these changes."

From a Welsh perspective, where is that money coming from when the NHS already accounts for more than half of the Welsh government's budget and it would take a brave politician to stop directing money towards health?

On top of that, the UK government has recently reversed its original plan to use an increase in national insurance - a UK-wide tax on earners - in order to provide long-term funding for social care - and slower growth in public spending is expected from 2025.

'Missed the boat'

Is it therefore time to dust off a 2018 report by economists Prof Gerald Holtham and Tegid Roberts?

The idea: an income tax increase of between 1% and 3% specifically to fund elderly social care in Wales.

First Minister Mark Drakeford and Plaid Cymru leader Adam Price have said recently that the idea merited a revisit.

But Mr Thomas said the Welsh government had "missed the boat".

"I think there was an opportunity to do something on tax and on social care a few years back, probably before the pandemic, and it would've been in the system by now," he said.

"You now say to people that you're going to tax them during the middle of a cost-of-living crisis and it's not going to be very popular, is it?"

Ms Young, however, said a case could be made for higher taxes if people develop a sense of "national ownership... a national pride around social care" and its importance.

"The principle, 'I pay for something, I get something in return' is a fair one but then you have to feel like it's worthwhile what you're paying for," she added.

The Welsh government said: "Social care plays a very important role in people's lives - supporting people to live independently in their own home and in the community. It also supports the wider health service.

"We continue to invest in both the NHS and social care together and greatly value everyone working across our health and care services, with Wales spending more per person than any other UK country.

"We have invested in the Real Living Wage in social care and are working with the sector to improve terms and conditions to support recruitment and retention."

A lot of long-term thinking is taking place behind the scenes.

But with social care in Wales currently stretched to breaking point, a series of quick fixes are needed to ease the pressure on this vital if sometimes under-appreciated service.

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