2020 vision for Welsh 'public health'? Proposing 'public sector' footprints.

Abstract

Health is a difficult concept to define, not least as the determinants include access to healthcare, community cohesion, education, employment, environmental factors, genetics, housing and lifestyle. Both the challenges and opportunities for public health are to engage on these diverse agendas across a wide range of partnerships. In Wales, there are perhaps further opportunities to advance the public health agenda given that there are a range of powers devolved to the Welsh Government.Wales is a relatively small country with a resident population of around three million people. Similar to other countries within the United Kingdom, Wales has an ageing population which leads to increasing demands on health and social care services. Another issue is increasing financial pressure, leading to the dual challenge of needing to do more with less. Extrapolating some basic common sense to this situation, if more health and social care output are required for decreasing resource input, the efficiency of the 'system' needs to be increased. That might also mean that the size, structure and function of the existing 'system' are reevaluated.National policy in Wales can be questioned. At the organisation level, reforms to the National Health Service and Local Government tend to occur at different times with different drivers and often resulting in geographical footprints that are not coterminus. Individual policies are also open to challenge; for example, a national dignity in care programme1 was ended in 2011, and yet several years later, issues were reported within Welsh Hospitals.2Policy in Wales is complex and there remains a level of divide in health policy and social care policy. The last reform of the National Health Service took place in 2009, with the creation of seven integrated health boards from 22 smaller local health boards. In addition, three trusts were created: Public Health Wales, a trust for cancer care and another to deliver ambulance services. Sadly, the high profile of ambulance response times in the Welsh media has occasionally distracted the debate away from health to politically charged emergency healthcare.Discussions are now underway about local government mergers from the current 22 to a smaller number, with inherent tensions and controversies. Given we know that health and social care are interlinked, why is the obvious step of a simultaneous reform across both these services not being considered within contemporary policy? Is there an even bolder step also of a public sector footprint? Is there courage for it?Could Wales establish regional public sector footprints with one integrated health and social care provider? Could other public sector partner bodies such as fire, ambulance and police also work to the same footprint with a collaborative mindset? Figure 1 outlines existing regions in Wales that are currently used for programmes such as 'Supporting People', which addresses housing-related needs. This footprint might not be fit for purpose in future, however, as there might be a case for a dedicated mid-Wales3 region that combines the current Mid and West region - in purple - with parts of North Wales, with knock on for boundaries of the other regions.Some of the current Welsh challenges might be solved with effective policy. Wales is a relatively small country geographically, with travel between any locations possible within one day. This has implications for the planning and provision of services, plus the opportunity for relationship building. The latter might be at the practitioner level, organisational level or at a thematic level with all Welsh networks. Perhaps a final opportunity that exists is that Wales has an evidence base for policy development,4,5 as well as a vibrant research culture. This includes the world famous Caerphilly cohort study6 to help inform on healthy ageing policy in Welsh communities.Setting a footprint will be difficult with many questions. …