Integrated care in NHS Wales – what can England learn from its neighbour?

What does it take to run a truly patient-centric integrated health system? What does the Welsh journey with integration tell us about the future for England?

Paul Mears (CEO, Cwm Taf Morgannwg University Health Board) joins Robert Hull (Senior Consultant – NHS Insight & Interaction, Mtech Access) to explore the integrated care model in Wales and the lessons England can take from the Welsh experience.

In this NHS Whispers webinar, guest speaker Paul Mears shares his experiences leading a Welsh health board. The 7 Health Boards in Wales have been operating as integrated systems for over a decade. With the NHS in England just getting to grips with integration, we explore what England can learn from the Welsh experience.

Robert and Paul explore:
 - How NHS Wales is structured and who the key decision makers are
 - How the integrated healthcare system works in Wales and how this differs to what’s happening in England
 - How priorities are set and what shapes decision-making at health board level
 - The nuances of the Welsh health system and what this means for industry
 - How Welsh Health Boards work with industry and the lessons here for ICBs and industry in England
 - Prudent healthcare and what this means in practice
 - How industry can best engage with health board leaders, what channels to use, and what messages to bring

This episode was first broadcast live as webinar in November 2023

Learn more about this webinar at: https://mtechaccess.co.uk/integrated-care-in-nhs-wales/

Discover how we can help you with your NHS engagement and UK market access strategy at: https://mtechaccess.co.uk/uk-nhs-insights/

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Transcript

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- [Announcer] Welcome to this Mtech Access Webinar. At Mtech Access, we provide health economics and outcomes research, and market access services from strategy through to implementation. Our unique NHS relationships guide and validate everything we do in the UK. We work with over 80 NHS associates to bring our pharmaceutical and MedTech clients authentic insights into the NHS. We can help you answer key questions related to the NHS from how to communicate with integrated care systems, places and primary care networks, to how to capture pathways of care. Get in touch today to discuss your market access goals. First, though, I hope you enjoy the webinar.- Hello everybody, and welcome to this Mtech Access NHS Whispers session. I'm Robert Hull and I'm one of the Senior Consultants at Mtech Access in our NHS Insights and Interaction Team. And it's my pleasure to bring you to our webinar today, which is all about integrated care in NHS Wales. And you know, what can England and like I said, the wider UK learn from Wales and how it's put together, its integrated care system, how it's innovating and what has been doing recently. We've got a really good mix in the audience today. So we've got lots of people from the industry and also the NHS. And I'd also like to welcome some of our NHS associates who sort of play a big role in the work we do at Mtech Access. For those who don't know us very well, and might be sort of coming to this webinar, as you know, the first time they've come across us or met us, Mtech Access is a specialist health economics and operational research agency. We also do a lot of market access, other bits of research too, and health economics. We've got a good track record in expert delivery and we used to do lots of different bits of support for pharmaceutical companies and MedTech, and also work as a collaborative partner to the NHS. But today, as I said, we're going to be focusing on NHS Wales and it's my pleasure to welcome our guest and speaker today, Paul Mears. So Paul, you are the CEO and Executive of Cwm Taf Morgannwg. Apologies if I butchered that again, but very much a warm welcome and yeah, if you could maybe give a little bit of an introduction about yourself and we'll kick off and sort of go through that conversation.- Great, thank you Robert. And good afternoon everybody. Nice to be here with you. Yes, as Robert said, I'm Paul Mears, I'm Chief Executive of Cwm Taf Morgannwg, University Health Board. I'll just give you a little bit of a background to the Health Board. We're, for those of you who don't know, the Welsh system in Wales, the NHS is organised under seven Health Boards. So each looking after a geographic area of the country. And we are, my Health Board looks after the area that covers the three local authorities in Wales of Bridgend, the Rhondda Cynon Taf Local Authority and Merthyr Tydfil. So it's basically, all the valleys, the South Wales valleys and down to Bridgend and Porthcawl on the coast characterised by obviously, the post-industrial mining communities, very much a key part of our community and the area we cover. We're serving a population of about 450,000 people and we have a budget of 1.3 billion pounds to care for the population that we are responsible for. Just to be clear, so the Health Board, what do we actually do? Well, the Health Board is responsible for both commissioning and providing services. So a bit different to the ICS structure in England where we actually are directly responsible for provision of care. So we have three district general hospitals that we deliver services through. We also provide all of the community services to our population. So district nursing, community therapies, health visiting, school nursing, those sorts of things. All of the mental health services. And that ranges right through from low-level support, right through to Tier IV secure services for both adults and children. And we also provide public health services, which are actually under the Health Board. So again, slightly different to in England where public health sits with local authority. We, in Wales, have public health sat within the Health Board. So broad range of responsibilities in terms of provision, but we also commission all of the primary care services. So GP services, optometry, dental, pharmacy, we are responsible for commissioning all of those services as well. So it's a very broad set of responsibilities, but a really great opportunity when we're talking about integration of care, to think about how we can really maximise the potential that the structures that we have in Wales present us with.- Thank you, so that's a really sort of broad breadth of activity. So where does the CEO role sit in that? Where or how do you focus if it's really the question?- Yeah, no, absolutely. And it's an interesting one, I mean, perhaps just give a bit of a background to me as well because my background prior to working in this job, I've been in this job for three years now and I started my career in the NHS in England and worked for many years down in Devon. I was, worked in community services in Torbay in Devon for many years where we did a lot of work on integration of health and social care. And I was director of ops in the integrated app hospital provider there, where we brought in all the social care services into the local, from the local authority into a care trust down in Tor Bay. I then went and worked in a hospital down in Tor Bay as Chief Operating Officer, so I got experience of working in acute hospital services. And then I moved from there to Somerset where I was Chief Executive of Yeovil Hospital, where we did a lot of work as part of the NHS England New Care models work a few years ago, looking at different ways of delivering services in an integrated way, particularly, they're looking at the interface between primary care and secondary care, which took us into the territory very much of primary care. We set up Symphony Healthcare Services, which still is of a large scale GP provider, which is now running about 15 GP practices in Somerset. And we also did a of work looking at how we integrated a different model of care using data to drive our approach. So that sort of led me into a space of getting interested in that whole area of integrated care. I then actually, when I left Yeovil, did a couple of years doing independent consultancy work and did a lot of work with McKinsey working on integrated health system work. So I guess in terms of my job now, it's the perfect opportunity I guess, to sort of bring together my experience of having worked in community services, social care, primary care, hospital services, and think about how do we use the opportunity we have in Wales to sort of bring about a real change in the way and shifting our focus into much one, or which is not just about delivering better care for people when they come into our facilities today, but also how do we start to really get into that space of thinking how an integrated model of care could start to make an improvement in health outcomes for the population. Because given the demography of the population we serve, we have some really, really difficult health outcomes that we need to try and tackle. So as a chief exec, I'm slightly sort of schizophrenic in a way.'cause one minute I'm focusing on what are we doing today in terms of how many ambulances are waiting outside the hospital or A&E performance, or waiting times for orthopaeedic surgery. And at the same time thinking about, well, how do we actually make an inroad into the long-term health outcomes for our population? So it can be quite a challenging role because you're constantly lifting your eyes from one very operational here and now today to the long term, but that in some ways makes the job that really interesting'cause it doesn't mean that we've got one me and my team, there is just one team of people for my population responsible for the leavers, if you like, that we have at our disposal.- Yeah, so when you're dealing with those challenges, you know, we hear a lot of the news about the different challenges faced by the NHS, you know, whether that's workforce or capacity, or winter pressures. What are those key challenges that face you, I guess, you know, are they all the same as the national ones or are there some real sort of ones with a Welsh-focus that you think you might have at a slightly unique sort of, yeah, what are those?- Well, I think... So as I said earlier, I started this job three years ago, so arrived in the midst of the pandemic. So, and our population in Morgannwg was particularly hard hit by COVID because of the demographic profile of our population, the comorbidity issues in our population. We had some of the highest transmission rates during the COVID pandemic, and sadly, some of the highest death rates from COVID in the pandemic, not just in Wales, but across the UK. So, and prior to COVID, the Welsh waiting list decision was already more challenged than probably the English system was. So yeah, in terms of the key challenges in common with the rest of the NHS, the recovery from COVID...- [Robert] Let's just give it a second, I think our webcams have been taken off due to maybe a slight technical difficulty. Now you were talking about the particular challenges you'd faced. You joined during COVID.- Yeah, so sorry, the waiting list challenges, yeah, yeah, yeah. So the waiting list challenges, I've just described there and the particular complexity of comorbid populations that we're having to deal with. I think the other, the other big challenge, like everybody is workforce and in common with everyone else in the NHS at the moment, trying to get enough capacity and resource to deal with the support that we need and to get the workforce in that we need is a big pressure for us. And I think, you know, we're working closely with our colleagues in other Health Boards to think about novel ways of sort of bringing new workforce. But I suppose the other big challenge facing everybody is the financial resources, you know, everybody's strapped for cash at the moment, aren't they? And therefore that brings a challenge, but I think it also underpins why the current model of care is probably not fit for purpose. And we need to start to think about a more longer term financial plan that is about how do we tackle some of the long-term determinants of health because ultimately at the moment, we're pouring more and more money into the most expensive bit of the system, I.e the hospital sector, when actually, really what we need to be trying to do is think about how do we move more money upstream into prevention and public health interventions that will start to help deal with some of the burden of disease pressures. So yeah, I mean, the challenges are similar. There are some particularly acute challenges in my part of Wales because of the demography of the population. But I think to be honest, it's just the level of degrees of severity of the pressures that the rest of the NHS is facing as well.- [Robert] That's really interesting. So, you know, national pressures, but you know, maybe slightly more pronounced in certain parts and others. And how are you looking to combat these, you know, there's quite a lot of work in collaboration with industry in some parts of England. Is that an approach that you guys are taking? I've read some really encouraging bits about, you know, community groups and sort of their role that can be played in South Wales. So, you know, are there any particular ways that you'd like to highlight that you think are quite effective for meeting these challenges?- [Paul] Yeah, so as I said earlier, one of the big challenges has been, you know, some of the demographics of our population. But I also think what we've tried to do as part of our strategy as an organisation is think about how do we turn that into an opportunity as well. So one of the real strengths of our community is that sense of community that we have some really strong voluntary sector groups, community groups, communities in the valleys that are very self-sufficient and are very, very local. You know, so really strong sense of community that comes out of the post-industrial mining, mining towns and villages. So part of our challenge as a Health Board was to think about, well, how do we capitalise on that and use that social asset more actively and try and support and encourage local communities to take more control of their health and wellbeing? How do we get some of the messaging out into those communities? Because, you know, frankly, there is an element of mistrust of public sector organisations in some of these communities. And so us, as a Health Board, rolling into town and telling everybody to stop smoking, eat more healthily, lose weight, take more exercise, is pretty much going to fall on deaf ears. But if it's the local voluntary sector leader or community group leader who people know and respect, and trust having that conversation, there's probably more likelihood that that will be accepted and understood. So we've built up a really strong relationship now with a number of voluntary sector groups, community groups. We run a regular community leaders forum where we bring those people together. We talk about some of the things that we're trying to achieve as a Health Board, and they effectively take on that role of becoming our agents, if you like, with their local communities to help spread that message and start to integrate that messaging into those communities. So I think that's something we see very much strategy for moving forward of engagement and involvement of local communities and helping shape that. So that's one sort of group of stakeholders I think we need to be really very alert to. But I think you'll put your question about industry. I'm a great believer that there is a massive amount of opportunity for the NHS to work more collaboratively with industry partners. I think it's probably something historically, the NHS has been slightly nervous about.- [Robert] Sorry, could you just repeat that last sentence? I think, again, our audio went, so we might have to just stay off the webcam and just use the audio.- [Paul] No, yeah, yeah, yeah, that's fine. I was just saying that I think there's been this challenge and tension maybe in the past, and probably more so in Wales than I'd seen in England of that slight nervousness about working with industry. But I think that is shifting and I think we are starting to see a greater degree of collaboration now with industry partners. There's quite a good structure in Wales to interface with industry life sciences partners through the Life Sciences Hub in Wales, which is a arm's length body that sort of coordinates and provides an interface between industry and the NHS. But I also think there are some more tactical innovations and opportunities that Health Boards are starting to exploit in working with partners, whether that's around data, whether that's about working on UK models, MedTech companies, pharma companies. So I think there is a growing recognition, I think in the NHS in Wales that the problems facing us are so significant, they're not going to be able to be solved by ourselves alone. They're going to require us to work in a collaborative and joined up way with other partners.- [Robert] That's really interesting. So if there's a company you think they might have a really good piece of innovation, whether that's, you know, digital or a bit of tech or, you know, maybe a pharmaceutical intervention and they think it could be really useful in Wales, how would you suggest that they go around contacting, you know, yourselves or your colleagues, or other parts of the NHS in Wales? You know, how do they make the meaningful engagement and collaboration happen?- [Paul] Well, I think, as I said earlier, there's a really good opportunity with the Life Sciences Hub in Wales who are really linked in. So they're a really good starting point and I would certainly suggest making contact with them because they're already working in that interface between the NHS and industry. I think also, you know, getting in contact with chief executives is directly is I think something that I certainly, I've been used to and I'm very happy. It doesn't mean I'm always going to be able to respond myself to it, but certainly we've got an innovation team within my organisation who would be the people who would then pick up to follow through on those conversations and follow that through. I think the other thing to highlight is in Wales that we do also have a really interesting structure around value-based healthcare. So we have the Welsh Value in Health Centre who are really active in looking at opportunities to drive greater degree of value and improved outcomes in healthcare. And again, they're a good route in, and Dr. Sally Lewis, who is the Director of the Welsh Value in Health Centre is very much networked into various industry partners who are looking at opportunities for driving greater value in the NHS in Wales. So there's a number of routes in, I think there I would suggest people follow through and certainly, I'm always keen to hear and listen to views and thoughts of industry partners of what they can do to help us tackle some of our challenges.- [Robert] Yeah, I think value-based procurement is becoming ever more important to understand, I guess also in England and the wider UK. So I know the NHS England is very much embrace it and has a new commercial team or newish now, I think they've been around for about 18 months, sort of driving forward value-based procurement and trying to simplify the process. So it's encouraging to hear sort of the same process in Wales. To jump a a little bit. So I know that sort of the Welsh system is sort of embraces something called Prudent Healthcare and it has some documents out around that. Would you be able to sort of expand a little bit on that and maybe whether that's how that figures into your thinking and?- [Paul] Yeah, no, I mean, absolutely. So the Prudent Healthcare philosophy has been around in Wales for a number of years now. And really, it is that principle of value-based care, so that how do we deliver better value? Sorry, how do we live the better outcomes for our population whilst also making best use of the resources available to us. So there is a lot of work and it underpins much of the work we're doing in Wales, that philosophy of value-based healthcare, Prudent Healthcare, thinking about where we can make lower level interventions that are better outcomes for patient and at lower-cost. And as I said, we have a team, a national team overseeing that work across Wales and every Health Board in Wales will have a value-based healthcare lead or team working on local initiatives that are trying to support clinicians who want to think about implementing lower-cost interventions to improve outcomes. And, you know, we're doing some work at the moment in my organisation looking at diabetes, for example, which is a big challenge in my Health Board with the particular demographics that we have and thinking about, well, is there a different way we can deliver diabetes care that is about much more using technology to support it, lower level interventions? How do we encourage patients to take more control of their health as a diabetic patient? Is there a different way we can design clinical services that are much more about delivering that care for patients outside of a hospital setting? So in a lower-cost setting in community settings or in primary care, rather than those people being brought routinely back into hospitals. So, you know, it isn't rocket science, I would suggest, it's what all of us would want to be trying to deliver for our population. But I think it's quite helpful that that framework is really well-embedded here in Wales and it's sort of drives much of the narrative both from a policy perspective, but also from an operational delivery perspective within the organisations.- [Robert] And in terms of that policy perspective, you know, is NHS Wales sort of quite self-contained, or do you get quite a big steer from the Welsh assembly or NHS England? How does that focus work?- Yes, so obviously, health in Wales is devolved, so it's entirely the responsibility of the senate, the Welsh Parliament, and we have our own minister in Wales who sets the policy direction for the NHS in Wales. One of the interesting differences I've noticed coming in from England into Wales is that the sort of the line of sight between policy politicians and Health Boards is very short. So, you know, we have seven Health Boards. There's the chief executive of the NHS in Wales, who's also the director generally in the Welsh government for health and the minister. So it's quite close. So there is a benefit to that because, you know, the policy is in very much shaped and driven, and influenced by the feedback that we as Health Boards give to the policy leads in Welsh government. There can be a downside of it candidly sometimes, that means the politics is very close. And so politicians are probably more directly involved in health probably than I've been used to in England. Partly because of the scale of the budget in Wales, it's such a significant chunk of the wealth government budget. You can understand why they want to make sure they understand what they're spending their money on, but also health, like in everywhere, right? It's a very hot topic for lots of the population and the local democratic representatives get a lot of correspondence around health issues. So they understandably want to make sure they understand it as well. So there is an advantage to it though, however, because it's not just about Welsh government health minister, it's also about how does health and the opportunity for partnerships and industry partnerships, how does that play into things like the economic department of Welsh government and local government department of Welsh government. So it does feel quite integrated, if I'm honest, that the health doesn't sort of sit as a standalone part of government. It's very much interfaced into the economy department, into local government department, other areas of government. So there is a real drive within Welsh government to understand how any aspect of policy in government influences health and wellbeing of the population, which I think is a really positive thing given the scale of the challenges and the fact that we know that most of the issues facing people's health and wellbeing, the NHS input to that is probably about 10%. The rest of it's all driven by other factors such as housing, leisure, employment, education. So having a government that has that woven into its sort of thinking across all the departments is actually a really positive thing, I think.- [Robert] In that government thinking, you know, so you guys have had the integrated healthcare system or something sort of pretty analogous to it for, I think 10 or so years now. Is that still the direction that you get the sense that the Welsh government wants to go in, you know, do you like it? And do you know, I guess, do you have any advice for, as integrated healthcare systems, you know, evolve in England at different paces across the country? You know, are there any sort of top tips that you might have for them?- [Paul] So yes, you're right. The structure in Wales has been in place since 2009, so quite considerable amount of time. And I think people in Wales would acknowledge that maybe we haven't capitalised on the opportunities that that presents as much as we could have done, but I think that is changing. I don't see any interest in government in Wales to shift the structures that we've got. They're very clear that Health Boards are the primacy of how healthcare gets planned and delivered for the local populations that we serve. So that's a positive thing. I think one of the things I noticed coming in from England, which is think is a positive thing for us, is that, we have a capitated sum of money. So my Health Board has 1.3 billion pounds, we get given and it's for us to design how we best spend that money for the health improvement of our population. We don't have to try and negotiate with a whole set of other people if we want to try and make some changes. So if I decide that we wanted to, I don't know, develop a new incentive model to reduce admissions to hospital, we have the levers within our gift to actually develop an enhanced service for primary care to do that. If we decided that community services need to be reconfigured to better serve the needs of frail older population, we've got all of those services within our direct control, we can do that. So one of the things I find with the structure in Wales, which is helpful is it's a more simplified structure. It doesn't need loads of, you know, the number of stakeholders around the table are a lot lower, particularly from a health perspective, you know, we just have the Health Board. We have three local authorities that we have to work with in our patch, which obviously, are really important for our sort of integration of health and social care, but from a health perspective, it's not like in England where you're trying to sort of navigate through sort of an ICB, the acute hospital provider, the community services provider, the mental health provider, you know, we are all of those things in one. So it just makes it a more streamlined and efficient way of spending our time.- [Robert] And do you think that sort of streamlining is possible in England or do you think it is just that England is that much of a larger system and therefore we sort of won't manage to achieve it?- [Paul] So look, it is absolutely a much larger system and clearly there's a greater degree of complexity because the size of England and the scale of what responsible. But I suppose if you break it down to an ICB-level, I suppose we've now got a structure in England of ICBs overseeing the health needs for their population. But you've still got providers with their own chief executives, their own boards who obviously are now ever more integrated into the ICB, but there is still an autonomy of those organisations. That's the one difference that we have in Wales that we don't have that autonomy. It is all one and one budget, one set of executives running the organisation, one chief executive, one board, and I think maybe who knows where it will go in England over time, but it feels at the moment that maybe there's quite a bit of time and energy being spent trying to navigate quite complex accountabilities with the ICB and provider structures in England, which I think we feel, I certainly, I feel in Wales that we're able to perhaps not have to deal with that complexity. It's a bit more straightforward for us to get on and make decisions.- [Robert] Yeah, I can certainly recognise that. So from when I was in the NHS and the integrated care systems are coming together or still are coming together and it's, you know, trying to negotiate quite complex landscapes of different trusts, you know, trusts and former CCGs and things coming together, whereas, as anywhere else with that much tighter close knit approach, some of those challenges are already addressed to an extent. I guess sort of following on, on the integrated care system themes and England, we've got, you know, the priorities and operational planning guidance, you know, what's the Welsh equivalent of that? And can you offer any insights into it?- [Paul] Yeah, so we have a planning process, very much akin to that in Wales, integrated medium-term plans, which are aimed to be delivered over three years. There's a set of priorities that get set by government from the minister and from policy leads around areas to work on. So we have to respond every year in how we're going to be planning for the following year to deliver the priority set by government and policy. So it's very similar. The challenge I suppose, like everybody at the moment is, you know, there are so many priorities aren't there, you know, we've got to recover elective care performance, we've got to get A&E performance back on track. We've got to deliver improvements in mental health care, in maternity care, in develop further improvements in discharge with social care colleagues as well as then the longer term financial and population health improvements that we're all trying to make. So I guess like everybody at the moment, one of the pressures and challenges is juggling those competing priorities and trying to do that within the confines of what's available to us from a resource perspective, both from a financial resource, but also from a workforce resource as well because like everybody, we're challenged in terms of having the capacity in the workforce to deliver everything we want to do.- [Robert] And when you have those sort of workforce capacity challenges, that means you're trying to embrace sort of ever greater digital tools as we sometimes hear, or are there sort of other approaches that you use that might be worth sharing?- [Paul] Yeah, so I think certainly from my organisation's point, we're trying to look at how we think about the opportunities that digital brings us. I don't think it's the only, it's not the panacea that's going to solve all the workforce problems, but it certainly gives the opportunities and the tools for us to start to be a bit more productive and think about how we use digital solutions to make people's work-life more efficient. I also think there's something about how we can use technology to get patients doing more of things for themselves. We've had recently, we've piloted in our heart failure services, an app that enables patients to self-report their condition, their various vital signs that's remotely monitored by nurses. It means they don't have to come into hospital for routine appointments, which obviously, is where we want to be in the future. So there's definitely an opportunity for technology to provide them much of the solution. The challenge candidly we have in my organisation is that our digital architecture and infrastructure is not as well-developed as we would like. So we've got to make sure some of the core systems and processes are in place to enable us to be able to capitalise on opportunity of digital solutions. I think there's also something then about different models of workforce. So thinking about how it's the old things that everyone talks about, you know, getting people to operate at the top of their licence. So making sure that, you know, doctors, consultants, GPs, advanced practice nurses, therapists and others, they're all doing the things that only they can do and we're delegating as much as we can to other professionals and support staff so that we are actually getting only the professionals doing the things that they can do. I think, again, there's still more work for us to do here. I think we're a little bit behind the curve, I think, in Wales in some areas and things like advanced practise, nurse consultants, therapy consultants, advanced clinical practitioners, but we're certainly in my organisation doing a lot of work on that agenda at the moment. And then also just thinking about, you know, again, how do we make sure that we're not bringing people into hospital for things when they could be having that done in their own home or in a community setting. And so trying to reduce the burden on our hospital-based staff. So yeah, a lot like everybody, it's a big challenge, you know, that there's never going to be enough workforce, I don't think to, and it's not just a Wales problem or a UK problem is, it's a global problem in terms of workforce-- Very much so, yeah.- [Paul] So I think it does drive you though to think about innovations in different way of doing things.- [Robert] So, and with those innovations, how do you balance the costs or do you have any words of wisdom for anybody on industry who might be listening in, you know, how do you balance the cost of those innovations coming in? Is it that you need to see things that are sort of going to be cost saving within year, or are you still able to take a longer term view? Is there still that balance here in Wales? Because definitely in England we have that desire for savings within year.- [Paul] Yeah, well, I think like everybody at the moment, given the financial challenges, everyone's trying to chase the thing that's going to make them some savings in year. I think there's something about opportunities that are quick wins that can be delivered within a year, but that perhaps are done within the construct of a longer term financial plan. And I do think there's something here about, and I think this is part of how the NHS needs to perhaps adapt and change because I think historically, the NHS has been commercially quite naive and perhaps tends to focus on contracting for a certain number of things. You know, procurement tends to be about procuring items and things. So, and less, less used to going into long-term sort of partnership arrangements with industry that are about, you know, more long-term relationship. And I think think the NHS needs to perhaps start to think a bit more differently about how it does that. Certainly when I was in England, in my last Trust in England, there were a number of areas where we went into sort of longer term commercial arrangements with partners around estate developments, digital developments, clinical service developments. And I think that starts to build a trust and relationship between the NHS and the industry partner where actually feel that you're both waving towards a common goal and it's not just about how many of these did we buy or how many of those have you not delivered, it becomes much more of a, what's the long-term outcomes that we're trying to collectively deliver together and how do we contract and procure a service model that is perhaps slightly different to the ones that we've been used to procuring in the past.- [Robert] That's really interesting and I think there's that push across the UK to, you know, have that more integrated thinking, if I can put it like that. I guess, do you think there are any sort of further nuances of the Welsh system that industry might need to consider as compared to sort of whether, you know, England or Scotland, or Northern Ireland?- [Paul] Yeah, so I think just being cognizant, the fact that within the Welsh government, the historic appetite for industry partnerships with the NHS has been low. Though I do think that is changing now, so just to give you an example, we're currently in a procurement process looking at diagnostics and looking out, looking for a partner to work with us on diagnostics. And that's being done not just within my health support, but a couple of the neighbouring health as well. So I do think that is becoming more accepted. I think there's a couple of things that I think are always a little bit proviso within these sorts of arrangements in Wales, which are, how do we start, how do we show that whatever the arrangement we're going into with a commercial partner, how does it have a timeframe on it that says, you know, this is for a period of years, but it's not a necessarily an open-ended arrangement. The ambition would be that that would be developed through and mainstreamed into the NHS at the end of that contract term. So, you know, there's always an ambition to see, well, how are we using this relationship with an industry partner to help build our own capabilities within the NHS so that at a point in time, we would hope that we would be able to carry on as the NHS alone. So I think going into that and recognising that sometimes it's something that people would want to see. I think there's something about, and rightly so in Wales, a great degree of focus on the core concept of the NHS being an anchor institution. So how does a partnership with industry help the NHS develop and grow its responsibilities towards our communities? Whether that's looking at opportunities for training and development of local people, developing the skills of people to get jobs in the NHS or within the industry'cause I think, you know, we all know, don't we, that one of the biggest drivers for health outcomes is income. And so if we can help through industry partnership also grow the skills and capabilities of the local population, that is a also a big ticket for Welsh government because a key driver as a public sector organisation in Wales for us, is the backdrop of the Future Generations Act in Wales. So this is an act which is unique to Wales, which stipulates that every public sector body has to articulate how what it's doing now isn't just about improving the outcomes for people today, but also takes into consideration the needs of future generations as well, which I think is a really interesting concept. And it starts to get you into the territory of thinking not just about what we're doing today, but also where we're going down into the future.- [Robert] That really sounds like something that industry is going to have to be thinking about when they come to you with, you know, pilot proposals or projects, or collaboration agreements, or just I guess, selling directly into you. I mean, is it the case that you'd want to see sort of case studies or... So what sort of evidence would you want to see from a potential supplier that they can deliver?- [Paul] Yeah, well, I think definitely A, an understanding of the environment because I think, you know, it is a different environment in Wales, you know, both politically, governmentally, policy wise, there are some differences in nuances in Wales and I think there is sometimes a little bit of a frustration in Wales that people just sort of take something from England and sort of try and sort of fit it into the Welsh context. So a bit of sort of evidence of how people have understood the Welsh context and how it's slightly different, an understanding of some of the policy drivers and policy context. So reflecting the fact that we have a very strong focus on value-based healthcare in Wales, reflecting on the fact that we have the Future Generations Act, which guides and drives much of national policy, not just in health, but across all government departments. I would say also the Welsh language requirements are, you know, again, there are things in Wales that we have to have in both languages, and we have to pay attention to that, particularly from a health perspective when we are interacting with patients and things like that. So I think there's nothing there that would say is a massive barrier, but I think it's just things that when you're looking to position solutions into the NHS and Wales, showing that you've understood the context, showing that you've understood the particular nuances of the Welsh system is always really helpful. And I think just stand you in a better stead when you're having those conversations with both Health Boards NHS organisations, but also potentially government organisations in Wales.- [Robert] And for listeners who might be thinking, goodness, I'm going to have to learn a bit more about the Welsh environment, would you say that again, it's sort of life Life Science Hub Wales is the best place to go to sort of get that initial overview?- Yeah, I mean, so you know, I definitely, Life Sciences Hub are a good place to go and have a conversation with,'cause I think they can give you a very detailed understanding. They run regular opportunities for industry partners to chat, to come together to talk about what's going on in Wales and opportunities to interface into other key people within the Welsh system. But I think also, just taking the time to read some of the sort of policy documents that are out there in Welsh government, A Healthier Wales, which was published about five or six years ago now is very clear in terms of setting the direction of travel for the healthcare system in Wales. You've mentioned the Prudent Healthcare background, that's very much still current and there's information out there around the value-based healthcare work that's going on. So I think, but there's quite a bit of stuff out there that's available, which would help give some context and set some of the architecture out there that you would be able to sort of get relatively easily from a search online, but also as I said, Life Sciences Hub or indeed, you know, bilateral conversations with Health Boards and others would be probably helpful as well.- [Robert] Thank you. I think that's a really good set of insights onto, yeah, how people can make those initial first steps into understanding the Welsh landscape. So a slightly different area that I'd like just to probe on slightly is, you know, you've got the sort of the regular commissioning of service we talked about there, but how does specialised commissioning work in Wales? You know, how do you guys end up funding high-cost drugs?- [Paul] Yeah, so obviously, as I said earlier, we get as a Health Board and allocation of money for all of the healthcare needs of our population and the seven Health Boards in Wales collaborate and we have a joint committee of all the Health Boards called the Welsh Specialist Service Committee. And so we have a dedicated group of people in that management team supporting that committee whose job it is to commission specialist services on behalf of the seven Health Boards in Wales. So they will be doing a lot of the horizon scanning of new procedures coming on stream, new drug therapies that are coming on stream and we'll be making recommendations to the joint committee about things that we should be commissioning in Wales or indeed if we don't have the scale of demand, or can justify doing it in Wales, how do we commission from other providers in England? And there's already a number of arrangements in place for specialist services to be commissioned for patients from Wales to go into England to have various treatments that are of very high, you know, high-niche things. So we've got a specialist service committee that do all that commissioning on our behalf, but ultimately, it's the Health Board's money that they're spending. You see what I mean? So we get sort of effectively top-sliced for that resource and that gets managed through the specialist service committee.- [Robert] Okay, that makes sense. And you mentioned the horizon scanning for new things that would be great to implement. How do you get an innovation notice there? Did you have any sort of insights on how that works?- [Paul] Yeah, so we have a body in Wales who oversee sort of new medical devices and sort of go through that approval process so that we have, it's like a NICE type of model but for devices in Wales, Health Technology Wales do that for us. We obviously subject to NICE guidelines as well. So we implement the NICE guidelines, but Health Technology Wales do that horizon scanning of new devices that are coming on stream and we'll do the evaluations of new devices. And they work closely with the Life Sciences Hub as well, so that's where much of that comes through and then that gets disseminated out into Health Boards, and also through specialist commissioning if necessary to look at how we deploy those across the NHS in Wales. I still think there's probably more we can be doing there. I think one of the challenges you have and like everybody is the adoption of some of those things because it isn't just, we were having conversation on the other day actually about high-cost cancer therapies that, you know, there's a lot of new cancer drugs that are coming on stream, lots of new high-cost therapies for cancer that coming on. But of course, it isn't just the cancer drug costs that is incurred by the NHS, it's all the sort of care, ongoing care costs that are associated with the drug therapy. And sometimes we look at the cost of the drug, but we don't take into account perhaps the end-to-end total cost of care for the patient because of the sort of outpatient activity or the diagnostic activity that that patient may need.- [Robert] And do you think there's a place for industry to maybe step in and help with those sort of wider costs or the wider role in the community, or do you think that's something that has to come from within the NHS itself? You know, is there room for collaboration there and-- [Paul] No, I think there is, and I know that there is an opportunity and I think in many industry partners I've spoken to previously are potentially interested in the opportunities of thinking not just about how they provide the medical device or the pharmaceutical, but actually, you know, could we think about taking a cohort of patients and actually almost working collaboratively with the NHS to design a model of care that is involving the therapeutic or MedTech device. But it's also about thinking about how do we provide the nurse resource that might support that or the clinical input into the conversation. So I do think there is something we should be thinking more actively in the NHS about. I mean, again, this is a personal thing, not necessarily an NHS in Wales thing, but I do think, you know, provided we still maintain the principle that the service is free at the point of delivery for the patient, my personal view is it should matter less about who's actually delivering it, provided the patient gets a timely and good quality outcome for their care. So I do think there are opportunities to think particularly in some sort of cancer is a good example isn't it, of sort of how do you start to think about perhaps different models of delivery that are about collaboration between industry, not just in the therapeutic intervention but also in the sort of care, ongoing care needs for that patient.- [Robert] Yeah, and that makes sense. And so in that, in terms of delivery of that care, do you sort of see increasing digital care and telemedicine or are you sort of thinking more physical people or a bit of both?- [Paul] I think it's probably a bit of both, isn't it? I mean, if you think about what's gone on in England, and again, we're just having conversations about this in Wales at the moment around virtual wards for example. There's lots of examples now coming out aren't there, of how many patients are being able to be cared for remotely using digital technologies, remote devices, those sorts of things. So I think that definitely has a big part to play moving forward. But I also think, you know, there are opportunities where, you know, industry providers may have skills and expertise that can be deployed very actively, whether it's around population health management, whether it's around particular care pathways for particular groups of patients. So I think it's probably a combination of data and information technology support as well as potential clinical advice and support into teams. I mean, it's interesting, isn't it? When you look at a parallel, we work already in the NHS quite actively with charitable organisations. So think about Macmillan or Marie Curie, you know, I was visiting a district nurse team last week and they were describing how they work very actively with Marie Curie nurses working alongside the district nurse service. So, you know, we've got examples of where we're already working alongside other organisations delivering clinical care to patients. I suppose there's, you know, if we challenged ourselves, why would it be any different to think about working alongside a clinical team from an industry partner who've got expertise in professional knowledge in a particular area. Why wouldn't we want to capitalise on that and think about how we use that more actively with an NHS organisation?- [Robert] Yeah, I it was very encouraging to hear that there's, you know, creative thinking, well, maybe not even that creative, but you know, there is flexibility in Wales to think about how things can be delivered as long as it's, you know, still that NHS free at the point of use as whoever's delivering it maybe matters slightly less in your view, I mean, do you struggle at all with digital literacy? So down where I am on the south coast, there are some areas which have much reduced digital literacy. And so, you know, while digital is great, it has to be some digital first, but you still have to maintain the other parts of that pathway. Do you ever consider the same?- [Paul] Yeah, we do and I think particularly given the demography of the population we serve, there are some pockets very much where digital literacy is relatively low or the availability of digital tools is quite low. So, you know, there's examples where, you know, you could give everybody a mobile phone, you know, to help them manage their health condition more actively, but if they haven't got the money to pay for the data on that phone, then you're going to be sort of barking up the wrong tree there. So there is definitely something we are doing to think about how do we support upskilling of people to use digital tools more actively. But I also think there's something there about how we, you know, sometimes there's a danger that we say, well, we need to solve that problem before we do anything. I would either to say, well, let's design the solution that fits 90% of the population that can use the technology and then work out how we support the 10% that can't. Because sometimes I sometimes have a nervousness that we don't do anything'cause we're trying to design the solution that fits the 10% first and let's deal with the 90% that people that can use the technology first and then work out how we come up with the solution for the other 10%. So, but it is a real issue and also not just with our patients, you know, candidly, you know, our age profile of our staff is skewed towards the latter end and you know, again, some of our older members of staff can feel a bit unsure and uncertain about using digital tools to interact with patients. They sometimes feel more comfortable, you know, doing something face-to-face or on paper because it's just what they've always been used to. And we see quite a lot of people towards the end of their careers saying,"Well, you know, I'm retiring in the next couple years, I don't really want to invest much time and energy in getting grips with this new technology solution because I won't be here in a couple of years time and it's not something I'm particularly comfortable with." So, and we just have to recognise that, I think that is natural isn't it, at people at that stage in their career. But there's also a lot of our newly qualified staff, you know, new qualified nurses, newly qualified doctors who are used to using digital tools in every aspect of their daily life and would find it odd to come to work and not be using digital technologies to make their life easier or to make their patients' life easier. So I think there's something about how do we capitalise and use those new and upcoming skills that we're seeing from our younger members of staff to help coach and support some of the older members of staff in seeing how this could actually make their lives easier and make their care for their patients more easier.- [Robert] Absolutely. I think maybe one thing I'd just like to follow up on that is I've sort of worked a lot with different NHS organisations and looking at bits of digital technologies that they can introduce, and one thing that even staff who are quite interested in adding new digital piece of tech is they don't want yet another dashboard. So do you have any advice to companies on, you know, is that the same in Wales, I imagine it is, but are those sort of Welsh systems or APIs, or digital standards that companies should be looking to understand and build towards to make sure that their systems can integrate seamlessly rather than creating yet another dashboard for-- [Paul] Yeah, yeah, yeah, yeah. I think the question of interoperability is really, really important. And I think certainly in Wales, like England really, you know, the drive is to have much more open architecture APIs and there is a, there is a, there is a strategy in Wales now of developing a national data registry so that all the data collected in health and social care systems will be stored centrally. So no matter what interface you're using, you should be able to access the information about a patient, whether they're in Cardiff, Aberystwyth or Wrexham, you know, so that I think gives a good platform from an architecture perspective. So the need for open APIs to interface into that is really, really important. I think, you know, one of the things that slightly worries me with the NHS is, our ability to move at scale to adopt to new digital technologies. And because of that, sometimes I think clinicians and indeed patients may well start to go find their own solutions. So, you know, there's such a plethora on there of apps out there now for people to manage-- Absolutely.- The risks are, if we can't move quickly as the NHS, patients will just go and find their own solutions to manage their own health condition. And that will be happening outside of the architecture of the NHS. So I think one of the big challenges of the NHS moving forward is how do we use all that data and information that's being held and collected in, you know, people's apps, their smart watches, whatever else it may be. And how do we sort of make sure that we can get intelligence and insights from that? Because I think there is a danger, we try and design architecture that is quite big and large scale and a bit slow when actually, you know, the technology is moving so fast in this space and by the time we've designed that, you know, it's moved on and we're almost already playing catch up from the day it's launched.- [Robert] Yeah, absolutely. I can see that being a challenge and maybe industry can contribute towards, you know, working out what that framework is to sort of bring that agility. We're coming to the end of the session and so I think, you know, maybe time for a couple more of your insights, but yeah, if you were me and you'd been asking yourself questions here, what do you think I've missed? What do you think people who are sort of looking at Wales and looking at England, you know, are there any sort of key lessons that I've missed off asking you or other insights you could bring?- [Paul] I suppose if I was you or if I was an industry partner, I might be asking, is it worth me investing time and energy to spend time in Wales when it's a relatively small population compared to the wider English system? I would suggest to people that, to answer that question, I'd say yes, because in some ways, because the Welsh system is quite small and contained, it does enable a relatively simple conversation to be had with the NHS in Wales and maybe gives a greater opportunity to innovate and try things out in Wales that could then be spread into England. So I would make a play for that. Maybe I would ask as well, are we set up and are we open to industry partnerships in Wales? And to which I would answer, I think probably historically, less so than in England, but I think that is changing and I think there's been quite a shift in over the past couple of years, both from a policy perspective, there's been quite a lot of new leadership coming into the NHS in Wales, many of whom have worked in England, who've been used to seeing things in relationship to industry partnerships. So I do think the environment is changing. So I would definitely say, you know, the environment is different now, I think, to perhaps where it was a few years ago in terms of the acceptance and readiness for industry partnerships. But I think also just saying to people, again, to bring it to a conclusion, I do think the opportunities in Wales are significant, not just within the NHS space, but also to think about, you know, how do you tie into things like other industry partnerships and MedTech developments that could generate employment opportunities, industry opportunities within the wider NHS and public sector in Wales. So I do think the environment, it feels like quite an interesting environment to be, pointing your attentions to.- [Robert] Thank you, yeah, that certainly sounds like there's a huge number of opportunities in Wales for companies to move in and collaborate and succeed. So that's a really encouraging, maybe a good note to finish on as well. I think that's a very positive note to end on. So I think it'll just just remain to sort of say thank you so much Paul for coming along and talking to us today and yeah, we really enjoyed the having this conversation and I think I've learned a lot, thank you.- [Paul] Great, thanks Robert. And thanks to all for listening and hope it's been helpful. Thanks for your time.- Thank you, bye.- Thanks then, bye-bye.- [Announcer] Thank you for watching. If you'd like to find out more about our work with the NHS or how we could support your market access goals, please email, info@mtechaccess.co.uk or visit our website at mtechaccess.co.uk.