Published: 21/11/2002, Volume II2, No. 5832 Page 11

The far-reaching restructuring of healthcare in Wales is intended to facilitate joint-working across professional boundaries.But there are still a few 'details' to be resolved. Roger Dobson reports

There are four months left until D-day in Wales. On 1 April, five health authorities will be wiped out and 22 local health boards will spring into life.

A brave new world? At the NHS Confederation in Wales annual conference this month, delegates were optimistic about what the changes will mean: but concerned that the implementation timetable is slipping badly.

The final nine health board chief executives, of the total of 22, will be appointed within the next few days. The post of finance director for Wales was re-advertised in last week's HSJ. And one regional director appointment still remains to be made.

And there are concerns that structures below senior level are still being finalised: 'The rest is pretty fluid - and that is putting it kindly, ' said one senior manager.

Welsh health secretary Jane Hutt told the conference she has no doubts about the new structure which she believes will mean organisations will be better placed to work with each other.

She pointed out that the reorganisation of health authorities should encourage more working across boundaries, with the 22 LHBs coterminous with local authorities.

'We are now delivering the new structures which will facilitate joint-working with local authorities and bring greater accountability and responsiveness to local needs, ' she said.

She told delegates: 'An important benefit comes from the shared boundaries... between local authorities and NHS organisations.

'This is something which will be capitalised on as the local health boards fulfil their statutory duty to work in partnership with their local authority and others.

'Already, strong relationships are being built in some areas between health and social care, and we have been at the forefront of bringing the patient voice into decision-making.

'Uniquely in the UK, we are well placed to work together and fashion solutions which really meet our needs, ' she said.

'We must learn and work across boundaries. We all need to be working together locally, regionally and nationally across boundaries to look at imaginative ways of dealing with the issues we face.

We need to seek out and implement best practice, from whatever quarter, adapting it as necessary.'

A devolved Wales is ideally placed for all those involved to work as a team to deliver a health service which rivals the best, she added.

Ms Hutt said that devolution facilitated teamwork: 'With the establishment of the Assembly, we can take decisions here that make sense for Wales, and the Assembly can provide real support and leadership in drawing together views from across Wales.'

Dr Fergus Macbeth, deputy director of cancer services at Velindre Hospital, Cardiff, and a member of the National Institute for Clinical Excellence guidelines advisory committee, said that research on how clinical governance was perceived had shown that one of the issues was that it had still not got round the problems of a silo culture, with different professions working in isolation.

They were, he said, not linking horizontally and that was making clinical governance difficult.

They all report upwards, but there was little horizontal communication.

'In our view, it clearly shows that investment in people and management does have an impact on patient care, ' said Kevin Sullivan, policy and public affairs manager at the NHS Confederation in Wales.

But outside the conference hall, some managers remained apprehensive about the looming reorganisation.

The coterminosity with local authorities is designed to improve co-operation between health and social care, leading to less bed-blocking and more jointly funded projects.

But there remain concerns.

Some health managers would have liked to have seen 15 boards rather than 22 covering the same areas as the existing trusts, and with the number of local authorities also cut to 15.

'There is a view that the new boards - 22 for a population of less than 3 million people - will be too many, ' said one policy adviser. In some areas where there is extreme deprivation, those boards will not gain from economy of scale because they are too small.

'They will be on the back foot.'

'It is going to take a while to work through, and there will be a little bit of pain on the way, but the feeling is that if it works the way the government sees it working, there will be improvements.

'If that vision, which is a bit motherhood and apple pie, does come to fruition, it will improve things.'

The structural reorganisation is not helped by a change in the resource formula which comes in to force on the same day. It is designed to improve targeting of resources. Deprived areas like parts of the South Wales valleys are likely to benefit, though there will be no losers.

'We think It is a very good idea in principle; There is just a concern about it coming in on the same day.There are also come concerns that it is based on the Welsh health survey which used self-reported health status data.

'We are not overly sure about the methodology. Overall, I think we are better advanced on this than we are on the structural changes, ' said one manager.