Please note: We need to thoroughly review this topic with partners and communities, including communities of interest. Resources, at the time of this review, are stretched to the limit.
This topic, detailing the increasing demand on frontline NHS and social services has been included in the well-being assessment because of high levels of public interest in the issue and the potential for the public sector to work together in a different way to manage and respond to this demand. Many of the issues discussed elsewhere in this assessment, such as the ageing population structure, the rising numbers of older carers, issues of social isolation, and the number of people living in deprivation, are increasing the pressure on the provision of health and social care by public services. Please read this topic alongside our assessment of social care and health as a key employment sector.
Underlying reasons for the increasing demand include:
increasing need: the changing population – as more people live longer there are greater numbers who develop the conditions that are commoner with age. People also have had fewer children and more people are dependent on public services for care. However, at the same time, the age at which people develop these is getting later and more of us are healthy for longer.
increasing need: chronic conditions – increased diagnosis, medicalisation and a higher proportion of older people had led to a higher proportion of people with at least one chronic condition, and many with multiple. This has led to an increase in the complexity of the care and support that is needed which has contributed to the rising expenditure.
increasing demand, which may not reflect needs that health and social care services can always meet – people’s expectations are rising; technology advances drive NHS costs higher and shift expenditure away from social care; there is a need for solutions that are non-medical, such as social networks, or practical support to maintain independence.
Emergency care – whilst there are obvious season trends in the number of people attending at Glan Clwyd Hospital emergency department (ED, formerly called accident and emergency or A & E), there is a steady increase in the overall number of people using this service. The impact of this rising demand can be clearly seen from the decreasing number and proportion of attendees who have been seen within 4 hours. We previously reported the number of people using ED and raised the question about whether people needed to use ED or whether some of these needs could have been met in a different way, reducing the pressure on our hospitals.
Clearly, our experience of health care and use of health services over the period, during the Covid-19 pandemic – has changed dramatically. We had seen a growth in online health consultations, more so in north west Wales, prior to the social distancing measures imposed during the Covid-19 pandemic. These increased exponentially during the lockdowns, and still continue to be in place for many health services, particularly in primary care. However, there is a growing concern and wish for face to face consultations.
We have seen, and expect to continue to see rising demand for health and social care services at the same time as experiencing recruitment problems in both of these key sectors. A key challenge for health and social-care sectors is dealing with the delays in operations, appointments and disruption to other routine health services caused by the Covid-19 pandemic. It will take some time to ‘catch up’. What-is-more, there is evidence to suggest that demand for mental health support in particular, has increased further following the social distancing and other restrictions placed on people’s lives since March 2020.
Furthermore, ONS data cited by the Wales Centre for Public Policy indicate that a higher proportion of NHS staff and teachers have had Covid-19 condition compared to other occupations. This may have long-term implications for the health service and teaching professions (for example, should ‘long-Covid’ be persistent), as we emerge from the pandemic.
 Source: Performance against 4 hour waiting times target by hospital, StatsWales
 Wales Centre for Public Policy (2021). Briefing on well-being and the impact of Covid-19 and Brexit.
Research conducted nationally by the British Medical Association in 2014 showed that GP consultations had increased by 24% since 1998, with the ‘average member of the public’ seeing their GP twice as often in 2008 as in 1998. Despite this increase in demand, the number General Practitioners in North Wales has remained fairly static. This is putting pressure on local GP services, which is overflowing into hospital admissions.
 Source: General Practitioners workforce headcounts, StatsWales
At the Wales level, while estimates vary significantly, prior to the COVID-19 pandemic, life expectancy increases in Wales looked set to continue, although the rate of increase has slowed over the past decade. However, this increase in life expectancy has not translated in to a higher ‘healthy life expectancy’ (the years someone spends in good health), which has decreased slightly in the past decade. This trend is driven, in part, by inequalities faced by those living in the most deprived areas in Wales, who are most likely to report ill health. Ageing populations are also more associated with higher levels of chronic health conditions and ill health. However, older people tend to provide unpaid care and make valuable contributions to local communities.
Current projections estimate that to meet demand, expenditure on health will grow from 7.3 per cent of GDP in 2014-15 to 8.3 per cent in 2064-65 and from 1.1 to 2.2 per cent of GDP on long term care up during the same period. Projections show that within Wales and the UK as a whole, the old age dependency ratio, which gives an approximation of the number of people being supported by the working age population, will drop considerably over time until 2037. This means that the number of those most likely to require publically funded services will increase relative to the number of economically active people that are able to provide tax revenue. 
Welsh Government’s vision for the NHS in Wales ‘Together for health’ was launched in November 2011 and sets out the aspirations for a high quality, safe, effective and person-centred health system. It aims for:
health to be better for everyone.
access and patient experience to be better.
better service safety and quality will improve health outcomes.
To achieve this requires sustained and long term change to account for the advances in medicine, new technologies and a population that is ageing and living much longer. This means a reconfigured health system fit for today and future years that is built on:
prevention, self-management and home-based services, recognising the important role carers play in helping maintain independence at home.
integrated health & social care centres, partnerships and teams.
hospital clusters, networks and regionally based services.
planned specialisation and consolidation of care into centres of excellence.
‘Together for health’ recognises that the current system needs to radically change and rebalance, shifting services away from hospital to become more preventative and community focussed.
We are likely to see increasing demand due to demographic change, with increasing care provided at home, together with more complex needs as people are living longer.
Positively, life expectancy is predicted to continue to improve (see our ‘ageing well‘ and ‘increasing pressure on health and social services‘ topic for more information). If past trends continue, it is predicted that by 2039 those aged 65 and over will make up 33% of the population, whereas those aged under 25 will make up only 23% (currently those aged 65+ make up 23% of the population, and those aged under 25 = 27%). Because most chronic health conditions are associated with older ages, we can expect the prevalence of chronic illnesses to increase in the same period. Improved life expectancies also mean that people with complex needs are living longer than ever before. As people live longer, the cases of dementia will continue to rise. This could lead to increased demands on health and social care services, and on unpaid carers hyperlink.
Over the next five to ten years, the sector faces rising demand and reduced availability of resources, as well as structural reform. Such changes are likely to lead to a more diverse set of employers operating in the sector and a more joined up approach to service delivery by health and social care staff. Existing occupations are likely to expand beyond their current parameters, and new roles are likely to emerge which fill gaps between the traditional health and social care professions. The potential for economic growth in this sector cannot be understated.
As a result of Covid-19, we have learnt a great deal about the demand and capacity shortfall in our hospitals and wider health and care services. There is a clear need to have sustainable services that can respond to increases in demand for care and referrals into the health and care system. This must be done in a way that supports people to access the right level of services, which may be different from those that have been offered traditionally in the past. We have learnt that we can do things differently and we must build on the innovation and change that has benefitted us during the pandemic.
 Welsh Government 2018-based sub national projections, principal projections
People have commented that it is increasingly difficult to access some services within their community. However, when they are able to access a service virtually it can be positive. Although this is not the case of all, as some people struggle to be seen face to face or feel unable to articulate their issues or concerns confidently in a digital environment.
We need to thoroughly review this topic with partners and communities, including communities of interest. Resources, at the time of this review, are stretched to the limit. We also need to understand demands in relation to paediatrics and safeguarding.
We are not sure currently how we can balance opportunities posed by online services, which can remove travel barriers for instance and produce cost savings for services, with the challenges around the quality of the service from the user’s perspective. How big an issue is this?
This topic does not yet give due consideration to the climate and ecological change needed (mitigation and adaptation).
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