The health and social care sector in north Wales is identified to be one of the largest employers in the area, and therefore contributes significantly to the economy. The sector offers over 17,000 jobs in Conwy County Borough Council and Denbighshire County Council. In 2019, it was reported that of 17.1% of all Conwy County Borough employees and 25.6% of Denbighshire’s were employed in the health and social care sector.
Changes within the sector are being driven by demographic change (increased demand for care), social and political factors (including the push for resource efficiency), technology and innovation (advances in treatments and opportunities for patients manage their own health), and growing patient and service user expectations. These drivers are generating skills and performance challenges in all of the key health and social care occupations, as the sector responds to changing demands.
The age profile of Betsi Cadwaldr University Health Board (BCUHB) remains broadly consistent with previous years. The ageing workforce is a challenge for the Health Board, with around 17% of the workforce in the 65 and over age band, and therefore at, or approaching, possible retirement. 14.65% of the workforce is aged 30 and under. Data collected in 2018 shows that 23.3% of the Health Board’s GP workforce was aged 55 and over.
The challenges that impact on the Health Board and ultimately our patients are, the shortage of registered nursing staff and the difficulty that both primary care and nursing homes have in recruiting and retaining registered nurses.
North Wales is experiencing on-going and significant recruitment difficulties. These problems are exacerbated by the rural nature of the area, but are also evident in the urban coastal towns with recent examples of hard to fill vacancies in North Denbighshire. This has been identified as a significant short and long term risk to the provision of primary care services.
Across Conwy County Borough and Denbighshire, the Health Board continues to experience challenges in recruiting GPs and Nurses. The Medical & Dental vacancy rate is currently 7.3% despite efforts to recruit more GPs into the area. Since 1st April 2020, the GP workforce has reduced by 2.86 Full Time Equivalent (FTE), and in the same period the Health Board ran 33 adverts for GPs. We have, however, seen the nursing workforce increase by 38.13 FTE since April 2020 but the current vacancy rate remains high at 15%. Please also note that in recent months there has been a greater emphasis on recruiting nurses from overseas.
Recruitment problems become even more worrying when you consider the age profile of the current workforce. The potential for these GPs to retire early has increased following changes to pension legislation, which benefits highly paid individuals to take early retirement.
Results from a survey focusing on the health care workforce across the North Wales region found that on average, organisations had 5.73 unfilled vacancies for care and support workers. There have been a number of barriers in recent years to recruiting and retaining sufficient number of suitably qualified staff, but the most common is the rates of pay that are able to be offered. The second biggest barrier was competition from other social care and health employers, showing the demand for these services is increasing as there are various employers looking to recruit. Clearly, at the root of this are many factors, including the relatively low wages, high demands, and sometimes a perceived lack of esteem/value in the care career path in particular.
Although a lot of the data to outline the effects of the Covid-19 pandemic won’t be available until a later date, it is evident that the pandemic has had a vast impact on the social care and health sector.
The four harms, which have been used to describe the broad priorities which the NHS and social care in Wales have focused on over the past year, are still relevant.
Harm from Covid-19 itself
Harm from overwhelmed NHS and social care system
Harm from reduction in non-Covid-19 activity
Harm from wider societal actions/lockdown
Since the beginning of the Covid-19 pandemic, those working in the social care and health sector have shown resilience and professional dedication despite the fear of becoming infected and infecting others. The fear of transmitting Covid-19 led many health professionals to isolate from their families for months.
During the first wave of Covid-19, the Health Board held a recruitment campaign across north Wales and recruited retired GPs and Nurses back to healthcare to help fight the pandemic, primarily these were recruited to flexible Bank contracts. Similarly, where planned care services were paused, the existing workforce were redeployed to critical areas most affected. These actions helped to manage the Covid-19 response but the impact on staff has been unprecedented. In the Central community services, we have seen a steady sickness absence rate of around 4.5% over the last 12 months whereas the acute site in Ysbyty Glan Clywd has seen a rise from 6% to 7% over the winter months, which is reducing back down to 6% in recent months. Across the Health Board, the turnover of staff has increased by approximately 0.5% to 8.4% over the last 12 months.
Before the pandemic, the NHS and social care system both had significant staffing shortages. Stress levels for NHS staff were at 5-year highs, and only a third of staff felt there were sufficient staffing levels. Social care has a very high level of staff turnover (almost 1 in 3 leave their job every year) and a quarter of staff are on zero hours’ contracts. The pandemic and building resilience has been an extremely challenging time for staff in this sector.
The stay-at-home policy released by the UK Government was disproportionately affected those in lower paid jobs such as carers as they still had to put themselves at risk. Similarly, 80% of residential care workers in Wales are female, and so the stay-at-home policy has had a disproportionate effect on women. What-is-more, Covid-19 led to a pause in training for some health care workers.
The behaviour changes resulting from social-distancing measures – with the pivot to home working now common in many workplaces – means people are now able to apply for jobs from across Wales, UK and beyond. Furthermore, one emerging consequence of Covid-19 is that people are reassessing their situation and ambitions and are making different life choices, which sometimes involves leaving their roles. With the economic resurgence following the ‘lockdowns’ as a result of Covid-19, potential new employees and some existing employees, are taking up new positions in other sectors.
Since the last well-being assessment was conducted, it is fair to say that the picture as a whole remains the same with many of the same issues arising.
Since 2009 employment in health and social care in Conwy CB and Denbighshire has increased by about 600 jobs, primarily in the ‘other health’ sector. However, employment in residential care fell by about 350 jobs in the period.
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 ‘Supporting an ageing population‘ and ‘increasing pressure on health and social services‘ topics for further 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.
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. 
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.
The number of places for training GPs, nurses and allied health professionals is not sufficient to meet the requirements across the whole of the UK, as well as North Wales. The Welsh GP trainee system which sources trainees from Cardiff Medical School struggles to meet the workforce demands of the North Wales Primary Care workforce economy. Good relationships exist with the North West, both in Liverpool and Manchester Medical Schools, which could be developed further.
The development of the emergent medical school in Chester may also prove beneficial.
In addition to current recruitment and retention initiatives for GPs, the Welsh Government has recently announced the introduction of financial incentives for GP trainees, which include financial support for certain assessment costs and a bursary scheme for trainees who agree to remain in the area during training and for a year of practice thereafter.
Increased training opportunities for practitioners from a wide range of backgrounds is being developed to bring together education and innovation. This includes the development of advanced practitioners across nursing, therapy, pharmacy and mental health, working alongside GPs to ensure that they have more time to concentrate upon providing care for individuals with needs that can only be met by a GP. This will contribute to improved recruitment and retention of the workforce able to meet the growing demands of our population.
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.
Black, Asian and Minority Ethnic health and social care staff are over-represented in lower paid and lower status health and social care jobs in the UK. We were unable to identify Wales-specific information on the progression of health and social care staff by ethnicity. Therefore, it is unclear to what extent it mirrors the trend of decreasing representation as seniority increases, and very low representation at the highest levels of management seen elsewhere in the UK.
‘Long Covid’ is the term used to describe continued symptoms of Covid-19. ONS data cited by the Wales Centre for Public Policy indicate that a higher proportion of NHS staff and teachers have the condition compared to other occupations. This may have long-term implications for the health service and teaching professions, as the we emerge from the pandemic.
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 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).
 Kline, 2015; Race Disparity Unit, 2019; GOV.UK, 2020).
 Wales Centre for Public Policy (2021). Briefing on well-being and the impact of Covid-19 and Brexit.
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