Formal governance architecture such as processes, policies and procedures are relied on at the expense of examining how people actually behave and act, in effect the prevailing culture within which the formal governance processes are operating.

The two authors in this opinion piece are clear that the most immaculate system architecture will be ineffectual if people behave in a way that puts safe and quality services at risk and call for radical change in Wales’ approach to governance. The points made reinforce those made in The Bevan Commission’s recent paper Achieving Profound and Sustainable Improvement in Quality in Wales: An update and call for urgent action.

A large number of reports have found that medical errors are common and harm is affecting between five and ten per cent of patients. Half of this harm is potentially avoidable, but 20 years of research into quality improvement has only brought moderate improvements in the rate of patients who suffer from adverse events.

This report illustrates the value and potential of co-production in the prevention of harm through the experience of patient advocates, safety campaigners, health service researchers and people working in healthcare.

The ‘expert witnesses’ show how impactful patients? engagement in their own safety is, especially in the context of chronic disease when the patient is often the person with the best knowledge of their condition and the person with the best perspective to detect deterioration.

The paper summarises 13 testimonies that highlight how the knowledge of patients and those close to them has the power to prevent serious adverse events. This paper also tries to explore how structure, process and outcomes of health services might be affected by making greater usage of the knowledge, skills and passion of patients and their personal networks. It also explores the likely risks and benefits of technology to facilitate safer delivery of future healthcare.

Key recommendations

In a system that is struggling to manage complex healthcare, co-production between public and professionals has the potential to reduce adverse events and improve safety in the NHS

At no time have the principles of ‘Prudent Healthcare’ been more pertinent: Public and professionals need to work as equal partners to co-produce services, focus on those with the greatest health need first and do no harm, do only what is needed as we understand things with our current knowledge and at the same time reduce unjustifiable variation.

This paper intends to inspire those who require medical care and those who work in health or healthcare policy to explore alternative models in an attempt to reduce avoidable harm.

It is our hope, as authors and sponsors, that we can make this an annual learning event for the public and professionals, that it will inspire changes in beliefs and behaviours and ultimately lead to safer healthcare.

My request:

During times of great stress on the NHS, I’m appealing to all those in senior leadership roles across Welsh Government, NHS Wales and the University Health Boards to proactively involve patients, their wisdom, their experiences, ideas and views in the step-by-step planning that those in senior leadership roles are tirelessly engaged with in order to lead the country in our journey through and beyond the pandemic.

I am writing this Opinion Piece in my role as a Bevan Advocate.

Bevan Advocates are members of the public – patients, carers, and volunteers – who are passionate about the NHS. They provide insights into the real, lived experiences of health and care in order to help in making our NHS in Wales sustainable and fit for the future.

The Bevan Advocate network is potentially one such patient network that could provide genuine and rapid patient response, input and ideas and do so at a pace to meet the needs of Welsh Government and NHS Wales and Wales as a whole.

I make an offer to be part of coordinating that patient response from the network.

The Challenge

The World Health Organisation and governments worldwide have sent a noticeably clear message since the start of the pandemic in January:

“Most people recover, and fatalities are largely only among those with underlying health conditions.”

While the pandemic is strangely having some positive effects, such as the introduction of universal basic income in some countries, and a drop in air pollution, it is generally also making disadvantaged and vulnerable people even more so.

It is clear that various forms of lockdown and shielding will continue for many months, possibly up to two years until vaccines and treatments are widely available.

The four principles of prudent health:

As a Bevan Advocate, I frequently refer to the Principles of Prudent Healthcare, which were developed and refined by the Bevan Commission following consultation. Welsh Government formally adopted these principles as the underpinning philosophy in their 2018 policy document A Healthier Wales: our plan for Health and Social Care.

Achieve health and well-being with the public, patients, and professionals as equal partners through co-production

Care for those with the greatest health need first, making the most effective use of all skills and resources

Do only what is needed, no more, no less; and do no harm; and reduce inappropriate variation

• increases in domestic violence,

• increased numbers of vulnerable children being referred via safeguarding processes,

• a significant and growing negative impact on the mental health of the population with accompanying self-harming behaviours,

• deterioration in physiological health of those who are shielding and less able to maintain exercise.

Doing harm was clearly never the intention in terms of all the immediate decisions that have very sensibly been implemented; far from it. But, many of our approaches to “protecting the NHS and saving lives” are also now unintentionally causing significant harm as outlined above.

Reduce inappropriate variation using evidence-based practices consistently and transparently

Current approaches to lockdown and shielding are proving to be (inadvertently) grossly unfair. They unintentionally have emphasised societal inequalities, leaving:

• disadvantaged families, many of whom are BAME, with young children confined in small living spaces with no outdoor space, and without the finances to provide healthy family meals let alone to fund iPads for home-schooling their children

• the elderly in their own homes when they too deserve to enjoy fresh air and sunshine

• the terminally ill largely home-based, less able to spend as much of their remaining active time that they have with family and friends or to enjoy days out to places they want to visit while they still can

• parents whose children have serious medical conditions terrified of introducing the virus into their household

• children and adults of all ages with learning disabilities including ADHD and Autism confined inside for much of the day and without school to attend

• huge numbers of people of all ages with different health issues confined to being “home alone”; managing chronic illness requires good exercise and mental health and being “home alone” is the antithesis to this

On the other hand, those whose finances are more secure, have larger houses and gardens and a secure income are able to enjoy long walks or cycle rides in the countryside, fresh food on the table or the BBQ in the garden. They have lots of up to date IT equipment to do additional exercise with Joe Wicks, sing in The Great British Chorus with Gareth Malone and participate in online meetings as much as they wish.

Intriguingly, the rural “disadvantage” is turning into an advantage – providing very positive social isolation within a rural location. Soon, the challenges of having necessary medical consultations and avoiding arduous travel to do so, will be addressed as GP and clinician video conferencing facilities are rolled out.

My request

I, like everyone else across Wales and the UK, am hugely grateful for just how much the NHS has achieved against the clock to ensure the provision of expert care for COVID 19 patients. NHS staff are daily working directly with COVID 19 patients and risking their own health and lives as they do so. I cannot thank them enough.

As much as we have needed (and will continue to need) to prioritise COVID 19 and save lives, we now need to look more at reinstating the provision for vulnerable people and those with chronic illnesses. While clinics are ramping up video calls, what are the other areas of support that patients wish and need to be able to access?

I believe very strongly too that we also need to urgently find creative ways of new small steps to amend social isolating and shielding. If it is indeed to take 18 months to arrive back at “normal”, we need to find ways to allow the shielded, the vulnerable, families with young children, the disabled and the elderly to also get out safely into the fresh air, feel the sun on their faces too. To deny fresh air and exercise for 18 months will be hugely damaging in terms of the impact on mental and physical health. Personally, I cannot contemplate that scenario.

As we witness so much transformative change in ways of working, let us not forget the prudent healthcare principles and give the patient voice its full volume in these extraordinary times.

I therefore request the formal involvement of patients and carers in working with health professionals, NHS Wales and Welsh Government to work together and co-produce the steps of our journey through and beyond the pandemic.

Issues on which patient and carer voices (including those from the Bevan Advocates) can really add wisdom, experience and creative thinking include:

• Finding improved ways of approaching lockdown, isolation, quarantine and shielding which properly address the inequalities of the current system and best support the physical, emotional, and mental health of all

• Creatively addressing ways of improving the support for those with chronic illnesses, ensuring the best clinical support, while supporting positive emotional and mental health for all and addressing inequalities of access

• Ensuring that that any phased return addresses greatest needs first and in ways most acceptable to those with the greatest needs

• Identifying elements from these scenarios that can be included in the long-term transformation of NHS Wales

Becoming a Bevan Advocate:

Bevan Advocates are members of the public – patients, carers, and volunteers – who provide insights into the real, lived experiences of health and care to help to transform the NHS. The Bevan Commission’s programme welcomes new members who are passionate about contributing to health and care and making our NHS in Wales sustainable and fit for the future.

If you are interested in becoming a Bevan Advocate you can find out more here.

More info

The Bevan Commission ran two public events (one in North Wales on 2nd July and the second in Cardiff on 17th July 2019). The events are part of the Commission’s ongoing commitment to meaningful engagement and embedding the co-production principle in its work.

Throughout the events, participants explored questions around how health and social care is funded, were asked questions around taxation for services and offered their ideas for a more prudent health and care system.

In this report, key areas identified for action include:

• Improving communication both with patients and between clinicians and services
• Improving access to primary care
• Giving due consideration to the time and convenience of patients rather than what is convenient to the service
• Focusing on what matters to patients as they move towards end of life (which is rare to be admitted to an acute ward)
• The NHS regarding those who raise issues about current services as allies in the improvement journey and not as ‘troublemakers’.

The other evening, in our house, we broke the ‘stay at home’ isolation directive during this coronavirus pandemic. At eight o ‘clock we stepped outside our front door to join in the nation-wide ‘clapping for carers’ applause, in support of NHS staff. Oh yes, as neighbours, we were all in self-isolation, but yet, we were together, social distancing, in a group and part of a massive crowd stretching to every corner of our country.

Occasions such as this night make the mind meander, reflect and ponder… isolation, yet in a crowd. I turned over a relatively recent page from my memory. Lying in a bed in Ward 7 of Prince Charles Hospital in Merthyr Tydfil eighteen months ago, at about eight o’clock of an evening, I became aware of a low pitched hum. It proved to be the window blinds automatically easing down, to close.

Now, I would venture to suggest that the lights of Merthyr Tydfil were never going to challenge Las Vegas, but I needed to see them. They were my link with the outside world. In the hours that followed, darkness was joined by a new relative – isolation – even though I was in company, with other patients and the ever attentive support of the night shift staff.

Oddly, that feeling of being cut-off from the world, had happened before, twice, both in a medical landscape. In 1962, South Wales was hit by a small-pox epidemic.

International sports events were called off and life became threatened and insecure, even for students like myself, who felt, naturally, invincible. I ended up in the sick-bay, having been felled by the small-pox vaccine jab. It was a quarantine corner that, gradually, became crowded.

A few years earlier, in my embryonic early teenage years, I ended up in Morriston Hospital in Swansea, late at night, having fallen off a flat roof in the dark. Don’t even ask or wonder as to how it came about, it was embarrassing for an acne bedecked thirteen year old and very painful.

On that first night, isolation and loneliness set in, even though the sounds of the night gave me hints that I was not entirely alone. I was to learn later that I was in a ward of thirty beds, all in the one long room. The camaraderie of the early mornings and the dawning day, raised the spirit, even though they were the old days. Matron, clearly a direct descendent of Boudicca without any blood mix, would ‘pay a call’. If you were ill in bed, you had to be ill tidily, no crimpled bed-sheets tolerated. Visitors were constrained in numbers, two to a bed, no children allowed. They had to be held up to a window to wave to their grand-parents, much like these days of coronavirus non-contact and isolation. If you found yourself as one of three around a bed during ‘visiting’ and the clarion call went up that ‘ Matron was on her way’, you quickly looked for a bed with just one visitor, or none at all, then you swiftly moved to it, indulging, possibly, in intimate medical conversations with someone you didn’t know at all.

The hospital regimes, and the wider health field, had order, respect, responsibility and discipline in those days – it was accepted. Society, these days, in many scenarios and in the minds of those who challenge norms at every turn, does not allow that acceptance to lie comfortably with their freedom of everyday life as they see it. Selfish behaviour, by a sizeable minority, in the face of directives given during this health crisis, is proof of that. Social distancing, reasoned behaviour and self isolation are far from some wayward minds. Thank heavens for the reasonable majority.

The coronavirus crisis is testing in the extreme for everyone, causing immense stress in the health and care sectors in terms of provision. The cohesion of society is being stretched beyond measure, but communities will rally and individuals will respond wonderfully.

The simple event of that special night, the 8 o’clock ‘clapping for carers’ gives hope. Neighbours, who years ago, perhaps lived in a street where, over the back wall, a ‘chat and check’ unofficial care system was in place could possibly and hopefully, just have resurrected that system. I have a strong suspicion that life has changed and will continue to enhance in the coming months, our attitude towards our fellow beings; on this planet, and on your road. The community and national spirit of goodness will prevail.

Good will come from this extreme adversity and the National Health Service will grow from this. In my privileged role as a Bevan Commissioner I have the opportunity to see the NHS at close quarters. The Bevan Commission is Wales’ leading health and care think tank, bringing together a group of international health and care experts to provide independent, authoritative advice to the Welsh Government and leaders in Wales, the UK and beyond.

The Bevan Commissioners provide an independent lens to vet and view progress and performance in the health and care sectors of Wales. They represent a cross section of professional and highly respected practitioners, managers and academics, with huge swathes of past, or present experience across the whole spectrum of health provision and practice. Their aim is to ensure we have a sustainable health and care system that is fit for the future – and recognisable to its originator Aneurin Bevan.

Through our Bevan Advocates, who have experience of treatment within the NHS and Bevan Exemplars, who are innovative practitioners, the Bevan Commission gleans ideas, procedure and possibilities and canvasses boards and government, to instigate action and to help translate its thinking into practice.

I hasten to add, that I am at the ‘pavement’ level’ the patient and customer end of the service but I like to think that I can somehow represent the view of the people. And one thing I think would be shared by many, is the hope that after this distressing and challenging time, the NHS will be re-energised, even further respected, a pillar and back-bone of what this country is and stands for.

As for the NHS and care staff, over the past weeks and in the face of pressures yet to come, they have displayed an extraordinary selflessness, professionalism, commitment, co-operation and sheer bravery. The number of volunteers, hundreds of thousands, who have joined its ranks to help, express a groundswell of support, indeed of love, for the service. This is truly uplifting.

It is vital that once this crisis is over the NHS, over the combined sectors of health and care, will be encouraged and supported in innovation and development. It is a jewel which is precious and invaluable to have.

Roy Noble is a writer, broadcaster and a Bevan Commissioner. 

Here I am in rural South East Wales preparing this paper. I live next door to the village church and I normally hear church bells and congregational singing on a Sunday…but no more. Sundays are silent now. Even our church doors are locked. This killer virus is affecting society in so many ways. We all are worried and know people that are ill or that have died from it, so we must learn from this experience for our future generations. In that spirit, I give my thoughts as follows:

• Service providers and individuals have stepped up to the plate – NHS staff at all levels, care staff in the community, in nursing and residential homes have all been amazing and simply got on with the job. However we must not underestimate the profound effect of this situation on staff wellbeing. Staff have had to retrain and in some cases relocate to new environments. Many have been supporting the very sick and dying in their last hours, and the impact of this must take its toll. So support from local networks as well as professional support and counselling will be required to deal with ongoing stress and mental health issues. These staff have been going into work daily not knowing if they (or their families) will be safe. They have shown total commitment and bravery. We must recognise this and reward it and we must treat social care professionals and carers the same as health staff.
• There has been underfunding in the NHS and cuts in Local Authorities for many years which has left us poorly equipped and on the back foot. There have been a need to significantly increase intensive care beds and ventilators and there has been chronic shortages of PPE for health and social care staff. When I was a teenager, the South Wales valleys were scattered with clothing factories; Polikoff, Berlei, and later Burberry. These business employed many people -mostly women- who were skilled seamstresses. They would have been able to turn out PPE at breakneck speed. Instead, these places are closed and we are now dependent on importing the things we most need from around the globe.
• We must be better prepared and plan. Whilst the likes of Bill Gates predicted this would happen and argued that we had to fund and plan for this, governments world-wide largely ignored the warning. Instead, we are now spending billions on supporting the economy and building hospitals on rugby pitches. We have spent money that we didn’t have on the things that matter- saving lives. We need to stockpile the equipment we need for the future. We have to be agile and flexible to prevent it from happening again and respond overnight if the risks become apparent.
• The WHO has a future role to ensure that countries take responsibility for containing infections and how they are reported. We must learn from each other as actions taken by some countries appear to have resulted in fewer deaths and better economic outcomes.
• Society and our citizens have been amazing. They have obeyed government instructions to keep safe, done extraordinary things to raise money. Some 405,000 people so far have signed up for volunteering. We must capitalise on this and harness this energy and commitment to support communities post the pandemic.
• Stop doing the stupid stuff. It’s surprising that we now have money that we never had, we are not counting things just to tick boxes. We must work differently, use the services that we have responsibly and radically change for the future.
• Let’s not go back to the ‘old normal’ and do the same role, as in many areas it wasn’t working. Let’s grab the possibilities that this awful crisis has forced. In particular, fully integrate health and social care, roll out at scale and pace new technology and take full advantage of the community capital which we have now energised.
• Ensure everyone has accesses to IT at home. This pandemic has required us to do things differently. We have been Zooming, Facetiming and Skyping. IT enables us to order food on line, exercise each day, learn a language- the opportunities are endless. However there are a number of our older generation who may need help and support to set this up so that they can have the full benefit. Not only will it enable them to access the world but it will also keep them in touch with families and friends and prevent loneliness and isolation. I think this is a priority for the future and maybe a charity- with the help of the volunteers mentioned above- could be funded to do this?

On a more personal note, the NHS is very precious to my family, as it is to the whole of the society. However it must be acknowledged that social care plays as an important role. All staff who work in the caring professions need to be recognised for their dedication, loyalty and commitment. I have recently been re-reading Nye’s book ‘In Place of Fear’ (due to be re-released in July in print and as an e book) and although written in 1952, much of its content still resonates today.

“Society becomes more wholesome, more serene, and spiritually healthier, if it knows its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide”.

Imagine for a moment what our world would now be like without the NHS and social care?

The silence has been recently broken by the bells being rung for the Thursday night ‘Clap for Our Carers’ initiative. It is so very lovely to hear. So to all the staff caring for sick and vulnerable people in hospitals and the community, to all those other services and key workers who are being amazing, stand up and take a bow- you deserve all the applause you are getting.

Written by Nygaire Bevan, Bevan Commissioner, with contributions from Mr Sukh Singh Dubb- OMFS, MBBS (Hons) BSc (Hons) MRCS BDS (Hons), Registrar in Oral and Maxillofacial Surgery, Addenbrooks Hospital, Cambridge University Hospital.

Whilst it is clear that both the UK and Welsh Governments have made significant efforts to mitigate some of the economic impacts of Covid-19, the situation for those in a previously economically precarious position and for those whose income has significantly reduced remains very difficult. Whilst we are all in it together in facing the threat of Covid-19, it is important to recognise that its economic and social impact is not evenly distributed. Even prior to this pandemic, 11.5million people in the UK had less than £100 in savings to fall back on and more than one quarter of Welsh households did not have enough savings to cover their regular income for just one month. It is clear that there are gaps in the effectiveness of current governmental support. Additional Welsh Government funded support has partially filled some of these gaps in Wales. These proposals for the Welsh Government were documented in the Citizens Advice Cymru report ‘Helping people through the Covid-19 pandemic’, but the impact of many individuals will still be massive.

With many individuals having been made redundant, having reduced hours or being put on furlough, many are trying to manage on reduced incomes. Those most impacted by this are people whose income was already precarious. The self-employed in Wales make up 13% of the workforce aged 16-64 (183,000 people) and the majority of these have experienced immediate and near total loss of income. Many of these will not fit the criteria for obtaining government support. In the last two weeks of March, the volume of Universal Credit claims increased from an average of 100,000 in a two-week period to 950,000 claims. The delays in initial payments, the low level of the benefit and the difficulties being reported by people trying to make this claim remotely, are all extremely concerning.

Universal Credit and information about employment have been the focus of many enquiries to the Citizens Advice website in the recent past indicating these issues are the main concerns for people. The information via the Citizens Advice Twitter feed (see graph below) reflects the surge in claims. There were 185,000 page views on Citizens Advice Universal Credit advice pages in a single week, a staggering 265% increase on the same week the previous year.

Source: Citizens Advice

Given the situation with people’s income, Citizens Advice predicts that difficulty with paying bills and debt in general will grow. While it is true that the UK government has been fairly bold on helping with debt – including mortgage holidays and evictions being banned- these are all delaying arrangements (the debt remains but payments are put back). The worry is that these arrangements may come to an end while people’s incomes have not recovered in the same timescale. The risk is that debt problems will accumulate even while these protections are in place resulting in a tsunami of bankruptcies, evictions and service disconnections later.

While the concern about the future approach to debt will, if not managed well, lead to an increase in housing and homelessness problems, one bright light is that when a crisis drives policy, it is possible to make a huge difference to street homelessness. Given the direct and serious impact of poor housing or homelessness on ill-health, the continued provision of affordable and appropriate housing for these individuals should remain a priority. It will be important to remember what has been so rapidly achieved on a situation that was previously described as impossible to address!

We have been driven to quickly adopt many new ways of working and there have been major changes to ways of contacting the NHS, including video links and telephone services. It is important that the country does not simply revert to the previous ‘business as usual’ once this crisis ends. It is already clear that many people have taken a different view as to what is an emergency as opposed to a more general health concern, from the huge drop in attendances at emergency departments. People need to be encouraged to undertake better self-assessment (and self-treatment in many cases) in the future. Access to primary care looks to have improved as people can get a telephone call back the same day rather than waiting days or even weeks for an appointment.

If this situation has not taught us the singular interdependency between health and social care, then we have been blind to the work currently being done. Likewise the mismatch in resources between the two sectors, which previously existed and continues to do so, (for example in access to Personal Protection Equipment).

Overall, I see the potential for an eventual positive outcome; which may make the horrendous losses of this epidemic seem meaningful. This can be a catalyst for changing our approach to the economy, for tackling the inequalities currently endemic in our society and how we measure success (a focus on wider wellbeing rather than purely wealth).

Accepting and understanding the direct link between the universality of access to health and social care and the need to ensure the economic health and appropriate housing for everyone is vital if we are to achieve equality of outcomes. Progressive taxation remains the most important weapon in the government’s armoury to provide universal access to essential health and care. The delivery of health and care must be based on the principle of maintaining wellness and in particular ensuring a sound foundation of health for all.

This is the moment to be bold (as Aneurin Bevan was in his time) and genuinely consider a form of Universal Basic Income based against the real Living Wage and managed through the taxation system to ensure those with the least are supported.

This is the moment to properly reconsider the impacts of monetary and benefits policy on disabled people and ensure that the aim of any scheme for Universal Basic Income is to enable full participation in society for all. I acknowledge that there is a cost to this. The economic cost of Covid-19 will have to be met and taxation will inevitably need to increase.

I propose that we measure the success of our response to this crisis (in part), by whether Wales has also risen to the task set by Sir Michael Marmot in his latest report on health inequalities:

“There can be no more important task for those concerned with the health of the population than to reduce health inequalities”

Fran Targett OBE was until her retirement in 2019, Director for Citizens Advice Cymru and is a Bevan Commissioner.

As the Covid-19 situation develops, health and care services continue to work under unprecedented pressure. Across health and social care, staff at every level have adapted to the unique challenge – taking on great personal risk in the process. 

As last Friday’s VE Day celebrations marked the victory and the personal losses of so many 75 years ago, we are all starkly aware of the lives lost to Coronavirus.  Each life lost leaves families irreplaceably bereaved. 

Just as in the war, shortages of equipment mean improvisation in the face of increased risks, so today staff had adapted rapidly.  People have not abandoned their posts.  Some of our lowest paid have borne the brunt of frontline duty, exercising great skill and human kindness at the same time. 

As we plan to emerge from this crisis, we need as a nation to decide what we value and which old practices we will abandon.  In the long haul ahead, Health and Social Care services will need to maintain their vigilance more than ever to ensure that places of care do not become reservoirs of infection. 

People with serious non-Covid conditions need treatment in isolation from Covid risks. 

The place of remote consultations by telephone, emailed photos and videoconference will become a permanent feature of much of healthcare, with pharmacies accepting emailed prescriptions.  For security, they will need remote access to records. 

Perhaps the greatest challenge will be how the population views healthcare and people’s expectations from the NHS.  Covid has shown us all that the most dangerous of conditions are often out of reach of modern medicine – diseases, like criminals, are one step ahead as we try to catch up to gain some control.

Emergency Departments must be reserved for major trauma and life-threatening urgent conditions.  They must never again be crowded places, with people sent there ‘to be checked’.   

Those in the community who are ill must be seen, diagnosed and treated in the community – that requires 24/7 services that are rapidly responsive – not sent to Emergency departments where they wait with others before returning home again.

The care sector has been revealed to be the most vulnerable of all – the heroes of yesteryear reside there now.  We owe to many of them the freedoms we take for granted and the peace in which most of us have lived all our lives.  Their lives are reservoirs of wisdom, experience and resilience.  They are the Second World War survivors of the ultimate sacrifice that gave us our freedom; we call them heroes.  Yet they have been living out their last days often dependent on social care.  Now, during this pandemic those who care for them have been their advocates.  Many of these carers sought refuge here in recent times from repressive political regimes and have served this new homeland of theirs by risking their lives to care.  It seems history has gone full circle.

The care sector, often relatively neglected and underappreciated, must be brought into the benefits of the NHS.  Staff need secure contracts; they need training to build on the skills they already have.  In communities, specialist medical and nursing services need to recognise nursing home medicine as a distinct and important discipline to minimise frailty and value lives.

The local cohesion that many describe during lockdown creates a foundation for better communities.  Behind closed doors alcohol abuse has flourished, frayed tempers and disordered minds have result in violence, all too often the victims are children.  As we emerge, everyone must be open to recognising the unthinkable in our midst and be prepared to step forward to speak up for those who for whatever reason cannot speak up for themselves.  It is only by a zero tolerance to abuse in all its forms will the future be better.

During this crisis, we have learnt to appreciate each other, the value of human relationships, the nature around us and our responsibilities to each other and the planet. Days for those bereaved will never be the same.  Children suffering loss at many levels will need a strong society, exemplified through excellent teachers, to keep them safe and give them confidence to achieve their potential in their lives ahead.

With the passage of time, the world will reflect on the Covid-19 crisis and seek to identify lessons that can be learned.  Ethicists may conclude that the predominant emphasis on individual autonomy and personal ‘choice’ gave way to recognition that we cannot control those things that really matter.  No one chose to get Covid, yet many have died from it.  Covid has shown the intrinsic value of each human life, however vulnerable, and the powerful interconnectedness of human relationships. 

Society may look to politicians to chart a way forward, but the task will not be easy. 

Perhaps society has turned on its head; our resilience lies in the ability of every person to rise to the occasion, the creativity to find solutions and to generosity of spirit.  We have seen how rapidly, and selflessly, public services have changed to meet the crisis. 

Without people in good health of mind and body, who look after each other, our economy cannot be rebuilt and those services that we have taken for granted will not be there.

The Covid-19 global pandemic is a health emergency unlike any other we have experienced in our lifetime. Increasingly, it is bringing attention to the mental a physical health impacts of the crisis, and in so doing shining a light on some stark realities.

Realities that have always been there but which now stand out much more noticeably.

In ‘normal’ times, we know that about one in four of us experiences a mental health difficulty of some kind, most commonly depression or anxiety, although poor mental health can affect anyone, and most of us at some point in our lives.. That makes mental health problems among the most common health conditions of all, affecting every family, every workplace and every community.

However, we know that our chances of having a mental health problem are far from equal. Children from the least wealthy households are four times as likely to have a mental health problem by the age of 11 than those from the wealthiest. Rates of mental ill health are twice as high among people with long-term conditions, people with learning disabilities and older people living in care homes, while people from many Black, Asian and Minority Ethnic communities also face a higher risk of poor mental health in adult life. We now know from a growing evidence base that our mental health is influenced by our environment at every stage in our lives, and that poverty and inequality, fear and insecurity, violence and abuse, and loneliness and isolation all put us at risk of poorer mental health. Put simply, inequalities in society drive inequalities in mental health.

Sadly, many of these same inequalities are now being seen to put some people at a higher risk of developing severe illness from coronavirus, and of losing their lives.

We do not yet know whether people living with a mental illness are at a greater risk from coronavirus. But we do know that the virus itself, and the measures being taken to try to control its spread, are having a damaging impact on people’s mental health and likely to lead to an increase in poor mental health across the population over the next year. The trauma of being treated in intensive care, of losing a loved one in such troubling circumstances, or of working in hospitals treating people with the virus, are likely to have put people at greater risk of mental health difficulties both immediately and longer-term.

For many more, a loss of livelihood resulting from the lockdown, increased exposure to violence and abuse at home, and the effects of quarantine in reducing social networks will all have significant effects on mental health. While most people who are feeling frightened, stressed and anxious now will recover quickly as we return to some kind of normality, for many the psychological legacy will last much longer and cause long-lasting distress.

These are troubling realities, but we can take action now to protect and promote mental health, to offer effective help to people who need it and to bring about lasting change as a legacy from the crisis. We can equip schools and businesses with the knowledge and tools they need to enable children and adults to return to ‘normal’ in a safe and secure environment to help them to process the trauma many have experienced in their own ways. We can ensure that people who have been treated for coronavirus or suffered a bereavement are offered help for their mental health so that they know support is there if they need it. We can reach out to people with long-term conditions, offering psychological support alongside the care they get for their physical health.

By putting our mental health at the heart of the recovery from Covid-19, we can help heal society both immediately – in addressing some of the most serious effects of the pandemic in communities – and for the long-term, making changes to health and care that have been needed for some time but which are now more important than ever.

The Bevan Commission believes it is uniquely placed to provide independent counsel and support to Welsh Government in reviewing the impact and informing ongoing plans and developments of Covid-19 on various aspects of Wales’ life and service provision.

This paper aims to provide Commissioners with an overview of some of the main areas arising from the Covid-19 crisis during the last few months. It highlights a summary of some key issues and early findings based upon available information in the following 6 areas:

• Contingency preparations/modelling
• Lockdown
• Test and Trace
• The NHS and Social Care
• Health Inequality
• Communications

The paper acknowledges the uncertainty of some information, lack of robust evidence and the changing circumstances presented as Covid-19 unfolds. It tries to avoid over use of hindsight to criticise decisions made by those who faced (and still face) uncertainty as to the correct course of action and for which ‘the science’ does not always provide a clear way forward.

The opportunity is taken to provide a brief insight into how these issues may impact on the future, but in the main, this short paper reflects on experience to date which taken with wider evidence – will be used to inform the Bevan Commission’s future thinking, actions and next steps.