Evaluation of 'More than just words' the follow-on strategic framework for Welsh language services in health, social services and social care, 2016 to 2019 (summary)

'More than just words' is the strategic framework for Welsh language services in health, social services and social care in Wales. The original framework was launched in 2012, and the follow-on framework, which is the focus of this evaluation, was launched in 2016. The aim of the follow-on framework was to promote and support the use of the Welsh language across the sector, focussing on seven key objectives.

1. National and local leadership, and national policy
2. Mapping, auditing, data collection and research           
3. Service planning, commissioning, contracting and workforce planning 
4. Promotion and engagement        
5. Professional education
6. Welsh in the workplace     
7. Regulation and inspection

The aim of this evaluation was to assess how and to what extent 'More than just words' has achieved its intended aim, as well as to identify barriers and facilitators to implementing the follow-on framework’s seven objectives. The report focuses on the findings and conclusions of the final evaluation research and analysis. Previous phases of the evaluation set out a theory of change and the evaluation framework.

Evidence was gathered through qualitative interviews with stakeholders, service users, and university students studying health and social care courses. This was supplemented with desk-based research, which involved reviewing national and local strategy, policy and planning documents, as well as research documents and existing data.

National and local leadership, and national policy

The 'More than just words' follow-on strategic framework considers leadership at a national and local level to be a key requirement in ensuring that use of the Welsh language is strengthened across the sector. Stakeholders perceived that support for the Welsh language has increased amongst many, but not all senior executive personnel across the sector. However, this support does not appear to have been sufficient to prompt the sector-wide changes required to meet the aims and objectives of 'More than just words'. The findings also suggest that strong leadership support demonstrated by Welsh Government ministers when the framework was first launched in 2012 has become less prominent in recent years.

References to the Welsh language and 'More than just words' are included within many national policies. The findings indicate that these references in national policies are reflected in similar references being included in many local strategy and planning documents, particularly within social care and social services supported by local authorities. However, there were few examples of how the references within local planning documents have been used to inform and guide actions in practice, particularly within the health sector.

Mapping, auditing, data collection and research

The evidence suggests that progress has been made in recording the Welsh language skills of the workforce, particularly across health boards through the electronic staff record. However, gaps remain in the data, particularly in primary care. Very few examples were identified of how the data gathered has been used to inform workforce development and service delivery plans.

Examples exist of processes that have been in place to gather data relating to the language preference of service users. However, the evidence suggests that these processes have been inconsistent both within and across settings. Few examples were identified of how this data has been shared between service providers or used to guide service delivery.

The findings suggest there has been support to develop Wales-specific digital healthcare systems. However, stakeholders indicated that the availability of digital healthcare systems through which data can be gathered, accessed and shared in Welsh, and those which can record and share the Welsh language preferences of service users, is limited. Some stakeholders suggested that the Welsh language has tended to be considered as a ‘bolt on’ to systems once they have been developed rather than at the design stage.

Research identifying the need for Welsh language service provision and the Active Offer is available, and the findings indicate that this research has been used to good effect to influence Welsh language policy across the sector. Stakeholders were of the view that in order for this research to influence practical service delivery changes, it needs to be accompanied by evidence on effective service delivery interventions and examples of identified good practice. 

Service planning, commissioning, contracting and workforce planning

Very few examples were identified of actions relating to the Welsh language included in service delivery and workforce development plans, or bilingual skills strategies, that had been implemented in practice. Pockets of good practice were identified; however, these practices had not been implemented in a consistent manner across the sector. Stakeholders were of the view that, in many cases, these pockets of good practice have been driven by the efforts and enthusiasm of individual Welsh language officers and/or other practitioners. The evidence also suggests that there may have been an overdependence or unrealistic expectations placed on Welsh language officers and champions in relation to the extent to which they could influence sector-wide changes in Welsh language service delivery.

Stakeholders suggested that the implementation of actions to strengthen and support the Welsh language has in many cases been limited by a lack of understanding of how to put the aspirational aims included in local plans and strategies into action. Further barriers identified include a reluctance among some workers to use their Welsh language skills, often due to a lack the confidence in their Welsh language skills or fears of miscommunicating important clinical information in Welsh; a reluctance among some managers to include Welsh language skills as a requirement within job descriptions; a lack of data to justify allocating resources; and limited financial resources. The findings demonstrate, however, that Welsh language officers and champions have tried to address these barriers by raising staff members’ awareness of the importance of Welsh language provision and the need to deliver the Active Offer in order to encourage them to use more of their Welsh language skills.

Promotion and engagement

One notable change since the introduction of the follow-on framework has been the use of ‘Working Welsh’ lanyards and other visual markers by practitioners across the sector to notify others that they are Welsh speakers. Evidence from stakeholders and service users suggests that this has increased the ability of service users to identify Welsh speaking staff and their confidence to engage with them in Welsh. However, stakeholders noted that some practitioners have remained reluctant to identify themselves as Welsh speakers, often due to the confidence and fear issues. Some service users noted, however, that even the use of some Welsh by practitioners could make a big difference to them.

Some stakeholders were of the view that examples of good practice in relation to delivering services that meet the Welsh language needs of service users should be more widely celebrated and applauded. Also, information relating to good practices could be further shared across the sector to encourage their replication elsewhere.

Few examples were identified of activities aimed at school and college students to promote the advantages of having Welsh language skills for careers within health, social care and social services. Stakeholders indicated that more could be done to raise young people’s awareness of the opportunities to use Welsh language skills in careers within this sector.

Professional education

The evidence indicates that significant progress has been made in the provision of new Welsh language courses in health and social care, and in the focus placed on the Active Offer within existing courses. This has included large increases in Coleg Cymraeg Cenedlaethol’s investment in Welsh language and bilingual higher education courses and modules in health and social care. It has also included a requirement within a new contract issued by Health Education and Improvement Wales (HEIW) to education providers to offer annual sessions to raise students’ awareness of the importance of the Welsh language in delivering healthcare services. However, some stakeholders reported that progress in provision has not necessarily been accompanied by significant increases in the demand for and take up of Welsh language courses.

Welsh in the workplace

Stakeholders referred to various examples of Welsh language training offered to, and taken up by, members of the workforce. Most training has been aimed at new learners. Fewer examples were identified of training aimed at staff with intermediate or higher-level skills, although stakeholders noted that it is these individuals who are most likely to use the language if they have the confidence and opportunity to do so.   

The general approach has been to gently encourage take up. Stakeholders considered this to be an appropriate approach, given the high level of work pressure on staff. However, this approach does not reflect the targeted training the follow-on framework suggests is required to achieve significant increases in the Welsh language capacity of the workforce. Some examples of more targeted training approaches were identified, such as the National Centre for Learning Welsh and Social Care Wales’ development of a sector-specific training scheme for the social care workforce.

The findings identified some barriers to accessing the training available. These included a lack of time to attend face to face training; fear (particularly amongst some social care workers) about the academic expectations; and the reluctance of some employers to offer this training as they considered it difficult to retain staff who have Welsh language skills.

Stakeholders noted that supporting staff to improve their Welsh language skills does not by itself ensure an increase in the use of the language in the workplace. Many workers who can speak Welsh do not use it in the workplace. Rather than support to further develop their language skills, these workers need encouragement, support and the opportunity to use the Welsh language skills they already have.

The evidence suggests that progress in implementing processes aimed specifically at recruiting more staff with Welsh language skills into the workforce appears to have been limited in many areas of the sector. Stakeholders noted a general reluctance to include the Welsh language as a required skill within job descriptions, particularly for hard to fill vacancies. The findings suggest that more progress has been made in raising awareness of the importance of Welsh language services and the Active Offer amongst new recruits during the induction process.

Regulation and inspection

The findings suggest there has been a lack of clarity on the division of responsibilities for regulating and holding the health, social care and social services sector to account in relation to progress against the aims of 'More than just words'. Stakeholders reported that the statutory obligation to meet the Welsh Language Standards set by the Welsh Language Commissioner has become the main factor that holds organisations to account in relation to delivering services in Welsh. The standards came into force for social care and social services in 2016 and NHS organisations in 2019. However, primary care services remain exempt from the standards, which stakeholders suggested has limited their emphasis on delivering Welsh language services.

Service user views

Evidence from service users suggested that the availability of Welsh language services and the Active Offer has varied across geographical areas in Wales, largely in line with variations in the proportion of the local population that speak Welsh. However, service users noted that Welsh language services, particularly specialist healthcare services in hospitals, were often not available at all even in areas where Welsh is the language predominantly spoken.

Many service users reported they were reluctant to ask for a Welsh language service when it was not offered, particularly in hospitals. Some service users, including those who spoke Welsh and English fluently, noted that receiving services in Welsh had a positive impact both on their overall experience and in many cases on their health and wellbeing outcomes.

Evidence from service users suggests that the availability of bilingual information has differed across services. Some service users noted that Welsh versions of print or online information often includes terms they are not familiar with, or does not use plain Welsh. This, in their view, makes the information difficult to understand.

Influence of COVID-19

COVID-19 may have a long-term (possibly permanent) influence on the way the sector operates, with implications for Welsh language services. It has reaffirmed the importance of Welsh language services, particularly for vulnerable individuals. COVID-19 restrictions prevented relatives or friends from accompanying or visiting these individuals at health or social care settings, and therefore their ability to support communication or offer words of comfort and encouragement in Welsh.

Stakeholders reported that COVID-19 has also created some opportunities, including greater use of online technology to improve access to information, including online Welsh language training to some workers across the sector. It has also created opportunities for some Welsh speaking practitioners to provide online services and thus reach more Welsh speaking service users across a wider geographical area.

The evaluation findings demonstrate that some progress has been made in relation to each of the seven 'More than just words' objectives included in the follow-on framework, although none of them can yet be considered to be fully met. Overall, the findings suggest that the strategic aims of 'More than just words' may have gained more traction within social care than they have within health.

Areas of progress

'More than just words' has set a clear strategic direction and raised awareness of the need for a continued increase in the provision of Welsh language services. By placing the principle of the Active Offer at the heart of its strategic aims, 'More than just words' has conveyed the importance of Welsh language service provision not only as a right or a choice, but also as an essential need for many Welsh speaking service users.

Regarding specific objectives, the evidence suggests that key areas of progress include an increase in the use of visual markers to identify Welsh speaking staff; the investment in Welsh language health and social care higher education courses; and an increase in the focus placed on the importance of Welsh language provision and the Active Offer, both within higher education and within inductions for new staff members. 

Achievement gaps

Gaps remain in the progress achieved across all seven of 'More than just words' objectives. In particular, the evidence indicates that 'More than just words' may have successfully won the hearts and minds of many strategic level policy makers and frontline practitioners, but less so at the operational planning level. A discrepancy is evident in many areas of the sector between understanding of the importance of Welsh language provision and understanding of how to deliver it effectively in practice. As a result, Welsh language services within many settings have been more limited than they should have been, and the Welsh language skills available have remained underutilised. Training to date has not been strategically targeted towards specific areas of the workforce where the greatest need for Welsh language skills have been identified. Also a lack of consistent data relating to the Welsh language skills of the workforce as well as the Welsh language needs of individual service users, accompanied by a lack of available systems and processes to gather and share this data, have been further barriers to fully achieving the framework’s objectives. 

Understanding of the role of, and need for, 'More than just words' appears to have become less clear among some stakeholders in recent years, in particular following the introduction of the Welsh Language Standards. The findings indicate that there is a continued need for 'More than just words'. However, its role may need to change from being a strategic framework upon which the sector can plan provision, to being an enabler, supporting and guiding the sector to implement practices that support the delivery of Welsh language services and the Active Offer. There is a need to ensure the sector understands how it can complement rather than duplicate the standards.

Recommendations

• As 'More than just words' is now a well-recognised and strong brand, there is a need for Welsh Government to continue to use it and the fundamental principles it represents, to support and lead the way in strengthening the use of Welsh in the health, social services and social care sector.
• The Welsh Government should ensure that 'More than just words' evolves from a strategic framework for Welsh language provision into a three to five-year implementation framework that offers practical guidance to support the sector to increase its use of the Welsh language and progress further towards delivering the Active Offer.
• Within its role offering practical guidance, the Welsh Government should ensure that 'More than just words' takes on the role of an enabler, supporting the sector towards implementing practices that adhere to the Welsh Language Standards. 
• Service providers across the sector should continue to document examples of practices relating to the way they use the Welsh language across the sector. The Welsh Government should consider establishing a central online portal to facilitate the process of gathering these examples and to make them widely accessible across the sector. Examples of successful implementation of policies and practices that support the Welsh language and the Active Offer which the Welsh Government also consider to be good practice should be further recognised and celebrated under the 'More than just words' brand.
• The Welsh Government should, using the principles of 'More than just words', continue with efforts to win hearts and minds through its focus on the Active Offer and use of service-user focussed examples to illustrate the need for Welsh language provision. This will be a key factor in supporting the shift in culture required to encourage sustained increases in Welsh language provision. 
• Individual health boards and other sector representative bodies should appoint a member of their senior / executive team as a 'More than just words'champion. These champions would have responsibility for encouraging and supporting the implementation of practices that support the Welsh language and the delivery of the Active Offer within their settings.
• The Welsh Government should, under the 'More than just words'brand, place particular emphasis on enabling the implementation of practices that support the Welsh language in primary care, as well as any other areas of the sector where the Welsh Language Standards do not currently apply.
• Whilst the Welsh Language Standards require organisations to keep a record of the Welsh language skills of their staff, 'More than just words' should place an emphasis on its role in guiding the sector to gather consistent data relating to the Welsh language needs of service users and use this data to address any Welsh language skills shortage. The sector could also benefit from further support relating to how patient and workforce data collected could be used to plan workforce development and service delivery, and guidance to implement these plans. 
• Senior representatives across the sector need to adopt a more strategic and targeted approach to Welsh language learning to achieve a significant increase in the Welsh language competency of the workforce, with a focus on encouraging the use of the Welsh language in the workplace, especially for those who can speak Welsh but lack the confidence to do so.
• Digital Health and Care Wales needs to support the development of IT systems that incorporate bilingualism at the design and development stage, especially systems capturing language preference and workforce skills information.
• Welsh language officers, champions and other representatives across the sector need to further promote career opportunities within health and social care that require or benefit from having Welsh language skills. This could be achieved by facilitating closer links with other partners including Careers Wales to arrange school and college visits during which Welsh speaking alumni who now work in the sector could outline to students the career benefits of having Welsh language skills.
• The Welsh Government should review the role and purpose of the 'More than just words' Partnership Board in the context of the need to provide scrutiny and support in the implementation of Welsh language policy in health and social care. As part of this review the Welsh Government should consider charging the Partnership Board with the responsibility of maintaining a close focus on new developments in relation to the way services are delivered across the sector. This would include offering support and guidance, where required, to ensure that the Welsh language is fully considered in any general service delivery changes that take place across the sector.
• The Welsh Government should consider a relaunch of 'More than just words' to coincide with the start of its new government administration term. This could include encouraging Welsh Government ministers to demonstrate public support for 'More than just words' and communicating how it complements the Welsh Language Standards. This would provide an opportunity to further increase the profile of 'More than just words' within the sector and communicate its intent and purpose for the future, taking into consideration the new strategy and policy context within which it will operate. 
• The findings of this evaluation conclude that although progress has been made in relation to the seven 'More than just words' objectives, none of them can yet be considered to be fully met. As such, the Welsh Government should consider commissioning another evaluation to review the progress achieved during the next three to four years. Any future evaluation should also include a focus on the ongoing / longer term impact of COVID-19 on the need for Welsh language services and the sector’s ability to provide Welsh language services.
• To assist future evaluations, the Welsh Government should encourage the sector to gather and share routine information that would help assess future progress and address some of the data gaps encountered in this evaluation. This could include data on the Welsh language skills of the workforce, the Welsh language needs of service users and details of Welsh language services available across settings, particularly services aimed at priority groups. 

Report Authors: Stuart Harries and Nia Bryer

Views expressed in this report are those of the researchers and not necessarily those of the Welsh Government.

For further information please contact:
Eleri Jones
Telephone: 0300 025 0536
Email: research.healthandsocialservices@gov.wales

Social research number: 55/2021
Digital ISBN: 978-1-80195-837-0

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