The NHS in Wales: a report from the death zone

On April 11th this year, addressing a conference of the Conservative Party in Wales, Prime Minister David Cameron described the NHS in Wales as a “national disgrace”, and the border between England and Wales as a line between life and death.

In the 87 years of my life I have heard a great deal of lying, by some of the most skillful and brazen liars in the business. This lie rose higher than any attempted before, at least in this field dominated by professionals with a serious training in science. Always alert for anything that might reach the Guiness Book of Records, UK media seem to have accepted this lie pretty much at face value.

The problem

In the millennial year 2000, the Welsh Government gained control of Wales NHS policy, though not of its funding, nor of its civil service appointments. The NHS now consumes 45% of the Government’s total budget. For 13 years, this central funding grew year-on-year under the Barnett Formula. From 2013 onwards, it will fall.

Funding has never matched Welsh needs, which have always been greater (per head of population) than in England, because Wales has always had higher rates of sickness and premature death. For a comparable population, one must look to the North-East of England, with a similar history of heavy industrial dereliction and consequent ill health. On this comparison, NHS Wales is doing a bit better than NHS England on all the usual measures (waiting lists and so on).

With the present Barnett formula, Wales now loses £3-4m a year compared with the regions of NHS England.  Beginning from this already handicapped starting line, in 2013 central funding for Wales NHS began to shrink year-on-year.  At constant values, it will fall to its 2005 level by 2015, while medical science continues to expand what really can and should be done to expand and improve lives, as well as the inflationary effects of the pharmaceutical industry and disease-specific strategies for diagnosis and treatment.

Faced by this apparently insoluble problem of rising public expectations and diminishing resources, the Welsh Government has shown exceptional loyalty to professional consensus principles of Public Health, seeking to maximise health gain for its whole population, at minimal cost, in a situation of continuing economic, social and political crisis.

First steps towards solution

Led first by Rhodri Morgan, later by Carwyn Jones, and by a succession of generally brave and imaginative Secretaries for Health, and by two excellent Chief Medical Officers (Tony Jewell followed by Ruth Hussey), the Welsh Government has stuck to three basic principles notably lacking in England.

They have done their best to return to Bevan’s original principle of an NHS as a public service, entirely free at time of use, and free from pursuit of profit. All care is now free, except within dentistry, and even for that there is a commitment to return to free care in the future. For all care, the NHS is preferred provider, and where private providers are still used, the intention is to eventually to return to public service. This preserves the status of health care in Wales as a social gift rather than a commodity, and Wales NHS as a protected economic space within which to develop a more civilised society of the future.

Secondly, the Welsh Government has recognised that efficient and effective use of medical and social services requires integration and shared budgets, so that (for example) hospital beds occupied by people who no longer need hospital treatment can be released, by funding more care in the community through social care budgets. Opposition parties in Wales, and Government parties at Westminster, know this. The Coalition Government has even proclaimed its own devotion to integration of medical and social services, because having seen it work well in Wales, they thought they might gain a few points by claiming the idea as their own. But they, opposition parties in Wales and Government parties at Westminster, still denounce Labour in Wales for refusing to ring-fence NHS spending.

Thirdly, the Welsh Government has done its best to reduce work unsupported by controlled evidence that it produces any net health gain, and concentrate work where such evidence abounds (prudent care). Most obviously, this means taking National Institute for Clinical Excellence decisions more seriously, whatever firestorms mass media, and lobbyists from corporate interests, may raise. This will be possible only if public opinion can begin to understand the nature of scientific evidence, if more scientists themselves can begin to take the social functions of science more seriously, and if broadcast journalists can resist their own subordination to corporate interests.

Much less obviously, this implies concentration of resources where they are most needed, and where per-head spending is now lowest in relation to per-head needs. This redistribution of resources will be extremely difficult, and so far has barely begun, though at Public Health and Ministerial level the intention is clearly there. In poor communities, most notably former coal-mining valleys and many rural communities, primary care is overworked and understaffed, although there is still a huge volume of needs not yet addressed. Work in these areas, particularly in primary care, can yield much higher outputs of health gain, than in wealthier areas more attractive to GPs working as small businessmen. Current Health Secretary Mark Drakeford is on track at least to begin to address this issue seriously, for the first time since 1948.

Hope or despair?

Looking forwards into approaching history, rational choice between hope and despair depends not upon the weight of evidence either way, but on the different leverage exerted by different interests. We are many, they are few. For more than 66 years, UK citizens have experienced through the NHS a successful economy in which skilled care was a gift given according to need, paid for from taxation unrelated to illness, and at least somewhat skewed towards ability to pay. This provided virtually all the evidence the world has ever had, of how democratic socialism might work in practice: a space in which to learn.

Did we actually learn anything?  Time will tell.  None of our current leading politicians seem to have learned anything.  Many seem to have lost whatever learning they ever had.  But I think most of our patients, and most of the professionals who served them, learned a great deal.  In this respect, we have a great deal to teach Americans, who lack this experience, and nothing to learn from them.  So I see every justification for hope that the lived experience of the many will outweigh the powerful lies of the few.