NHS Wales Performance on the Line

Marcus Longley argues for a constructive response to a new report criticising Welsh health service productivity.

Publication of the Nuffield Trust’s report on the ‘productivity’ of the four UK nations’ health services has ruffled a few feathers. Using published data, it argues that in several key respects the English NHS delivers more for the money spent on it than do the services in Wales, Scotland and Northern Ireland. If true, this might be an important indictment of a key area of devolved policy making. (The report, Funding and Performance of Healthcare Systems in the Four Countries of the UK Before and After Devolution, can be accessed at www.nuffieldtrust.org.uk).

There are important caveats, which Scottish and Welsh Government spokespersons were quick to point out.  First, the data are out-of-date – the latest relate to 2006 – and since then key parameters such as waiting times have improved dramatically. Second, the definition and measurement of ‘productivity’ is notoriously difficult in a service where many of the most important outputs (whether patients recover as well as they should) are often not systematically measured.

Nevertheless, the report does highlight some interesting facts which may undermine one or two cherished myths:

  • Fact 1 – NHS Wales is not obviously under-funded. In 2006 it got around 10 per cent per head more than England as a whole, and about the same as regions such as north east England which have similar levels of ill health. It may be that it costs more to provide healthcare in rural areas, which would penalise Wales – but then Wales get considerably more per head than south west England, for example, with similar issues of sparcity and remoteness
  • Fact 2 – NHS Wales does quite well in comparison with England in terms of numbers of staff. For example, in 2006 Wales had about 50 per cent more management and support staff per head, and about 40 per cent more nurses, midwives and health visitors.
  • Fact 3 – patients and citizens in the four countries all express the same levels of satisfaction about their NHS – generally, very high.

The report also raises some interesting questions about what it calls ‘crude productivity’. For example, why does Wales carry out so few day cases compared with England, Scotland and Northern Ireland? This is generally accepted as a good indicator of the efficiency of hospital services, and Wales has been trying for many years to increase its proportion of day cases compared with hospital admissions. Or, if one looks at treatment rates per head, why is it that north east England (with similar levels of ill health to Wales) provided almost 10 per cent more out-patient consultations than Wales in 2006, and almost 30 per more in-patient and day case procedures?

The report argues that much of this difference can be explained by “the greater pressure put on NHS bodies in England to improve performance in a few key areas such as waiting and efficiency, through use of targets, strong performance management, public reporting of performance by regulators, and financial incentives”.

This is highly debateable. Nevertheless, the questions which the data raise will not go away, and the people of Wales are not well served by a response that plays the man rather than the ball – criticising the data and the perspective of the study, rather than the facts presented. Wales does not want an NHS that underperforms, and there is some evidence here that, in some respects, it may have that. Thankfully, the NHS in Wales is taking this sort of data seriously, and seeking to improve its performance.

The case for the prosecution is not proven, but nevertheless there is a case to answer.

Marcus Longley is Professor of Applied Health Policy and Director of the Welsh Institute for Health and Social Care, University of Glamorgan.

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