Welsh NHS has much to teach the English

Julian Tudor-Hart defends NHS Wales against its critics across the border

Last week Prime Minister Cameron labelled the Welsh NHS “a scandal”. To the contrary, it’s ‘doing more with less’ more effectively than the English NHS – and without privatisation.

The Welsh created the NHS, modelled on miners’ mutual aid schemes. They have so far strongly resisted attempts to return healthcare to market competition. Since devolution a new generation of socialists has been quietly running NHS Wales as a public service – not for private greed. And for this reason, the Welsh NHS is now under attack from a propaganda Blitzkrieg.

The crescendo of political and media attacks on NHS Wales are light on evidence. So why do we hear hardly a squeak of dissent from the opposition front bench in Parliament, to defend their own Party’s Welsh Government?

Nine out of 10 patients who used Welsh hospitals and GPs last year were satisfied or very satisfied with their care. In contrast across Britain as a whole only six out of 10 respondents said they were satisfied with the NHS (a sharp decline from peak approval of 71 per cent in 2007).

Why is Labour not pointing this out?

In the English NHS central planning has virtually disappeared. Each hospital is supposed to compete with its neighbours for survival. Every state service must compete with other services for its share of the budget.

On the other hand Labour’s  government in Wales still believes that public services should be centrally co-ordinated and planned towards shared social goals. If a local hospital is performing badly, people in Wales still expect state action to improve it, not personal choice to go to a competing hospital elsewhere.

Welsh central planning has enabled co-ordinated action across separate institutions and budgets. In Cardiff, hospital A&Es and local police share anonymised information, leading to fewer violent incidents and hospital admissions.

There is no question that times are hard. The Welsh Government has faced disproportionately higher cuts in its centrally allocated funding – 20 per cent across the board, a context many saw as politically motivated to discredit the Labour-led government. Faced with such bitter austerity, the Welsh Labour Government decided not to ring fence NHS spending. Instead it took advantage of its more planned environment to allow it to better integrate health and social care services. As a result, councils’ spending on all services (except education) fell by only 9.3 per cent in Wales last year, compared with 15.6 per cent in England, according to the Institute for Fiscal Studies.

But key indicators for Wales NHS are moving strikingly in the right direction as a result of improved working across primary community and acute healthcare and social services.

In Wales, emergency hospital admissions of people with chronic conditions fell sharply in 2011-12, by almost 15 per cent for diabetes and 17 per cent for lung diseases. Similar falls were not seen in England.  In Wales, re-admissions for these diseases (probably the best single measure of clinical failure) dropped even more steeply, by almost 30 per cent and 25 per ent respectively.

David Sissling, chief executive of NHS Wales and director general of health and social services, said shared responsibility for both NHS and Social Services, through Local Health Boards, made it far easier to deliver integrated services.  “They don’t have any allegiance to hospital-bed care”, he said, “and you can think about designing a care pathway without having to think about it in terms of transactions that bring two or three different organisations into the equation.”

This success was so obvious that in May 2013 NHS England announced its intention to integrate all NHS and social care services by 2018. Of course it did not acknowledge that Welsh Labour was already doing it.

In Wales there is one Minister with overall responsibility for both the NHS and Social Services. There are strong democratic Local Health Boards and the Chief Medical Officer for Wales still has a powerful role.

In England, in contrast, the Minister has no responsibility to secure a comprehensive health service, the Chief Medical Officer role has been marginalized to the point of invisibility, the whole public health system is in tatters, and Public Health medical staff are streaming out of the service.

Last year ‘death rates’ in six Welsh NHS hospitals were said to be much higher than the English average. NHS England’s Medical Director Sir Bruce Keogh felt compelled to ask his opposite number in Wales to set up an enquiry. He did this in confidence; and so, of course, it was immediately printed and broadcast.

Patients enter hospitals because they are sick. Some of them die, either while still in hospital, or after they have returned home. Outcomes depends on age, the type and degree of sickness, differences in provision of home care, and differences in where patients want to end their days. The proportion of all deaths occurring in hospital throughout UK varies from 45 per cent to 60 per cent.

If hospitals are compelled to compete in league tables for mortality, they may find ways to admit more people at lower risk and avoid those at higher risk of dying in hospital, or send patients home sooner, so that they die at home. Similarly the drive to meet A&E waiting time targets can give rise to unneccessary admissions, admitting someone to an already crowded ward solely to avoid them tipping over the four-hour target. Politicians and media commentators should be careful what they wish for.

Of course, there is plenty of genuinely bad news about health in Wales, and some (though much less) about health care in Wales. The Welsh have been poorer and sicker than the English for at least 300 years. They have more of the principal causes of ill-health and premature death: more heavy industry, more unemployment, and lower average earnings.

In any public service, there will be a few exceptional cases of bad practice, which should be looked into. If relatives complaining of bad treatment refuse permission for their NHS medical records to be made public, as in the case of Anne Clwyd MP’s unfortunate husband, it is impossible for anyone to judge where, if at all, the NHS failed.

Valid comparisons would compare Wales not with UK, but with the North East of England. But the Blitzers don’t care about validity.  Any stick will do, to keep Britain on the Right course – to privatisation.

In England, Simon Stevens took over last week as Chief Executive of the NHS after a stint as President of UnitedHealth Europe, the European branch of the largest private healthcare corporation in the USA. Stevens’ background is impeccably New Labour. As Blair’s chief health policy advisor he helped Labour Health Secretary Alan Milburn to create the ‘market’ that encouraged the takeover of NHS provision by private health companies, justified as ‘competition’ and ‘choice’. In his first speech last week he talked up the “innovation value of new providers”.

His return to these shores has been enthusastically welcomed by fellow Blair-era survivors, including Blair’s former Political Chief John McTernan. Writing in the Spectator McTernan claimed Stevens will be the “perfect partner” for Jeremy Hunt to “save the NHS”.

Following up on Twitter McTernan claimed the best argument for more of the Blairite ‘market-orientated revolution’ in the NHS was “NHS England vs NHS Wales, for a start”, And he added, “I’ll be surprised if you can find anyone to defend NHS Wales”.

The Labour Party has always contained two groups: ‘reasonable’ people who adapt to the world as it is, and ‘unreasonable’ ones who insist on trying to change the world and make it a little more civilised. Let’s call them Collaborators and Resisters.

Promising to rescue the NHS from Conservative privatization, the Blair-era Collaborators helped Labour win the 1997 general election. They then pursued policies of NHS privatisation more vigorously than any Conservative Government had dared.

What has been the result of this collaboration? For ordinary voters there is no sign of any caring capitalism to reward their trust.

The present opposition front bench in Westminster struggles to resist Tory privatisation. They are faced with accusations that the Tories are only pursuing the Blair/Brown government’s policies towards their logical conclusion – a private service for those who can afford it, supplemented by a bare-bones service of last resort for those who can’t.

But their caution in opposing privatisation only emboldens the NHS’s enemies. Another former Blair advisor, Lord Warner, last week offered to save England’s NHS by introducing crude direct charges to patients (with the Kings Fund adding similar suggestions). Warner speaks for the notorious thinktank Reform, which has been trying to shift NHS funding away from general taxation onto sick people ever since it was set up in 2001.  Reform and its ilk have never explained why taxing sick people is a better way to fund healthcare than taxing everybody according to their ability to pay. Most people in Wales still understand that very well indeed.

So far, the attack on the Welsh NHS has met little effective resistance from Labour at Westminster. Labour should be proud – not ashamed – of its record in Wales. We should all reject the Blair-era voices calling for more markets, ‘choice’ and ‘private solutions’ on both sides of the border.

Julian Tudor-Hart is a retired GP and President of the Socialist Health Association of Wales. This article first appeared on the OpenDemocracy website.

7 thoughts on “Welsh NHS has much to teach the English

  1. I don’t know much about the English NHS but I have relatives working in the Welsh one and they would not recognise this complacent nonsense. The reason for the higher satisfaction rate in Wales has nothing to do with the services and everything to do with the docility of the Welsh and the relatively small middle class here – and they are the ones more likely to complain about poor service. I applaud the effort to plan the service rather than marketise it but the dirty little secret is that there is not much planning in the Welsh NHS. Individual health boards proceed on their own and resist any attempt by the Health Minister to co-ordinate them or impose economies by waving shrouds and claiming any cuts will lead to scandals. The Health Minister is relatively new and is doing his best but he faces a situation out of control. As for the integration with social services, that is an aspiration not a reality and one that looks unlikely to be realised very soon. But the Welsh government need not and must not hide behind an ideological barricade. There is no dispute in Wales about the undesirability of marketisation so there is no need to hide the huge flaws in the service in order to resist marketisation. We want a national health service but we’d like it run tidily. Is that too much to ask?

  2. From the BBC at http://www.bbc.co.uk/news/uk-wales-26975376
    ‘ Wales demonstrates improved performance on a number of indicators, but shows deteriorating performance on waiting times since 2010, with striking rises in waits for common procedures such as knee or hip operations. In 2012/13 a typical Welsh patient waited about 170 days for a hip or knee replacement compared to about 70 days in England and Scotland.’

    Can we even believe these figures? At Llanelli they are about to deal with urgent cases from 2012.

  3. The customer satisfaction figures may be part of the problem. The Welsh are brought up to be cringingly grateful for the NHS because it is said to be ‘free,’ so there is a culture of not complaining about it because any complaints are seen as ‘attacking the NHS.’

    That is why Ann Clwyd really deserves praise for daring to tell the truth on the subject. Yet, on the principle that ‘only Nixon could go to China,’ perhaps only a left-wing Labour MP could get away with even mentioning the issue. Wider debate has been stifled deliberately by vested interests screaming ‘privatisation’ when any reform is suggested.

    An elaborate mythology has been built up to protect the status quo. For example, the article states that ‘the Welsh created the NHS, modelled on miners’ mutual aid schemes.’ Both parts of that statement are factually wrong. All three main parties accepted the principles of the Beveridge Report – it happened to fall to a Welshman to implement them in respect of healthcare, and he botched the job. He imposed a super-centralised model which is the very opposite of the mutual aid schemes.

    The mythology persists in equating the super-centralised model with the principle of universal healthcare free at the point of delivery, so that any criticism of the former is seen as a rejection of the latter. In fact most developed nations have some form of universal healthcare but none has copied the super-centralised Bevanite model. We are not the ‘envy of the world.’ International comparison confirms personal observation that British critical care and cancer treatment in particular are visibly below modern standards. Our primary healthcare actually seems to be in decline in some respects – getting an appointment with a GP seems increasingly like getting an audience with the Pope.

    Given the advances in medical science, information technology, and management theory, it is doubtful that even Bevan himself would adopt the Bevanite model today.

    There need be no contradiction between universal healthcare free at the point of delivery and a system centred on the needs of the individual client rather than on the vested interests of a centralised hierarchy. Indeed, if we are to preserve the NHS and turn it into a 21st Century public service, Welsh patients need to be less patient and start thinking of themselves as customers with customers’ rights.

  4. This is a very welcome report especially in the context of the highly dramatic, if not over-dramatic, comments being made by David Cameron and his acolyte, Jeremy Hunt. David Cameron describes Offa’s Dyke as being “the line between life and death” whereas Jeremy Hunt has stated that NHS Wales is “sleepwalking towards a Mid-Staffs style tragedy”. A sure sign that an argument is losing traction is when it is portrayed in such apocalyptic terms. And there is, of course, a long history of anti-Welsh bigotry which has emanated from England down the centuries. The underlying theme of the current Conservative attack is that if it’s Welsh, it must be inferior.

    Which is why the Nuffield report provides a welcome breath of fresh air in terms of establishing facts as a basis for understanding the problems facing the Welsh NHS rather than fatuous comments from politiclans with an axe to grind before the election. So the relevant facts are these, relating as they do to the average waiting times for knee and hip replacements:

    Scotland 67 days;

    England 77 days;

    Wales 170 days.

    So England is underperforming Scotland by 15%, something Jeremy Hunt might like to explain.

    What the overall report tells us, however, is that the Welsh NHS is on a par with the other nations of the UK, including England, with the exception of waiting times as indicated by the above figures. The report suggests, though does not categorically state, that the increase emanates from the cuts to the Welsh NHS budget made in 2010. This then is the issue that needs to be addressed. In fairness, the waiting time figures have been coming down since 2012 but there is no doubt that these figures are a source of disappointment and concern.

    Mark Drakeford’s explanation is that money was diverted to the related area of social care. I wonder if the electorate would have sanctioned that if they knew they were swapping it for longer waiting lists as a result. However, the questions that Mark Drakeford needs to answer are:

    1 Do you accept the figures outlined in the report?

    2 Can you confirm that it was the cuts implemented in 2010 that were responsible for the increase in waiting times?

    3 What time do you consider acceptable for those waiting for hip and knee replacements?

    4 What measures do you intend to take to reduce these waiting times?

    5 What criteria do you intend to use to judge the success or otherwise of these measures?

    It is a matter of conjecture as to whether these times are specific to the areas of hip and knee replacement or are indicative of longer waiting lists in other areas of treatment. But we should reject the attack on the reputation of the Welsh NHS made in such hysterical terms by David Cameron and his followers, especially when the facts tell us otherwise.

  5. “If relatives complaining of bad treatment refuse permission for their NHS medical records to be made public, as in the case of Anne Clwyd MP’s unfortunate husband, it is impossible for anyone to judge where, if at all, the NHS failed.” I am sorry that a retired GP repeats (from Carwyn Jones) this ridiculous criticism of Ann Clwyd MP. Diagnosing failure in the NHS does not require making people’s private medical records public. This comment is the ugly side of a centralised health service in which the establishment has the power to pick off individual critics in this personal way, threatening them with losing their privacy if they dare to complain. Ann Clwyd deserves the support of her fellow socialists.

  6. Personal experience – the care my husband has had, and we live on the dreaded border with Hereford – has been excellent especially from primary care. He has had multiple investigations and operations and has never had to wait. Professional experience- Wales struggles to meet needs outside the main stream and is especially poor for mental health and CAMHS compared to England.

    Though I agree with much of the article, I do feel commissioning and providing should be on an All Wales basis cutting out many layers of bureaucracy. We need to accept that the public sector cannot meet all needs and there is a role for the private sector in routine elective surgery eg hips, knees, cataracts or buying these services in bulk from the English NHS. All Wales commissioning would help in planning for low incidence conditions eg a robust clinical pathway for anorexia. Those NHS staff who are long in the tooth like me remember the old Welsh Health board with nostalgia, they certainly knew where every cracked tile and radiator was located.

    On the question of the release of the health records (the hospital experience of Ann Clwyd’s husband), surely it is important that the records are released with her consent so that the public can see the alternative point of view. There is a great public interest in this matter, anything sensitive could be redacted. The staff involved and the hospital also deserve for their point of view to be known rather than press reports unthinkingly recycling the same allegations.

  7. Rhobat Bryn Jones’ figures on waiting lists highlight a key point. Scotland, like Wales, has resisted the marketization of the health service introduced in England. Yet its figures are better than England’s while Wales’s are worse. There’s the mystery. The Scottish service is well run, with adequate accountability and managerial control. I don’t think we can say the same in Wales. It is true I believe that spending per head is higher in Scotland and that is part of the story – but only part. This should not be primarily an ideological discussion but an enquiry into why public service management appears to be inferior in Wales.

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