The Welsh NHS and its English counterpart

Last week Betsan Powys posted something that gave me, and I guess everyone in Wales, cause for a small smile of satisfaction; namely that the much trumpeted difference in NHS waiting list times between Wales and England was not so clear cut as people had been led to believe.

While it's not possible to directly compare figures between Wales and England, as the data is not collected in exactly the same way, it is possible to get a rough indication of performance between the two, helpfully provided at a briefing on today's waiting list figures.

So with those health warnings in mind, at the end of December 2009:

In Wales, 89.9 per cent of patients waiting were waiting less than 18 weeks.
In England, 90 per cent of patients waiting were waiting less than 18 weeks.

Winner? Wales – by a whisker.

In Wales, 0.7 per cent of patients waiting were waiting over 26 weeks.
In England, 4.5 per cent of patients waiting were waiting over 26 weeks.

Winner? Wales

In Wales, no patients were waiting over 36 weeks.
In England, 47,459 patients were still waiting over 36 weeks.

Winner? No contest.

In England, the tolerance level for their 18 week maximum wait target is set at 90 per cent. So – or so at least the argument goes in Cardiff Bay – what you gain on the time you lose on the tolerance.

Betsan Powys, The Long Wait – 11 March 2010

As others—notably Welsh Ramblings in this post—have said, a small difference in waiting times probably doesn't matter very much. If Wales is slightly ahead now, we might well find ourselves behind in a few months time. And all of us will be aware that whenever an arbitrary target is set there will be a temptation to organize resources in a way that helps meet that target (like SATs in schools) at the expense of making more sensible and practical decisions about patients as patients, rather than as statistics. Even yesterday we have a reminder in this article that figures might say one thing, but that the actual experience might be different.

If we want to look at differences between our NHS and that in England we need to stand back and look at the bigger picture.

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One part of the Politics Show yesterday stood out for me as a perfect example of something that I've said on more occasions than I can count. The biggest change in the NHS came about by restructuring the NHS as an internal market in which clinicians caring for people in need of treatment would buy that treatment from one of a number of competing providers. The stated aim of that reorganization was to drive down cost and provide choice. It was brought in by the Labour Party as a way of responding to the more right-leaning inclinations of middle England (Tony Blair got elected by being as right wing as, if not more right wing than, the Tories) ... but the reorganization in England was duly replicated by the Labour Party in Wales. The most obvious sign of this was to break up the existing Health Boards into 22 smaller units, precisely so that they could compete with each other over the provision of services. Yes, it meant a lot of duplication, but ideology dictated that the benefits of competition would outweigh the duplication.

     

I've perhaps shown more of the clip than is necessary to make the point, and the point is of course overlaid by a number of other points, but I wanted to put things into context. Gordon Brown firmly believes that he saved the NHS by introducing the internal market (much as he saved the world economy, I guess) and it is something that we can see he remains proud of. And we all know that so much money has been poured into the NHS over the past decade (in England by the UK government, with a proportionate amount to the devolved administrations) that things were bound to improve, despite the wastefulness and unnecessary duplication of the internal market. But what Labour did has fundamentally changed the ethos of the way that the NHS works, because it imposes a competitive business model on a service in which most of the staff are motivated primarily by compassion and the desire to help others rather than money and profit. The NHS works better when the people in it collaborate with each other rather than compete with each other.

I think Sally Austen expressed that perfectly in the clip, especially when she talked about the demoralizing effect it had on clinical staff, wearing them down and draining energy that should be directed towards patient care rather than squeezing the last penny on a funding deal with that part of the NHS that would provide the best care for the patient. And, as Mike Weston said afterwards, when staff are put under that sort of pressure what develops is a culture of blame and fear rather than cooperation. He was looking for a fundamental reappraisal of the way the NHS in England works ... Mr Brown seemed blind to the big picture and only tried to offer solutions that addressed the symptoms rather than the root cause of the problem.

In short, I fear for the NHS in England because I think the direction they have chosen is in danger of destroying the nature of the service. Apart from the most outspoken free-marketeers, nobody wants this. But, in the same way as with the Royal Mail/Post Office, politicians cherry-pick the things that will make an easy "efficiency saving". So, for example, if the profitable bits are farmed out to private companies who can do the same thing slightly more cheaply, the rest of the service will find it harder. And so, step by step, the NHS will keep getting cut back to the point where it only provides a basic safety net to those who can't afford better.

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In Wales it is different. Yes, we did follow the Labour model in the early years of devolution, but we then decided to dismantle the internal market ... and yes, that did mean another change of structure. It was awkward and embarrassing, and change for the sake of change is useless, but once you realize you're heading in the wrong direction there's no real choice.

The reversal came about as the result of the 2007 election. Although there was a commitment in Labour's manifesto not to use PFI/PPP for capital NHS projects (a very welcome U-turn) there was nothing in the Labour manifesto about dismantling the internal market. The closest they got to it was a mention of ending competitive tendering for hospital cleaning contracts!

So the change clearly came because of Plaid Cymru. But that isn't to say that Labour AMs weren't willing collaborators. I like to imagine the conversation between Tony Blair and Rhodri Morgan, with the latter saying, "Well of course we don't want to get rid of the internal market, Tony. It's one of your greatest achievements. But the Plaidis are insisting on it, and it's either working with them or us being in opposition." At that stage Blair was on the point of retiring anyway and so didn't kick up a fuss. Why not leave Gordon to handle the mess that would be bound to result from abandoning sane, right-wing policies? "Bloody Welsh, they never know what's good for them", shouts Blair as Rhodri leaves. Rhodri walks out of the office with a spring in his step, then allows himself to punch the air once he thinks he's out of range of the security cameras. Labour in Wales got the sort of NHS they wanted (well, I'm not sure that applies to their MPs) but until then had been afraid to stand up for.

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So there are now three big differences between our NHS and that in England: dismantling the internal market, the refusal to use PFI/PPP for capital projects, and an emphasis on dealing with longer term issues to improve the nation's general health and fitness. In the long term, doing it this way will make us healthier and save us money. Compared with these, the rest is less important.