Features: December 16th, 2003

Improving Health in Wales

By Jessica Mugaseth.

Reproduced by permission of the Public Management and Policy Association.

Annual expenditure on health and social services in Wales increased by some 27% between 1997 and 2000-01 and the Welsh receive 30% more funding per head on health than in England. Despite this, the NHS is still failing the people of Wales. Waiting times in Wales are amongst the worst in Europe and are rising monthly.

At the end of June, 5,846 people in Wales were waiting more than 18 months for admission, compared to just 9 people in England waiting over 15 months. In Wales, the occupancy rate in the acute sector is at 98%; 82-85% is the maximum level for the efficient delivery of services. This high occupancy rate is due in part to the fact that Wales has 19% higher attendance at Accident & Emergency and 40% more emergency admissions than the rest of the UK. Given these statistics it is not surprising that Derek Wanless, adviser to a new Welsh Assembly Government report on the future of NHS Wales, finds that the “current position (of the NHS in Wales) is not sustainable”.

The Review of Health and Social Care in Wales, published in July this year, was written by an Assembly Government team. Derek Wanless, author of the comprehensive report to the Chancellor of the Exchequer on the future of the NHS in the UK as a whole, agreed to act as an adviser to the team. How much input he actually made is not yet known. However his name on the cover of the report has ensured it received the attention health and social care in Wales need.

The review’s main aim was to examine how extra resources for health and social care in Wales, announced by the Finance Minister of the Assembly Government in October 2002, can be translated into improved performance. The report team took evidence from the key players in health and social care in Wales and reviewed available information and research. The team recognised that “often the information base on which to formulate is poor and there is more subjectivity than the team would like. Social care provision was even more difficult for the report team to get to grips with than the NHS.” This lack of data and an evidence base specific to Wales is a fundamental problem and the Wanless report does not emphasise enough the importance of developing a much more robust evidence base if sustainable and relevant policy is to be developed.

Despite these weaknesses, the review provides the Assembly Government with an extensive and explicit, if depressing, baseline assessment. This is a necessary first step in formulating constructive policies to improve the state of health and social care in Wales.

The need for a whole systems approach

One of the review’s main observations is the “insupportable burden on acute hospital services” caused by congestion at both ends of the health process. Emergency admissions (caused by excessive GP referral rates) are very high and impact negatively upon the delivery of elective surgery. At the other end of the spectrum, delayed transfers to alternative care settings place a huge burden on the system. The review recognises that immediate action must be taken to address the problems of excessive waiting lists.

The report suggests that the reason that GP referrals to hospitals are 40% higher in Wales than in England is because “at present there is often no perceived option other than the district general hospital available to GPs seeking help with medical emergencies”. This is supported by evidence from the Audit Commission to the report team which indicated that GPs “often feel that admission is the only way to access trust services”. Despite this recognition of a problem, there is no detailed analysis of this extraordinarily disproportionate high number of referrals by Welsh GPs. The Welsh Assembly Government must examine the reasons behind these statistics if it is to begin to ease the pressure on acute services.

Wanless is correct to emphasise the need to accelerate alternatives to acute hospital admission. These include reshaping services, specialist GPs, nurse practitioners, resource centres and diagnostic and treatment centres. Many of these options are being introduced in England, and in some places have already contributed to lower waiting times. However the recent reports from Oxford Eye Hospital indicate the problems of funding and staffing levels for NHS hospitals that could arise from the introduction of such measures, potentially exacerbating problems in Wales. The Wanless report makes no effort to identify good practice in other industrialised countries, an exercise that the Assembly Government could undertake.

At the same time as the need for restructuring primary health care and alternatives to hospital admissions, Wanless stresses the necessity to reshape the system to address the problem of delayed transfer of care. The report recommends offering alternative secondary care units to reduce the “excessive reliance on provision of care in institutional settings rather than in the community”. This recommendation comes in the wake of continual closures of care homes over the past years because of insufficient funds. Wales has also seen a 10% decline in domiciliary care over the past decade. However lack of exact data throughout the whole social care structure hinders sensible policymaking and development.

Holistic prevention better than cure

The report places a much-needed emphasis on the importance of preventative care. The relatively poor health of the people in Wales is well documented. Life expectancy is on average two or three years less than the best in Europe and figures for the long-term sick are disproportionately high. Deprivation alone cannot always be blamed. As Wanless puts it, everyone must be encouraged to examine their own lifestyle and take ownership for there our own health. The review takes a realistic approach, recognising that the hundreds of health promotion initiatives launched every year may not be having an impact on the health of the nation. Sensibly, it suggests that research should be undertaken to establish the cost effectiveness of these promotional campaigns.

The Welsh Local Government Association (WLGA) has also called for focus on how the NHS and local authority services such as housing, environmental services, transport and leisure can also work together to maximise the available resources and provide a holistic approach rather than a focus on systems that just ‘integrate’ health and social care. The WLGA emphasises the need to look at not only health ‘prevention’, as Wanless suggests, but also health ‘protection’.

Finding the capacity to deliver

Wanless also calls for the Assembly to “give thought to, and stimulate public debate about, the role of the state in providing care”. This suggests the need to re-examine the notion of ‘cradle to grave’ care that the NHS was set up to provide and could lead to some ideologically interesting debates both in and out of the Assembly building. The broad suggestions for a change in the system hint at a more diverse nature of provision for health and social care than we currently have.

Although the report recognises the “capacity shortcomings in workforce planning” and highlights the high vacancy levels in health and social care in Wales, it concentrates on improved performance management and improving information and communications technology (ICT) and estates as the means of developing the NHS in Wales. Liz Hewitt, Board Secretary of the Royal College of Nursing has already drawn attention to the report’s lack of attention to capacity issues. She has expressed concern over the effects on the health system of a shortage of nurses and other health professionals and believes that insufficient emphasis was given to the importance of expanding the healthcare workforce in Wales. Encouraging health and social care workers into Wales would play a fundamental role in improving the delivery of the overstretched system.

The report is keen to emphasise the importance of developing an ICT infrastructure to improve health and social care in Wales. This recommendation will be welcomed by many and will help enable the seamless integrated thinking behind the reports proposals between the health and social care systems. An improved ICT structure could also assist in sustaining accurate data as the basis on which to develop future policy.

Wanless suggests a system with stronger incentives which reward success and give greater freedom to good performers. The report also argues for sanctions, such as losing autonomy and a removal of opportunities to access additional funding for service developments, as a means of improving the management of the service. Incentives and sanctions do seem to be fairer than the current situation where Health Authorities that accumulate debts are given money to write them off, whereas those who have managed their accounts in a more professional manner receive nothing in return for their efficiency. However, it is essentially people’s health that is the important factor and nothing should be done which will endanger this still further, even if it has the effect of improving things in the longer term.

The time to act is now

The overarching theme of the review is to take a long-term view , rather than relying on short term funding, one off initiatives and changing priorities. Although this is a sound and necessary approach , there are significant immediate problems in health and social care that need attention. The immediate priority must be to tackle the long waiting times.

Although the report does not say anything new about the challenges facing the NHS in Wales, it does give a firm basis for making the necessary changes. It provides the Assembly with an extensive and unequivocal baseline assessment. Presenting the report to the National Assembly, Health Minister, Jane Hutt, said she would provide a detailed policy response. In the meantime she allocated an additional £4 million to the 22 new local health boards across Wales to help them tackle alternatives to hospital admission and delayed discharges. Devolution has given Wales the opportunity to act boldly with regard to its health and social care system and it is now essential that the Assembly Government take immediate action on the work of Wanless and his team to improve the health and well-being of the people of Wales.

Jessica Mugaseth is a Research Officer, Institute of Welsh Affairs.