WEAPONISING HEALTH CARE = A CASE OF MISDIAGNOSIS
The introduction of UK devolution for Wales and Scotland in 1999 is an enduring legacy of the Labour Government elected in 1997. It provided the opportunity for the various administrations to innovate and develop new policies in line with their national needs. Many of these policies have been adopted more widely across the UK while others remain local in line with devolved political priorities and mandates.
It seems to be a clear part of Tory general election strategy to weaponize the health and social care service in Wales and to present it as a service in total chaos and disarray. While the services do have real problems that need to be addressed, equally there is a need to acknowledge many of its positive achievements.
WHAT HAS WALES BEEN DOING?
Wales was the first UK administration to abolish prescription charges and hospital parking fees. Apart from England, which has a charge of £9.90 per item, all the UK administrations followed suit. The Welsh devolved Assembly (now Senedd) was also the first UK body to vote for a comprehensive ban on smoking in enclosed public places though the greater range of devolved powers allowed the smoking ban to be first implemented in Scotland to be followed by Wales and then England.
In 2009 Wales followed Scotland in abolishing the internal market in health care. The market survives in name in Northern Ireland while in England it remains an article of faith. In addition Wales has had a restrained uptake of the Private Finance Initiative (PFI) compared to its enthusiastic promotion in England with all the consequent adverse legacy of that policy. The Treasury Select Committee stated “ that PFI is now an ‘extremely inefficient’ method of financing projects”, (Committee publishes report on Private Finance Initiative funding – Committees – UK Parliament) The risks have been amply shown with the collapse of Carillion and Capita. Wales has just 28 current PFI projects which represent 1.5% of the capital value of all UK PFI projects, the lowest of the UK nations ( PFI and outsourcing: what lessons can be learned in Wales from recent developments with Carillion and Capita.)
More recently Wales has introduced Presumed Consent for Organ donation. This has led to significantly increased organ donation consent though the impact was not immediate. In 2016 the Welsh Senedd also voted for the Nurse Staffing Levels Act which requires Welsh Health Boards and Trusts in Wales to calculate and take all reasonable steps to maintain nurse staffing levels and inform patients of the level.
In 2002 free personal care for those over 65 years was introduced in Scotland and has been extended since then. While this has not been replicated elsewhere in UK the means test thresholds have varied between Wales and England. In Wales there is no social care charge if a person has assets under £50,000 which is twice as generous as in England and there is a £100 cap on domiciliary care fees.
In socially disadvantaged areas Wales maintained and enhanced the Sure Start programme with Flying Start which provided high quality childcare for 2–3 year olds, an enhanced health visiting service, access to parenting support and support for speech and language development. In addition this is now being supported the trail blazing Welsh Government free school breakfast scheme.
In children’s services this year the Welsh Government is committed to legislating to remove private profit from the care of looked-after children with provision being delivered by the public and third sectors.
The Welsh Government has also moved to have a fully registered and professionalised social care work force who must be paid the “ real living wage”. In England only half the social care workforce are paid the real living wage. And in Wales enforced zero hours contracts have been abolished.
INVERSE CARE LAW IN OPERATION.
In considering the performance of the Welsh health and social care service it is important to recognize that it is responding to the needs of a poorer, older and sicker population.
- Welsh GVA / head is about 72% of the UK figure with gross disposable household income (GDHI) per head in Wales in 2020 being £17,592 or 82.1% of the UK figure
- In Wales 21.1% of the population is over 65 years compared to 18.6% in England.
- Life expectancy for men in Wales is 77.9 years compared to 78.8 years in England while the comparable figures for women are 81.8 years and 82.8 years.(ONS)
- Healthy life expectancy is 61.5 years for men in Wales and 63.1 years in England while for women the figures are 62.4 and 63.9 years (ONS).
- The number of people with a disability in Wales is 21.1% compared to 17.7% in England (ONS).
- Hospital out-patient referrals have increased by approximately 20% from April 2012 to April 2019.
These differentials are not new and have long pre-dated devolution (OHE guide to UK Health and Health Care Statistics, 2011).
RESOURCE ALLOCATION
The level of public expenditure in Wales, including health is very heavily influence by the Barnett Formula which decides the Westminster block grant allocation which makes up the bulk of the Welsh Government’s expenditure. The short comings of this process in the overall allocation of resources to the then Welsh Assembly was highlighted by the Holtham Commission in 2009 and concluded that health need was being under-funded by about 14%. In 2016 the Welsh and UK Governments agreed to amend the Formula with a needs based element starting with a 5% supplement and rising in time to 15%. However, as the current Welsh block grant is now closer to the 20% per capita more than England, these new arrangements have yet to kick-in.
However this relative increase can give a misleading impression as it is mainly due to the “Barnett Squeeze”, a bizarre consequence of the way the UK Government allocates its Block Grant to Wales. This results in Wales seeming to get more relative funding as public spending is reduced in Westminster linked to changes in population growth and the devolution of further responsibilities to Wales.
Following devolution Wales benefited from the dramatic increase in health spending, initiated by the Labour Government, after 2001, growing by an average of 5.3% a year in real terms between 2001/02 and 2010/11. With the Global Financial Crash in 2008 and the Era of Austerity which commenced in 2010 with the Conservative / Liberal Democrat Government the situation radically changed. In the first years of austerity between 2010-11 and 2014-15 with health expenditure only increased by 4.5% due the poor Barnett allocation and to the Welsh Government’s decision of give a greater spending priority to local government / education. However between 2013-14 and 2017-18 expenditure grew at 17.4%. compared to a 12.7% increase in health spending across the UK. This brought Welsh health spending to 5% above the UK level and relatively higher compare to England.
In the wake of continuing austerity and the Covid pandemic in December 2021 the Welsh Government planned for a real terms 2.7% annual health expenditure increase to 2024-25 but the effects of inflation cut this back to about 1.8%. And even with latest expenditure spending plans from Westminster, the Welsh Government will struggle to get to its initial 2.7% target not least because its present level of Westminster funding is about £900 million less than was expected in 2021.
The Institute for Fiscal Studies has estimated that in 1999–2000, Scotland spent 22% more per person than England, Wales spent 12% more and Northern Ireland spent 15% more. But in 2019–20, on the eve of the pandemic, Scotland spent just 3% more, while Wales and Northern Ireland each spent 7% more.
In making these comparisons attention is rarely focused on social care even though it is widely acknowledged that this sector plays a crucial role in promoting well-being and health. The Nuffield Trust points out that in 2021 social care spending in England averaged £352 per head for adults compared to £478 in Scotland, £550 in Northern Ireland and £494 in Wales. This adult social care sum would be the equivalent of over 3% additional spending on health
WAITING TIMES.
Much of the comparisons between the health and social care systems in Wales and England only concentrate on waiting times, especially for hospital care. There are differences in the way that the figures are calculated between the two countries. In both countries “pathway” numbers are counted with some people being on more than one pathway. In England the calculation is made from when patients are referred to when they start consultant led treatment. In Wales the waiting time figures include all hospital referrals even when they do not include a hospital consultant appointment e.g. the patient is referred to an investigation such as endoscopy or physiotherapy – these patient waits make up about 11% of the total.
The NHS Confereration Wales (2024) has acknowledged that waiting times are greater and longer in Wales that in England. However, the situation is more complex than the headline messages or Tory propaganda would have us believe. Patients are certainly not waiting twice as long as in England as was claimed by the Tory Health Minster Steve Barclay in 2023 and some of the differences are accounted for by Wales giving a greater priority to patients’ clinical condition over length of wait.
In addition the Welsh Government’s Chief Statistician pointed out that a ONS survey in 2023 indicated that 29% of Welsh people were on waiting lists compared to 21% in England. She also points out that data on referral to initial out-patient appointments are not collected in England while in Wales this is the case, and some patients may be discharged at this stage without any treatment.
However same ONS survey also showed that 49% of people waiting in Wales had been waiting for longer than one year, compared with 23% in Scotland and 18% in England, so clearly the time of wait is a real problem that must be addressed. A recent BBC analysis indicated that the average waiting time in Wales was 21.8 weeks compared to 14.9 weeks in England with 21% waiting more than a year in Wales compared to 4.1% in England.
In A/E waits the Tory propaganda is misleading. While both Wales and England are struggling to meet their targets. Media reports show that for the fifth successive month to March 2024 Wales has performed better than A&Es in England against the four-hour target. A total of 58% of patients were seen in that time in Wales, and 55% in England.
WHAT SHOULD BE DONE?
We know that health outcomes depend mostly on the wider determinants of health, such as wealth, income, housing and education.
However, health care does make a difference to how and when people die, through either public health and primary prevention (this is preventable mortality) or through timely and effective healthcare interventions, such as secondary prevention and treatments. (treatable mortality).
There can be no way forward without significant improvements in money, people, infrastructure and innovation. All of these are needed.
The level of health and social care resources in Wales is determined in the first instance by the spending decisions of the Westminster government. As long as austerity continues at Westminster, all parts of the UK will have inadequate provision to address the backlog due to over a decade of austerity and the Covid pandemic as well as the increasing demand of an even older population.
Therefore, in the Welsh context an even bigger share of an increasingly inadequate health and care budget is not going to be sufficient of meet our needs. Spending will need to be more than the 1 – 1.5% increases which Nuffield Trust believes the major parties are planning after the forthcoming general election and which is well below what some commentators feel is required.
Primary care must be strengthened to better manage chronic disease and more acute conditions that do not require hospital care especially at Accident and Emergency Departments. Patients’ pathways to hospital care need to be re-designed with greater use being made of IT and diagnostic infrastructure. Elective capacity needs to be protected while ensuring that acute capacity is not always operating at the limits of being overwhelmed. The key role of social care has to be acknowledged and supported to ensure that care needs are not unnecessarily medicalised and that people do not linger in hospital beds when they are fit for discharge.