It all started in Tredegar, a small mining town high up in the Gwent valleys of South East Wales. Local firebrand Nye Bevan knew it could work, because it had done for his community for many years. The basic principle – individual security in ill health through collective solidarity – put healthcare in the control of the patient and the community. Doctors were highly valued public servants, and no one need worry about the cost of health care. Brilliantly simple, yet transformative. Good enough for the rest of the UK.
Would Nye be equally proud of the NHS in Wales now? Wales actually has a Bevan Commission charged with asking that very question on behalf of the Health Minister. Nye would certainly recognise the challenges: limited money but unlimited demand; NHS and local government sharing responsibility for care; patients and doctors seeking what partnership means; models of care inherited from a previous era... all issues that have been there since the start.
So what’s Wales’ approach? What drives painful change west of Offa’s Dyke? That famous Scot, Adam Smith, has no legacy here. Markets have gone from Welsh healthcare, and will probably never return given the predominance of left-of-centre politics. Similarly, we have eschewed a simple command-and-control where ministers and their civil servants make appointments and decisions across Wales directly.
Yet there will be a temptation for future Health Ministers to revert to this in their frustration at the slow pace of development. Because the most common criticism of the NHS in Wales, even from its most loyal advocates, is that it seems almost incapable of change at sufficient pace and scale. ‘Lovely policy and strategy - shame it didn’t happen’ seems to be the common lament.
This cannot continue: the issues facing the Welsh health service need a fast response. The underlying financial pressure, driven by more patients without more money, is as relentless in Wales as anywhere. Rather like in Northern Ireland, there is real concern about the sustainability of the current pattern of acute hospitals – too many, too small to staff– and mounting concern over the time it takes to implement serious change, despite numerous, bruising ‘public consultations’.
Other serious challenges are:
sustaining the GP workforce, a real difficulty especially in rural and more deprived communities;
making the much-discussed shift from hospital to community, and treatment to prevention; and
achieving the highly visible metrics which have become synonymous with success - all those process measures about waiting times at various points in the pathways.
Staff in the Welsh NHS are hurt and angry at what they see as unfair and politically-motivated bashing of the Welsh NHS, where statistics and real problems are taken out of context, and used to score points for the benefit of English politicians. There’s nothing like criticism from England to unite the Welsh!
Wales, too, has had its share of really serious service failure, where patients have come to harm. Nothing as bad as Mid Staffs, perhaps, but nevertheless a powerful reminder that the consequences of getting healthcare wrong are serious.
So if markets and command-and-control won’t get Wales out of these difficulties, what will? There is an emerging, three-part narrative which, although it lacks the beautiful simplicity of a direct order or the ‘hidden hand’ of supply and demand, is starting to acquire a level of coherence and depth which command attention
Since 2010, the NHS is Wales has been run by seven Health Boards which, as in Scotland, command the full range of services for a substantial population – all of primary and secondary care, together with public and mental health, for upwards of half a million people. So NHS provision is formally integrated, although with much still to be done to make that a reality. The next step is to bring health and social care together. The Minister now has new powers to force the pace, and he intends to use them.
2. Using transparent information to drive competitiveness
Increasingly the assumption is that all data on the health service is in the public domain, and in meaningful form. Patients may not have the ability to shop around, but they – and most importantly, their clinicians – will increasingly know who is doing best. Wales is now relying on the fact that no clinician wants to be at the bottom of the class – and invidious comparison drives improvement.
3. Prudent Healthcare
Introduced last year, Prudent Healthcare is the final element. It is about prioritising and controlling the use of treatments of little or no clinical value. It is a bold effort to engage the public positively in an agenda which could easily be received as rationing or a narrowing of the NHS offer. Led by the current Minister, Mark Drakeford, it includes four principles which together set the agenda:
public and professionals in equal partnership through co-production
care for those with greatest need first
reduce inappropriate variation
and possibly the most important of the lot:
do only what is needed, and do no harm
The principles are not new, but their combination, and the political buy-in, probably is. After all, who would want imprudent healthcare?
Will this narrative withstand next year’s National Assembly elections; predicted to be very close? Will all the barriers to change still overwhelm these hopeful signs? We will see.
Would Nye Bevan recognise the Welsh NHS today? I think he would certainly recognise most of the problems, and he would recognise the politics, too. Possibly he would recognise Prudent Healthcare which, if nothing else, is an attempt to take healthcare back to its origins and ask two simple questions: what are we trying to achieve? And what is the minimum we need to do to achieve it?
Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors' own.
This blog is part of an ongoing series exploring the devolution of healthcare systems across the countries and regions of the UK
Longley M (2015) ‘Prudent progress in the Welsh NHS’. Nuffield Trust comment, 29 July 2015. https://www.nuffieldtrust.org.uk/news-item/prudent-progress-in-the-welsh-nhs