Some more limited measurements can be compared, however. Great play has been made by parties other than Labour, in Cardiff and Westminster, of the recent struggles of the Welsh NHS with waiting times. The issue is a real one. As shown below, Welsh patients on average wait more than twice as long as those in England for some major procedures, including those where longer waits are linked to worse outcomes, such as coronary bypasses. To some extent, this probably reflects the tight funding of the Welsh NHS given the age and deprivation of the country’s population. This is a result, in part, of choices made in Cardiff after the start of austerity in 2010, but also more fundamentally of the Barnett formula, which does not reflect the level of need in Wales.
The Welsh government has tended to respond by claiming that it has made different choices, focusing on patient outcomes and protecting social care spending, which has been deeply cut in England with little respite in sight. There is some evidence that Welsh patients may have benefited from better care being available for them to go home to. The rate of patients being held up in hospital because arrangements cannot be made for them to leave safely is measured in England, Scotland and Wales, with monthly censuses in each hospital checking who should not need to be there. It has risen only slightly in Wales, while it has risen sharply in England, and spiked in 2014 in Scotland before recovering.
However, it is important to note that, on average, a Welsh patient still spends around two days longer in hospital than their Scottish or English counterparts. This suggests a system that may not be getting patients home safely as fast as it should, which could be a priority for improving efficiency.
The OECD, the think tank funded by a club of relatively wealthy countries, recently published a report looking at how quality of care was managed in Wales relative to other countries. It found that Wales had a real commitment to improving quality, but that health boards were not delivering improvement and new ideas as quickly as they should be. The report’s authors suggested that they needed help to do better at developing plans and learning from each other. They also suggested that a firmer central hand might be necessary to point local leaders towards clear aims and minimum expectations.
There is also a question about whether some of the most critical services are currently spread over too many hospitals in Wales. In 2012, an independent review suggested that mortality for some medical specialties was higher in Wales than elsewhere, but that it could be reduced if trauma and stroke care were concentrated in major centres. It also suggested that some fields had such shortages of doctors that it was not feasible to properly staff the number of sites in operation.
Proposals have been brought forward to reduce the number of sites providing the most urgent care from seven to five in South Wales. In North Wales, plans to end consultant-led care at one of three maternity units run by Betsi Cadwaladr University Health Board were brought forward – but then dropped after a public backlash.
What are the big proposals from Welsh political parties?
The Conservatives are promising a Cancer Patients’ Fund to support better access to cancer drugs and treatments. The rationale is understandable. The UK as a whole, including Wales, has a longstanding problem with rates of cancer survival, and some of the goals of the Fund are widely supported by independent bodies, such as a 28-day time limit for diagnosis.
But the party needs to spell out how the aspect of this fund that pays for new drugs would avoid the problems seen with the Cancer Drugs Fund in England. This paid for drugs that treated cancer – and no other condition – no matter how high the price was relative to the benefit to patients.
We argued that the moral issues of fairness to other patients in a cash-strapped system were never fully discussed with the public. And of course, with no requirement on value for money, the amount that could be spent was limitless. The English Cancer Drugs Fund ran up overspends of hundreds of millions of pounds, until NHS England was eventually forced to completely revise it. As of a few weeks ago, the Fund will now only operate as a stop-gap measure, stripped of its power to permanently fund drugs that do not meet efficiency standards.
Welsh Labour has pledged a New Treatment Fund across all life-threatening conditions. This removes the question of unfairness between groups of patients. But again, the important question is whether it will mean taking money out to fund new drugs when they do not deliver good value for money compared to the treatments already being relied on by patients.
In government, Welsh Labour politicians have created the agenda of 'prudent health care'. This aims to maintain or improve standards while addressing the financial pressure facing the NHS in Wales by reducing the amount of health care provided when it is not absolutely necessary, and encouraging people to think about taking responsibility for their own health. This shows some political bravery – but the OECD has also raised the concern that it might remain just an abstract set of ideas unless it is really backed up by concrete plans, instructions or financial incentives for NHS Boards.
Plaid Cymru has ambitious plans to bring all non-hospital care under the power of new, bigger local authorities. Bringing social care and health care together will be an important long-term step. 'Managed care organisations', which are accountable for patients as a whole, have shown some evidence of improving quality in the United States.
But our research looking at the four UK health systems since devolution underlined that big reshuffles of who is responsible for what can often have much less visible impact than would be expected. Changing who reports to which managers, and which organisational logo goes at the bottom of emails, may not be as important as the less tangible issue of relationships between different services – which take a long time to develop.
Are they addressing the real issues?
All the major parties have serious proposals on health. Access to drugs, which treatments to focus on, and how to make services work together will all be vital for the next Welsh Government to address. But at the same time, the campaign is skirting around some of the most difficult issues which Wales will one day need to tackle.
It is not clear that any are addressing head-on the challenge posed by the OECD: whether Wales is managing and supporting its health boards well to tackle the most difficult problems it faces in making efficiencies and turning around problems with waiting times.
The legitimate question of whether Wales could have higher-quality care if services in some fields were centralised has gone largely unmentioned. Doubts as to whether Wales has enough doctors in key specialties to properly staff current sites could be addressed either by centralising care, or by workforce policies to increase the number of professionals. Neither option has been widely discussed.
Moving local services away will never be a comfortable issue for politicians to discuss, and there is a real trade-off with how easily patients can access treatment. But the argument is worth having where lives are at stake.
Lastly, although financial pledges abound, there is a lack of discussion about the biggest questions in health care finance in the country. Was Wales right to protect social care while reducing health spending per person in the last parliament? Is health funding in the right range to meet to the country’s needs, and if not, what can be done about it?
Dayan M (2016) 'Health care and the Welsh elections'. Nuffield Trust briefing, 22 April 2016. https://www.nuffieldtrust.org.uk/resource/health-care-and-the-welsh-elections