Edwina Hart’s Welsh NHS

”You have bitten off more than you can chew on this one and… you will come to regret it.”

Thus spoke Liberal Democrat AM Jenny Randerson to Health Minister Edwina Hart in Tuesday’s Assembly debate about the reorganisation of the NHS in Wales (30 September 2008). She was referring to what critical commentators have branded as a move to increase Ministerial ‘interference’ in the running of the NHS.

Mrs Hart had just announced that, from next year, she will Chair a new NHS Advisory Board in Wales, as well as personally holding the NHS Chief Executive to account. She will also hold annual, public accountability meetings with each of the seven new NHS ‘unified delivery bodies’ which will replace the current seven Trusts and 22 Local Health Boards.

The majority of respondents to her consultation had rejected this model, preferring instead an arm’s-length relationship between the Minister and the NHS. After all, if such an arrangement was deemed good enough by Gordon Brown for the setting interest rates – surely also a highly political act – then why not for the Welsh NHS?

Mrs Hart argues that AMs would not accept anything less than direct accountability by Ministers:

”In a devolved Wales, it is both impractical and undesirable to attempt to create such a distance between political responsibility and service delivery.”

The NHS was a political creation, so of course it must be politically accountable. One also suspects that Mrs Hart doesn’t have much faith in other governance arrangements to make sure that the NHS really responds to what patients wants.

There’s something of a straw man about this, of course. No-one suggests that the NHS should be anything other than politically accountable. But the question is: accountable for what? Is it for the achievement of the aims set for it by the Minister? Or is it accountability for the minutiae of the workings of a £5bn organisation with 90,000 employees?

The dangers of her approach are threefold. First, Ministers – if not the current incumbent, then perhaps her successors – will make decisions on health policy more for short-term political gain than long-term public health gain. Second, they will stamp out local variation and experimentation. Third, it may collapse under the pressure of NHS complexity. Certainly, it flies in the face of Bevan’s great dictum from the early days of the NHS: the danger that “every time a maid kicks over a bucket of slops in a ward, an agonised wail will go through Whitehall”.

But this argument is over, at least for now. If the past few decades are any guide, NHS reorganisations generally last about three years, before a growing chorus for further change emerges, and another reorganisation becomes irresistible after about two more years…so look out for 2013!

It is interesting to see how the Minister is tackling some of the other perennial problems of health policy:

Cinderella services
Having now created seven all-encompassing NHS bodies, the Minister faces the danger that the so-called Cinderella services – mental health, primary and community care, health promotion – will lose out in the battle for resources with their more glamorous secondary (hospital) cousins. She has rejected the suggestion, made by a review that she herself commissioned, that mental health services should be placed in an organisation of their own. Instead, the Cinderella services are to have a Vice Chair in each NHS organisation who will be their champion of such services. This is new, and it will be interesting to see how it develops in practice.

Public health and local government
The link between the NHS and local government is another perennial issue. Better health depends upon local government and the NHS working together. It appears that this will now be the job of the public health service. However, it will be interesting to see how they find enough highly-trained staff to go round the seven huge health bodies, 22 local authorities, and all the national functions which they will also have to support.

The voice of the people
A third issue is public and patient engagement. This is vital in a system that does not believe in patient choice as a driver of improved services. At the national level, the Minister will represent the people of Wales in the big decisions. Who will do the same at the local level? The English approach – to give local government a formal scrutiny role – seems to have been ruled out, as have direct elections to the health bodies (the Scottish solution). So what’s the Welsh approach to be? We don’t really know yet, other than hints that Community Health Councils (CHCs) will play a big role. This will require a step change for these 34-year old bodies, which have few resources, and low public recognition. There are some exciting possibilities being discussed – including the creation of community-based forums and a variety of special interest groups, linked under a CHC umbrella by network governance. Let’s hope there is sufficient appetite for change of this magnitude. Timid local scrutiny, bought on the cheap, will not provide sufficient checks and balances for the seven new monoliths.

So what have we got?

Putting the pieces together, what will the new NHS in Wales look like? We can be sure of the following:

• The split between commissioners and providers (the ‘internal market’ that never was) will go.
• There will be some structural safeguards for services which might otherwise lose out;
• Managers and others in the NHS will come under a strong, national performance system;
• Local variation will be replaced by greater standardisation;
• There is a prospect of a revitalised opportunity for local people to scrutinise what their local health services are up to.

Is it worth all the disruption? Maybe. But the devil (as always) will lie in the detail, which has yet to be finalised. Watch this space…