Election Special 8: Manifestos avoid bad news on health

What’s the biggest challenge facing the Welsh NHS? A quick conversation with almost any senior clinician or manager in the Service will quickly show one issue stands head and shoulders above all others. The current service is simply unsustainable, and we need radical change.

This is partly a long-standing problem. For years we’ve put too many people in hospital and have struggled to improve productivity. And partly it’s new. Most health service managers are now having to work out how to cut six per cent a year for each of the next three years from their budgets.  That’s getting on for a fifth by the middle of the next Assembly term. Given that about 70 per cent of the budget goes on staff, you can do the sums yourself.  However, at least on the evidence of their manifestos, no party seems to be contemplating staff reductions.  So 70 per cent of the budget is almost out-of-bounds.

The Welsh General Election This is the eighth in a series of articles we are publishing in the run-up to the National Assembly election this coming Thursday. Tomorrow Professor Brian Morgan, Director of the  Creative Leadership and Enterprise Centre in UWIC’s Cardiff School of Management, finds a major swing in this election’s manifestos away from promising the earth and pretending that governments can solve every economic and social problem.

So, we need a radical re-balancing of care, and we need massive efficiency gains now. Looking to our would-be political leaders, what have they got to say?  The four main parties’ pledges on health suggest general agreement that:

• There aren’t enough services in the community, and it isn’t easy enough to see your GP.
• We aren’t good enough yet at keeping people healthy.
• Ambulances don’t get to you quickly enough.
• We don’t have a national cancer plan, and cancer patients don’t have a key worker.
• And generally, people with sensory impairment, mental health needs, stroke (generally older people), and  children –  should all get a better service.

It’s easy to get the impression that several well-organised lobby groups have very successfully got their issues into the manifestos, and it all sounds very good. But what about the service re-balancing and massive efficiency savings? In other words: what about the bad news?

They all agree that we need more services in the community, but no-one acknowledges that this can only be achieved by reducing services elsewhere. And on the detail of efficiency savings, there is an almost deafening silence. It’s as if we were still in the boom years of the last decade and Lehman Brothers were still going strong. Plaid Cymru are even using this slogan on their web site: ‘Only Plaid can protect our local hospitals’.

The Conservatives and Liberal Democrats are slightly less coy than the others about the financial pressures. The former would apparently solve the problem by ‘ring fencing’ the NHS budget, the policy of their English counterparts, and re-introducing a £5 prescription charge for a few people. But, as we know from England, this merely reduces the problem, it doesn’t solve it.

The Liberal Democrats want private finance, but not ‘conventional’ private finance initiatives. They also hopefully endorse a suggestion that £1 billion of the NHS budget is not being used optimally, and announce that they will create an Office for Health Spending to tackle the problem. Problem solved? Well, the £1billion referred to is the cost consequence of the un-balanced service mentioned above, so if we’re to liberate this vast sum we need policies to shift money out of hospitals.  Not surprisingly, this is not a manifesto promise.

Despite this air of unreality, there are several interesting ideas in each of the party’s manifestos.  To keep people healthy, all of them want to improve access to preventative services. Labour and Plaid Cymru, for example, each has its own version of a free annual health check. This will be an attractive idea for most patients, and only echoes what people with private health insurance have had for years. Of course, the devil is in the detail when it comes to assessing whether such an option actually keeps people well.

Plaid are also strong on reviewing the current UK contracts for GPs, dentists and others, and negotiating these contracts in Wales. This again sounds attractive – why not devolve this aspect of health policy along with all the rest? Again, however, the devil’s in the detail. It might make Wales more attractive to future GPs, and provide better care. On the other hand, it might achieve the opposite.

Welsh Labour will ensure that all staff – from top to bottom – take part in a National Customer Care Plan, with regular training. One can imagine many senior consultants being sceptical about this. But Labour have tuned into a strong patient voice which often recounts experiences of what, in any other service industry, would be called poor ‘customer care’.

Labour also talks about making Health Boards financially liable if their hospitals delay ambulances. This would be totally unremarkable in the English NHS, but is slightly bizarre tucked away in a Welsh Labour manifesto, where the prevailing view is that such ‘crude’ financial penalties are not appropriate within the ‘NHS family’.

The next Assembly will have unprecedented law-making powers, so how are they to be used in health? With the exception of a variety of legal bans on smoking, and changes in the law on organ donation, the answer is, hardly at all.  This is perhaps not surprising, given that almost all the parties have signed a self-denying ordinance when it comes to the main reason for health legislation: re-structuring of health bodies.

With the exception of Plaid and the ambulance service (Health Boards will take responsibility for ambulances), the parties seem to have learnt the lesson from England that structural change is a massive distraction.

Should we be proud of the quality of public debate on health policy in Wales, as revealed by the manifestos? For the most part they are perfectly worthy statements of reasonable aspirations. But the casual reader is hardly being prepared for what will be the toughest period to face the health service since at least the early 1980s. No mention is made here of reductions in service, longer waiting times, or fewer staff. We’ll wake up to a different world after 5 May.