Malcolm Prowle says the NHS cannot be isolated from other public services
The revenue support grant settlement for Welsh local authorities announced by the Welsh Government last week is welcome news in the dire financial and economic circumstances of the UK as a whole. The settlement leaves Welsh local authorities with an average reduction in grant of 1.4 per cent, ranging from a rise of 0.1% in Cardiff to a ‘floor’ of -1.7 per cent for most other authorities. In England, councils face cash reductions in the region of 7 per cent, significantly larger than those now felt even by the hardest hit authorities in Wales. Indeed, it will be interesting to see if the most generously funded English council has a grant change as kindly as the ‘floor’ -1.7 per cent grant reduction faced by many Welsh authorities such as Conwy, Pembrokeshire and Blaenau Gwent.
In fixing its budget, the Government wisely decided not to ring-fence and protect the NHS which was the approach adopted in England. Protecting the NHS from cuts makes no sense whatsoever and suggesting it casts doubt on the credibility of those who support it. Consider the following reasons why protecting the NHS budget, while cutting other budgets disproportionately, would have been wrong:
- The Prime Ministers of both Canada and Sweden (countries which went through major fiscal consolidations some years ago) strongly emphasised that any such ‘protection’ would be a mistake and was something they did not do in their countries.
- The NHS cannot be isolated from other public services. Drastic cuts in local authority social care budgets (caused through protection of the NHS) would have had as big an effect on the NHS as direct cuts in its funding.
- For the UK as a whole the productivity of the NHS has actually declined during a period of record growth in resources and there is little doubt this situation also applies in Wales.
What is needed in the NHS is root and branch reform to enable it to cope with a long term financial environment in which while demand is growing by 4-5 per cent a year there is little or no significant growth in resources. Included in this should be urgent consideration of the numbers of hospitals in Wales to see if the total fixed cost burden could be reduced.
Many years ago I participated in a US-UK exchange programme for senior finance managers in the health sector. The American delegates gave a presentation of their perceptions of the NHS. They had just two slides – on one slide they listed a wide range of problems of the NHS, including long waiting lists and variations in clinical outcomes. On the other they made a single declaration – “but you can’t change anything”. This statement encapsulates the problem that almost any change to the NHS is fiercely resisted by the public and the health professionals.
Let me illustrate this with a not so funny story. Some years ago I was involved in the preparation of a regional strategic plan for the provision of cancer treatment services in a part of England. This exercise took place prior to the publication of the well known Calman-Hine blueprint for cancer services but followed the principles subsequently outlined. The strategy recommended the closure of a particular and rather ancient radiotherapy unit in the region and the transfer of its patients to a more modern and more clinically effective facility. However, the proposal was greeted by a huge wave of furious opposition from MPs of all parties, health professionals and the general public such that the plan was eventually dropped. Some months later we heard that one of the radiotherapy machines was so old and worn that it somehow fell off it’s bearings. One really wonders how effective this machine could have been at targeting the radiation source on the patient’s tumor but that issue was never discussed.
It would be really nice if the main political parties could have a consensus approach to reforming the NHS in Wales. Unfortunately, every opposition party (of whatever political hue) adopts two main health policies for presentation to the general public. The first is to promise to cut the number of ‘administrators’ (I put the term in inverted commas since it is not always clear who is and isn’t an administrator); while the second is to promise to increase NHS funding but leave everything else virtually unchanged.
Staying unchanged is not a desirable option for the NHS. Some health care has no proven effectiveness, some staff are just not up to scratch, some procedures are outmoded by modern standards and some hospitals are just not fit for purpose in the modern high tech health world. Furthermore, contrary to the strongly held public perceptions, improving the NHS isn’t just about employing more doctors and nurses. It is about what those doctors and nurses (and other highly competent and often forgotten staff such as therapists, pharmacists, technicians) actually do.
Any government which tries to seriously reform and effect change in the NHS runs up against the barrier of the opposition parties (aided and abetted by the media) promising to man the barricades and ‘fight to save the NHS’ while whipping up public opinion to oppose the changes whatever their merit. We have basically just seen the same thing from the Welsh Conservatives in the Assembly who promise to protect the NHS without being prepared to say what other services they would cut to do that.
Overall the consequences of the Welsh Government not providing protection to the NHS is that Welsh councils are not faced with disproportionate cuts to their grants as are their counterparts in England. Although we might take issue with other aspects of the budget, on this issue it seems to me that the Welsh Government has got it right.
