Why we need to empty our hospitals

2010 may go down as the high water mark of the NHS in Wales. Performance peaked during the year, and was starting to fall away at the end. Two crude measures paint the bigger picture. First, there is a target that 95 per cent of people should be treated in hospital within 26 weeks of being referred by their GP. For three glorious months, this was achieved, peaking at 97.0 per cent in January 2010. However, by October 2010 it was down to 90.4 per cent. Second, 95 per cent of patients should wait less than four hours in Accident and Emergency. This target has never been achieved, but in July 2010 it reached 88.8 per cent.  By November it was down to 87.0 per cent.

LOOKING AHEAD This is the second of a series of articles we shall be publishing this week looking ahead to the prospects for key Welsh policy areas in 2011. Tomorrow: education.

Given the financial pressures ahead for NHS Wales, deprived as it is of even the meagre ‘ring fencing’ protection afforded the NHS in England, we probably will not see performance this good again for many years. Nonetheless, this performance is the best we have ever seen.  For example, in 2003 the referral to treatment target was 2 years (four times as long), and it was still not being achieved.

Janus-like, the NHS can look back to the years of plenty, and forward to a newly-integrated NHS. 2010 saw the consolidation of the latest re-structuring of NHS Wales. Instead of something approaching 40 statutory bodies, the NHS in Wales is now run by ten, the main ones being the seven Health Boards which are responsible for all services in their part of Wales. This simple, unified structure is in sharp contrast to England’s ‘Maoist revolution’, as one Cabinet Minister may have described it …

The Welsh re-structuring has been disruptive, but is now over, and the new Boards face a challenge probably greater than any of their predecessors: how to make real savings of about an eighth in their budgets over the next three years.  This will mean a series of minor retractions in service provision (for instance, minor A&E units, some maternity services), improving productivity by making sure all parts of the service follow best practice, and – the biggest challenge of all – making a reality of all the rhetoric about providing care in people’s homes rather than hospital. Some estimates suggest that up to a fifth of all people in hospital have no clinical need to be there. Given all this, it would be remarkable if waiting times did not continue to increase.

The other interesting thing to watch for the NHS in 2011 is whether the election will result in a different approach to leading the NHS. Will we see a move away from decisive and highly-centralised control towards an approach which devolves more substantial responsibility to the seven new Health Boards? These are big beasts, with plenty of talented leaders of their own, and with the ability to shape all parts of the local health system, hospitals and the community. Will the leaders at the centre have confidence that relaxing the reins a little won’t result in the horses slowing down?

Social care in Wales also looks forward to something new in 2011, following the publication in November 2010 of the report of the Independent Commission on Social Services, and the forthcoming White Paper. There was a huge sigh of relief when the Commission recommended that social services should stay in local government. Yet the report was not a ringing endorsement of current services. In particular, there was a call for a substantial shift from trying to organise services 22 times, once in every local authority, to working much more together, and also across the boundaries with the NHS. It commented on assessment processes and development of the workforce, and – with a cri de coeur about “unexpected jack-in-the-box Welsh Government initiatives” – it urged the Government to choose a smaller number of priorities, and stick to them.

There was also a powerful call from the Commission for services to be more responsive to what individual clients want – the so-called ‘personalisation agenda’. This will be an interesting challenge for 2011. No-one disagrees with clients having greater control – its good for promoting independence, preventing deterioration, and its what people want. However, to some extent personalisation has become associated – some would say ‘tainted’ – with personal budgets, which for many smacks of privatisation.

The great opportunity now for Wales is to invent a system which genuinely gives people control over the support they receive, without having the burden of dealing with all the administrative consequences, and pushing up costs. There are already some promising approaches here – the politically-correct term in Wales is ‘citizen-directed support’ – and 2011 may well resolve their future.

Finally, both health and social care need to decide where the citizen sits in their services. Few would deny that the wishes and needs of the client or patient should be key. But do we really know how to allow for personal choice? At the micro level, this means how professionals, organisations and individuals work in ‘partnership’ – a term that trips off the tongue, but often struggles to exist in reality. And at the macro level, it means devising systems which give citizens choices – without the sort of market chaos which threatens in England.

This is big stuff. In the solution lies a key element of the definition of Welsh public services. This will help to specify an approach for Wales which embodies our espoused values, and is sustainable in the context of future demography and public finances. We must make major progress on this in 2011.