John Osmond launches a debate on the priorities facing the Welsh Government in its biggest spending arena
What future is there for the Welsh health service model at a time when, as evidenced by the Health Bill that was approved by the Westminster Parliament last week, England is striking out towards an Americanised market-oriented system? NHS Wales prides itself on delivering socialised medicine along Bevanite principles that are corrupted as little as possible by the private sector. But how sustainable will this be alongside a market-driven more privatised system across the border?
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Future of NHS Wales Tomorrow: Professor Marcus Longley, Director of the Welsh Institute for Health and Social Care at the University of Glamorgan, gives his perspective on the future of the Bevanite Welsh health service model. |
Certainly, so long as the National Assembly’s present Barnett funding system is maintained, with the block grant being calculated according to changes in English expenditure, Wales cannot be insulated. The clear intention in England is to reduce public spending on health and compensate this by services paid for from within the private sector. The direct impact will be to drive down the block grant coming to Wales, since cuts in English health spending will automatically reduce the Welsh block by a proportional amount.
This should be the single most persuasive argument that the Silk Commission should take on board in putting forward its recommendations on changing the present Welsh funding system later this year. But I wouldn’t hold your breath in hoping that the Treasury will be remotely anxious in listening to this case.
Apart from the direct impact of English spending decisions there are more fundamental and systemic underlying reasons why the present Wales NHS model may be unsustainable in the future. One is demographic change. The number of people in Wales living beyond 75 is projected to nearly double in the next 30 years, from 263,000 in 2010 to 409,000 by 2035.
Increased life expectancy is, of course, to be welcomed. But it comes with its downsides for the NHS. This is because the longer people live the more they will make demands on the service. The lifestyles of many people will make this inevitable. For instance, it is predicted that by the end of this decade a staggering 85 per cent of the Welsh population will be overweight or obese, with direct knock-on effects for health. By 2030 it is being predicted that NHS Wales will be dealing with 100,000 more cases of diabetes every year.
In its emphasis on providing state-of-the-art secondary care free at the point of use in a hospital setting is NHS Wales simply dealing with the symptoms rather than the causes of ill health? There are five criteria against which the Welsh Government judges whether the Welsh adult population is leading a healthy lifestyle:
- Body mass index
- Not smoking
- Eating an adequate amount of fruit and vegetables
- Taking moderate exercise
- Drinking moderately
What proportion of the Welsh population would you say is living a healthy lifestyle according to all five criteria? Would you be optimistic and say 20 percent, or pessimistic and guess it was closer to 10 per cent? In fact, the accurate figure is just 1 per cent.
At a time when conventional hospital-based treatments, especially new drugs and medical technologies, are becoming ever more expensive, this suggests that the Welsh NHS model is addressing the wrong priorities.
The Scottish health system has similar values to the Welsh, certainly in respect of rejecting the English market-based approach. It is different in that, due to the favourable operation of the Barnet formula in relation to Scotland, the Scottish Government has had significantly more resources to pour into the health service. Yet to what effect? In June 2010 a report by the Centre for Public Policy in the Regions, based at the Universities of Glasgow and Strathclyde, provided some sobering evidence. It concluded that although Scotland spends 16 per cent more money on its health care system and employed 30 per cent more staff, the additional investment was not able to secure better, or even equal health outcomes. The reason was the relatively poor lifestyle of many Scots, in terms of smoking, drinking and levels of obesity. Despite making huge inroads in tackling heart disease, strokes, and cancer, Scotland’s figures in regard to these illnesses, as well as smoking and alcohol consumption, remained persistently higher than in the rest of the UK.
Broadly the same message applies to Wales. In these circumstances what should be our public policy response? One positive factor is that broadly the Welsh Government has taken all this on board. Unlike equivalent authorities in England, our seven health Boards have a public health responsibility. This is an acknowledgement that lifestyle behaviours that impact on health are not solely down to individual choice. They can be motivated and influenced by public policy and societal attitudes. Legislation around smoking in public places and alcohol pricing are cases in point.
But I think we need to go further. If we are to tackle the alarming impact of Welsh lifestyles that are determining health outcomes we will need a much more joined-up approach between health and education policy. The major lever the Welsh Government has here is to require that our primary and secondary schools have a much larger role in influencing the lifestyles of our young people and their parents. Is there a case for some kind of merger between the health and education departments within the Welsh Government?
Why will the English NHS reforms lead to an ‘Americanised’ market-oriented system?
Surely the defining feature of the American system (at least as far as people in Britain are concerned) is that people generally have to pay for their treatment. Clearly this is not the case with the NHS Bill.
Perhaps it would be better to compare it with Sweden – a decentralised, universal – i.e. free – healthcare system in which public, private and charitable providers all operate. That seems like a more appropriate comparison to me.
Surely the argument is that the underlying objective of the English NHS so-called reforms is to drive competition into the service from private providers, with the intention that over time more and more people will have little choice other than to opt for private, paid treatment. Of course, this is already happening across the system throughout the UK as waiting times have the effect of introducing a rationing system. If you need knee surgery, for example, and are stuck in a wheel chair and told you have to wait six months for treatment, then you are quite likely going to hand over £2,300 to have the operation within a week – if you’re lucky enough to have the spare cash. This is a road the whole NHS is going down, except in England, with the new Bill its a motorway.
The competition element is at the stage of GPs choosing whether to utilise a public/private/voluntary sector organisation to deliver free NHS care. I don’t think the competition applies to a patient having a choice between waiting for the NHS and paying to go private. Though of course, you’re right, this does already happen (and no doubt will continue to happen) but I don’t think that the former necessarily leads to the latter.
As I see it, if I were to go to a hospital in England, it would make no difference whether Ward X was run by a non-profit co-operative, some form of NHS breakaway trust or some American Healthcare Corp., I would be seen free of charge and treated. Provided of course that the government’s regulations ensure safety and quality of care, etc, then I see no problem with this.
No JO, I am with Jeremy Townsend. You are confusing collectivisation of supply with collectivisation of demand. The state can still pay for everyone’s health care but buy it in from competing private suppliers if it thinks that is more efficient than state provision. It does not follow that it will then privatise demand as well. If it saves money by changing suppliers you are right that Wales will be forced to follow suit via the Barnett formula. But if it fails and spends the same or more, Wales can please itself. Your knee case is irrelevant. That happens now when the NHS is state provided. The Bevanite model allowed for people to queue jump by paying. Nothing new.
I agree with Jeremy: ‘Americanisation’ isn’t the right description. The US healthcare system is based on private insurance. The NHS in England, even after the reforms have been passed, will remain a taxpayer-funded system free at the point of use.
The Coalition’s original vision in the White Paper seemed to be of the NHS as a kind of ‘social market’: GP consortia would commission care from “any willing provider”. Presumably this was based on the belief that competition to provide publicly-funded health services would increase productivity and hold down costs. To me this concept sounded a little similar to the way social care was increasingly outsourced to the private sector in the 90s.
John seems to think that the Coalition wants to drive up waiting lists. Although Andrew Lansley abolished some of Labour’s targets in this area I don’t think that increased waiting times are a conscious policy goal – if they are, it would be very poor politics. Headlines about waiting times are of course nothing new and have been an issue for as long as I can remember. The basic economic problem is that healthcare is a scarce good and without infinite resources, it has to be rationed. And how do you ration something? Either by queuing or by prices.