Questions from an amateur
Here in Wales, can we still afford the National Health Service on which so many of us depend? Is it really sustainable in the hard-up future to which we seem to be speeding?
All the time that the Welsh Government depends on financial allocations from Westminster to fund the NHS, every year the answer edges closer to ‘No’.
Take the Hywel Dda University Health Board, looking after the NHS in West Wales — Carmarthenshire, Ceredigion and Pembrokeshire. Hywel Dda is in the middle of an intense series of consultations about its planned reorganisation. A main purpose of the proposed changes is to reduce over-spending.
Three proposals are on the table. Here’s a short summary of plans for the main hospitals, but the detailed options, at www.hywelddahb.wales.nhs.uk, are well worth reading and responding to, before the deadline of July 12th 2018.
Two main hospitals – the existing Bronglais, Aberystwyth, and a new-build for urgent and planned care, somewhere on or just off the A40 trunk road between St Clears (Carms) and Narberth (Pembs). Withybush at Haverfordwest, Glangwili at Carmarthen and Prince Philip, Llanelli, would be downgraded from general to community hospitals, without accident and emergency or acute admissions.
Three principal hospitals – Bronglais, the proposed new hospital in the Carmarthenshire-Pembrokeshire borderlands, and Prince Philip.
As B, except the new hospital would be for urgent care only, and Glangwili would be a centre for pre-planned operations and procedures.
Anxiety and agitation
Community and town councillors at a consultation evening in Carmarthen on April 25th were far from quietly accepting the plans. They worried about long journeys to A&E, distant down the A40 (between 30 and 40 miles for my community in north-east Carmarthenshire, depending on the eventual site). They agitated that ambulances would get stuck in traffic jams, especially at holiday times. They praised the Wales Air Ambulance, but knew that it operates for 12 hours a day, not 24, and depends entirely on voluntary fund-raising. They were concerned that public transport services are, and will continue to be, inadequate to take patients and visitors to and from a new hospital.
At the same time, I sympathise with Hywel Dda, squeezed between the rock of rising demand and the hard place of not enough money, and so far unable to attract enough highly skilled, permanent medical staff. The upshot is that the board spends heavily on agency and locum staff, which as well as being more expensive than permanent personnel, can deny continuity of care to patients.
West Wales can feel quite remote, which is an attraction for holiday-making visitors but not necessarily for medics with partners wanting to work and children needing education, because in West Wales there isn’t much choice of schools or employment, and until the mainline railway is electrified, the region will not feel well connected to urban South Wales or onward to England. But in 2017 Prime Minister Mrs May vetoed the electrification plan. Could it be that the money had to feed the Democratic Unionist Party in Northern Ireland instead?
For mature consultants with grown-up children, it may be that West Wales is attractive for its landscapes and tranquillity, but younger medics often have different priorities. Hywel Dda knows this, of course, and the intended ‘Wellness Village’ at Llanelli could be a step towards raising the medical profile of the region…. if, and a very big if, there is enough investment from the private sector.
The health board’s budget for 2017-18 was £743.95 million, but that was not enough – an extra £69.6 million was spent, a total of £813.55 million. This was almost £2,119 for each of the 384,000 people living in the Hywel Dda area. The budget limit was £1,937 per head.
We are trying to run an advanced, comprehensive health service on a frayed shoestring that will soon break. All the time that Wales depends on largesse (or stinginess) from the UK Government, and the present Welsh Government continues its uninspired administration, this depressing state of affairs is set to remain. Yet if Wales were independent, would the Minister for Health have enough taxation revenue to channel more resources into a next-generation NHS? Given Wales’ relative poverty – gross disposable household income per head of £15,835 in 2016 compared with £19,878 for England as a whole and £27,151 for London (1) – the answer looks negative. Household members with an average of £15,835 left after taxes and National Insurance have been deducted, and with social security benefits added, are not likely to have had much tax liability in the first place.
Take as an example the median remuneration of the 8,053.7 full-time-equivalent employees at the Hywel Dda health board, which in 2016-17 was £26,483 (2). Just for illustration, in 2018-19 income tax on this nominal amount would be £2,926.60 and National Insurance, £2,167.08, leaving £21,389.32 before other deductions such as student loan repayments and pension contributions. That doesn’t leave much leeway for higher taxes.
Better elsewhere? Not really
It could be time to change expectations of what the NHS does for us. Costs of healthcare per head in the UK are already low compared to other ‘rich’ countries – in Switzerland the amount is 90% more, and in Norway almost 60% more, to take just two examples. The USA’s hugely expensive and far from universal system costs nearly two-and-a-half times more per head (and could be forced on the UK in a post-Brexit trade deal!).
New Zealand spends, per head, about 85% of the UK total. How efficient is their system, and could we adopt it? In New Zealand there are charges to see a GP, and a two-tier system with usually much longer waiting lists for publicly funded treatments than for private appointments. How about Spain, spending around 77% of the UK amount per head? That’s a creaking system too. As Pablo Avanzas, Isaac Pascual and César Moris write in ‘The great challenge of the public health system in Spain’ (3):
“In all EU countries (including Spain), during most of the second half of the 20th century, health expenditure has been growing faster than national income. The same is happening in all member countries of the OECD, so this situation calls into question whether the economic sustainability of healthcare systems, most of which were created and developed in times of greater prosperity, will be guaranteed in the future. In the context of a worldwide economic crisis, the impact of financial difficulties of healthcare systems has become particularly evident in Spain, where unemployment rate is one of the highest in the European Union.”
They also said:
“There are basically three ways to guarantee the financing of a quality public health system with universal coverage and free of charge: to increase the efficiency and effectiveness of the health provision system, prioritize health spending in relation to other public policies and/or increase income taxes for that purpose.”
In Wales, even if there were freedom to do so, there is very little scope to raise universal taxes, because of the country’s relatively low incomes.
Hywel Dda health board cannot prioritise health spending over other public policies, because health is its remit. The Welsh Government could do so only to a very limited extent, because in essence it is a distributor of monies authorised by the UK Treasury. The present Westminster Government has shown no interest in assisting Wales. So Hywel Dda is tackling the only available option, to increase efficiency.
There comes a point when ‘increasing efficiency’ means the system is too emaciated to work at all, but Hywel Dda could give itself a little breathing space if more permanent staff could be attracted to West Wales, to cut the £4 million plus a month or so costs – amounting to some £50 million a year – for ‘variable pay’ to agency personnel and locums, and for staff overtime.
Over the longer term, though, the questions will be even harder, and a new hospital between St Clears and Narberth is unlikely to be the answer. It will be new, and as such attractive to accountants (low maintenance costs) and recruiters (a magnet for staff) only for a very short time.
Surely the emphasis has to be on turning the system inside out from a focus on cures to prevention of illness, accompanied by infrastructure improvements – such as rail electrification – to help diversify and expand the economy of West Wales.
If that does not happen, when we are ill or injured the likelihood of receiving the most effective treatment will diminish, and rationing for those who cannot pay will become the order of the day.
(1) ONS Statistical Bulletin, Regional Gross Disposable Household Income 1997-2016, May 2018.
(2) The full-time equivalent was 8,053.7 people, 6,202.12 female and 1,850.58 male. The total headcount was 10,975 – 8,574 female and 2,401 male. Hywel Dda University Health Board annual report for 2016-17.
(3) Journal of Thoracic Disease, May 2017, 9 suppl 6, S430-S433.