Tuesday, 15 January 2013

Accountability vacuum causing problems for Welsh Labour?

With Hywel Dda Local Health Board formally adopting
its hospital reorganisations today, is this the
start of an uncomfortable period for Welsh Labour AMs?
(Pic : BBC Wales)
I only saw these last week, but there are two videos (here and here) of Sandy Mewies AM (Lab, Delyn) talking with protesters outside a meeting in Connah's Quay back in September. The protesters were campaigning to save Flint Community Hospital, which has been outlined for closure by Betsi Cadwaladr University Local Health Board.

Although this was a while ago, I think this exemplifies a big problem with regard public service delivery. Sandy makes repeated claims, or implied, that it's "not to do with me" – a classic politician's line if ever there was one.

Right, OK, she doesn't come across too well in the videos. However, in this case, she's technically right and it's going to cause the Welsh Government and Labour AMs headaches in the coming years.

Who runs the Welsh NHS?

Local Health Boards (LHBs) actually run and administer NHS services in Wales. The LHBs are the ones overseeing hospital reorganisations and consultations on reorganisations. These are run by appointed officers and managers, but those higher up are practically anonymous.

Community Health Councils (CHCs) are supposed to represent the views of service users and the general public. Local councillors are represented on those boards – in a similar way to police and fire services.

The Welsh Government, and by extension Labour AMs - like it or not - are politically accountable for these reorganisations. But in practice they have very little say in what's being done. They can only scrutinise really, and that's – primarily - being led in the Assembly by opposition AMs.

Labour AMs have been quiet with one or two exceptions. Backbench Labour AMs seem unwilling to speak either for or against the LHB decisions, and that was one point raised by the Flint protesters. I'd draw your attention back to what's been said about Assembly plenary sessions.

I'm convinced that's just one reason reason why some public services in Wales are poorly run, because it's always someone else (Councillors, AMs, MPs) carrying the can, even if they had nothing to do with the decision-making.

So, the decision-making ability rests in one place, the accountability rests with the politicians. They should be joined together. I think that's what most people would call "a functioning democracy".

Say what you like about PCCs, but at least you can't say that of the police anymore.

What's going wrong with hospital reorganisations?

I've said several times that the changes make sense - primarily because of shortages of specialist medical staff. I should be explaining why the changes are needed. However, whenever I go to do so, some other bungle appears – whether that's by ministers, LHBs or someone else. I go back to banging my head against the desk, hoping to wake up one morning and find I'm only human left alive, or that Wales is sinking into the Irish Sea, so we can put all this madness of thinking we have a functioning country to rest.

It's been rushed – Perhaps that's with one eye on NHS budgets, which are under immediate strain, but many LHBs are using 12-week consultations (the bare minimum) for the public to judge changes that will last decades. In an ideal world, this would've been phased in over several years. Even if it is going to be, that's not the impression given.

People still don't understand what's happening – This is supposed to be the point of the consultations, and some LHBs have gone some way in explaining the changes to the public. However, some consultations have been poorly attended and if you mention "hospital changes" to anyone in the street, they'll probably assume that means "closure". In fairness, sometimes that is the case – especially smaller community hospitals like Flint. Today it was announced that a community hospital near Llanelli will shut.

"No hospital is under threat, and no hospital was ever under threat in Wales" - Carwyn Jones, First Minister's Questions, May 1st 2012.

People assume the worst about NHS changes because that's what Labour have been saying to them for decades, putting it constantly in a position of danger unless Labour are running it. Heh. It has to be said that some opposition AMs are making the job harder too, but that's....their job.

Bad news follows more bad news – Again, this isn't helping things. Stories about people being treated in ambulances, missed targets, negligence, poor standards of care, failures to recruit specialist staff and sexed-up documents. Today there was issues surrounding Hywel Dda LHB's handling of reorganisation. Yesterday, ITV Wales revealed Carwyn Jones himself redacted parts of a report into the death of Robbie Powell – which is pretty damned serious by itself.

So, the climate isn't ripe for dramatic, fundamental changes to hospital services in Wales at the moment.

Us - Now, we the public rarely help ourselves. I think there's an expectation that to get "proper care" you need to go to a "proper hospital". We rarely hear about advances in things like emergency medicine or home care, which might reduce the need for hospital visits. We also expect NHS staff to perform miracles. I wish more people would pay attention to Welsh Government advice on things like reasons to call 999 or go to A&E. You can find out more information here.

I don't usually disclose what searches lead here, but one that sticks in my mind was "emergency arse doctor rectal surgery port talbot". I don't want to know.

Labour's problem

I feel sympathy for Sandy Mewies' situation in the videos. I don't like to see that happen to an AM (or politician in general), as she's only (sort of) trying to do her job within the confines of the job description. She's been placed in an awkward position.

The decision-making process seems complicated. Basing this partially off Community Health Councils recent calls for "stronger political leadership", here's how I understand it:
  1. Local Health Boards run and administer NHS services and propose reorganisations.
  2. Community Health Councils negotiate the changes with the LHBs "on behalf of the public".
  3. If there's a disagreement, and only then, it gets referred to the Health Minister (Lesley Griffiths).

There seems to be very little direct role in reorganisations for AMs other than to ask questions in the Senedd, or organise protests and petitions.You can understand why an inability to actually do something about it is going to look like inaction to the public - Labour inaction in most cases - if they're not willing to speak out on government policy one way or another on behalf of constituents.

Ideally, the LHBs and CHCs would be democratically accountable for these decisions in some way shape or form – perhaps answering directly to the Assembly's Health Committee. That's something Elin Jones AM (Plaid, Ceredigion) suggested last year, and several times before that, with regard finances. I think it'll have to go further than that. There's no point in putting local councillors on the CHCs, as local authorities are generally run along this arrangement too.

But, ultimately, Welsh Labour seem quite happy with the arrangement as they've done little to change it, other than push for greater collaboration between varying authorities at local and regional level.

At the very least they should consider Elin Jones' suggestion now, or Sandy Mewies will only be the first Labour AM to (on record) get this treatment. If Labour handled it like this in England or Scotland they would be toast, but being Wales and seeing as the Chuckle Brothers down the M4 are rather unpopular at the moment, I doubt this is going to affect the party electorally.

I want them to get this right, because as long as the changes are reasonable I think we might see long-term benefits through the creation of "centres of excellence". But, yeah, at a fundamental level they're making a complete hash of it.

The thing is though, it's not entirely backbench AMs fault. But you better believe it's going to be their faces and names to it.


  1. My only explanation for this is as follows.

    Labour do dont care about Wales and we'll still vote for them anyway because we have no alternative. So if a few people die as a result of them downgrading or closing hospitals then so be it. Dead bodies are a great stick to beat the Tories with, just ask Ann Clwyd.

  2. I didn't have you down as such a cynic, WnB ;)

    I'm not sure Labour will be able to make any sort of political capital out of this though, and the opposition parties would need to be completely inept to allow them to do so. Labour proposed this back in 2006, so it's not as if they haven't wanted to try and do something like this for a while.

    We all have ideas on what the NHS "has to be" in Wales, so it makes changes of any kind incredibly hard to push through even when they really are needed.

  3. I serve on a Community Health Council as a Councillor and have fought tooth and nail to oppose the BCU Health Board's flawed proposals to transfer neonatal intensive care from Ysbyty Glan Clwyd and Ysbyty Maelor to Arrowe Park which on its own staff's mission is failing within its Maternity Services. The CHC's response to the board is 'weak'frankly because I was one of 72 members who fought the corner of mother's and babies. If you ask for a demographic breakdown of membership of the CHC's you will understand why protecting Community Hospitals is high on the list of their issues and why other things such as neonatal intensive care is not. Also be aware that the Minister of Health APPOINTS one third of the members of the so called independent CHC, the voluntary sector appoints another lot and we know how influential Labour are within the third sector in Wales. Then we have Councillors. Is it any surprise that the CHC will probably reach a compromise with the LHB... anything to prevent the Minister having to make a difficult decision.

  4. I didn't know the Health Minister was involved in CHC appointments, Plaid Gwesyllt. I wish I could say I was shocked by little facts like that anymore, but I'm not. I don't know, I think I've almost had enough of this.

  5. Reconfiguration is going to happen, we just have to make sure that its about improved service provision and not just cost cutting (though it is inevitable that it would be). At least our situation is better then the bureaucratic dogs dinner that is the NHS reorganisation in England.

    My solution to the democratic deficit, create regional bodies elected that subsume the health authorities, police and education into themselves.

    But we have to realise that change will happen, I just want it to be under democratic control.

  6. Cibwr - or to make these public bodies accountable we could elect some kind of "national assembly".

  7. Thanks for the extra comments.

    Cibwr - I'm working on a five-parter on local government that will hopefully be posted in March. I'm thinking very much along the same lines as you, and perhaps the recent post on Your Voice, but obviously I'm going to go into a bit more detail then. But I've got to disagree with you on the "dog's dinner". Both are, but for different reasons.

    Pads - The LHBs being accountable to the Assembly's Heath Committee would be a start, but I doubt Labour AMs or the Welsh Government would go for it. If NHS services are going to be under regional control, then they probably need to be accoutnable to a regional tier of government, as Cibwr suggested. Otherwise, what's the point of the LHBs in the first place?

  8. Indeed Pads - however better that the overall strategy for health is set by the National Assembly, overseen by the health committee.

    Owen, I would suggest that social services are a natural match for health and this should be combined with health in the regional tier of government (transferred from the current county councils) - I have suggested a committee structure where it would be 2/3 elected representatives 1/3 experts appointed to the Health and Social Services committee.

    I am currently doing a bit of research into the history of local government reorganisation, the local government boundary commission for Wales suggested in a draft report a reduction in the counties to 4 with county boroughs for Cardiff Swansea and Newport, with a central Welsh council for common services. Its final report suggested 36 districts and 7 counties.... Will post something on my blog when I have completed it (hopefully with maps). There seems to have been a fairly continuous strand of feeling that we need larger regional local government for functions like health and social services - I wonder what went wrong with the Hunt/Redwood proposals that gave us our current network of 22 counties?

  9. Cibwr - I think there were 23 or 21 unitary authorities proposed in the 90s, it was eventually decided upon 22. I don't know the exaqct details behind it, but I have looked into the history behind it for my own posts, albeit brief references. I look forward to seeing what you come up with yourself. If I don't beat you to it, of course. ;)

  10. The original proposals were for 21, but Labour insisted that the proposed Heads of the Valleys authority covering Merthyr, the Upper Rhymney Valley, and Blaenau Gwent be split. David Hunt's reaction was reportedly "another Labour local authority would not make a difference". Fortunately demands from the Liberal Democrats to keep Radnor a unitary authority and from Plaid to keep Meirionnydd a unitary authority were rejected.