Fourth Assembly In Focus : Health & Care

Last time I focused on the economy – which no doubt would've brought some smiles to any Labour faces reading this as it was broadly good news. I think it's time to wipe any smug grins away.

Major Policy Initiatives of the Fourth Assembly

Human Transplantation Act 2013 – One of the flagship laws this term, which came into effect last December. The new organ donation system is a "soft opt-out" one, meaning that although consent for organ donation will be presumed for anyone who's lives in Wales for 12 months and dies here, families can still opt-out on their behalf. Prior to the law being passed, it was estimated 14 people died waiting for transplants in 2014-15.

Social Services & Wellbeing Act 2014 – Arguably the most complicated law passed in post-devolution Wales, with controversy hanging over it due to arguments over the criminalisation of "smacking", which threatened to derail the law at several points. In the end it passed after a mammoth round of amendments, and resulted in the introduction of a National Adoption Service, new complaints procedures and new assessments to ensure social services meet the needs of vulnerable adults and children.

Hospital reorganisations – A highly controversial and explosive series of hospital reorganisation and downgrades in south Wales, which will ultimately see full-time accident and emergency services withdrawn from the Royal Glamorgan Hospital in Rhondda Cynon Taf, as well as the construction of a £300million Critical Care Centre near Cwmbran. Opponents to the programme believe the emphasis should've been on recruiting extra medical staff, while the Welsh Government claim difficulties in doing so requires a major reorganisation to ensure "safe and sustainable" services (see also : South Wales Programme : The Evidence). It's not just south Wales, with maternity services set to be centralised in both north and west Wales, prompting what were often significant protests from the public.

Public Health Bill – ....assuming it gets passed next week. It includes various measures to improving the overall health of the nation including controversial restrictions on the use of e-cigarettes in public (the proposals for which having been relaxed somewhat, but made more complicated). There are also new licensing conditions for tobacco sales, tattoos and intimate piercings as well as new duties relating to public toilets. The law has, however, been criticised for being a missed opportunity and I'll come back to that shortly. Update 16/03/2016 : It was ultimately rejected by the Assembly.

Life Expectancy & General Health

The good news is we're generally healthier now than in 2011. The bad news is issues remain
on obesity and excess drinking - and have barely been touched by the Welsh Government.
(Pic : Wales Online)

Over the period 2012-2014 (xls) the average life expectancy at birth for Welsh men was 78.6 and for Welsh women 82.3. It's barely changed for women over the course of the Fourth Assembly, but Welsh men are living 0.3 years longer, so the gap between men and women has closed slightly.

Here's a comparison between the National Health Survey results for 2014 (and 2011) for people aged 16+:

• 19% of people described their health as fair or poor (21% 2011).
• 12% reported mental health problems (11% 2011), with stable levels of depression, but a rise in numbers reporting anxiety when compared to 2011.
• 7% reported diabetes - presumably both types combined (n/c since 2011).
• 33% reported having a limiting illness (34% 2011)
• 20% described themselves as a smoker (23% 2011)
• 40% said they drank above the daily recommended alcohol intake (43% 2011)
• 31% said they were physically active at least 5 days a week (29% 2011)
• 58% were either overweight or obese (57% 2011).

The good news is that, generally, people feel healthier than at the start of the Fourth Assembly, and there's been modest progress on key public health issues – smoking in particular seems to be going out of fashion.

The bad news is that obesity and overweight levels have somewhat stabilised but remain high, while it's a similar story in terms of excessive alcohol consumption – both areas largely missed by the Public Health Bill, with plans to introduce minimum alcohol prices and nutritional standards in schools and care homes ditched.

The Ambulance Service

It seemed not a month would go by without us being told that the Wales Ambulance Service Trust missed its response time targets for the umpteenth in a row. It's quite clear that for a large period of the Fourth Assembly, emergency ambulance response times fell significantly below the target set by the Welsh Government.

These national figures mask significant variations within Wales, with rural areas in particular – but also Cardiff – seeing worse ambulance response times than the national average (Why are Welsh ambulance response times so poor?).

Amidst a crisis in paramedic morale and performance, a major review in 2013 – led by Prof. Siobhan McClelland (Ambulance Required for Wales Ambulance Trust) – recommended the current 8 minute target time be scrapped or significantly altered.

National average ambulance response times against the Welsh Government's target - source

In October 2015, the Welsh Government applied the recommendations and ditched the 8-minute response time target for all but the most serious life-threatening calls – now called "red calls". Opposition politicians cried "foul play" or "shifting the goal posts", and they have a point – but the decision was the right thing to do as the target was based on a stopwatch, not patient outcomes.

Not being a cynical type, of course, I wouldn't suggest for a moment that the changes were brought in so a well-predicted dramatic improvement in response times would occur just before an Assembly election.

In addition to the changes to the ambulance service, the Welsh Government introduced the helicopter-based Emergency Medical Retrieval and Transfer Service (EMRTS, see also : Flying doctors set to take to the skies) which was designed to take emergency medicine consultants to patients in order to stabilise conditions at the scene and allow speedy transfer to increasingly centralised A&E departments.

Waiting Times

If you're a Labour member or supporter it's best you look away now.

There are loads of different statistics to choose from when it comes to waiting times, but I've decided to stick to those which are the most time-sensitive.

A&E target - source

Firstly, the number of people waiting in A&E for under 4 hours. It's clear the situation has deteriorated since Labour were re-elected in 2011, though not drastically, and there were signs of recovery towards the end of 2015. Nevertheless, around 20% of Welsh A&E patients are waiting more than 4 hours, compared to around 7% of patients in England and around 5% in Scotland.

Urgent cancer treatment target- source

Next, the number of patients who, when diagnosed with a cancer that requires urgent treatment, start that treatment within 62 days. It's been topsy-turvy during the Fourth Assembly, though again you're looking at around 15% of patients who need their cancer treated, as a matter of urgency, not starting treatment in the target time. However, this is roughly the same proportion as in England.

Cancer survival rates have improved in Wales, but for some cancers – like lung and bowel – we're significantly lagging behind.

Diagnostic and therapeutic waiting lists - source

Thirdly, there's the waiting time for diagnostic and therapeutic services. When Labour took office, around 2,200 people were waiting longer than 14 weeks. By the end of 2015 that was pushing 9,000 which is an improvement on a grim period between the end of 2013 and early 2015. England has significantly shorter targets – but it has more hospitals. In January 2016 just 1.6% of English patients waited longer than six weeks for diagnostic tests and around 9% in Scotland waited longer than six weeks in May 2015.

It can't get any worse than that, surely? Well, I've saved the "best" till last.

Treatment waiting times - source

The numbers waiting longer than 36 weeks, or 9 months, to start treatment have absolutely skyrocketed since 2011. More than 25,000 Welsh patients were in this position at the end of 2015 and it peaked at closer to 30,000 – that's a ~1500% increase since its lowest point in 2012. England has a target where 90% of patients should start treatment within 18 weeks, though it's worth pointing out that they've consistently missed that since the start of 2014.

NHS Staffing Levels

NHS workforce changes - source

I realise the graph isn't much use because of how it turned out – my apologies. What it demonstrates is NHS staffing levels have remained relatively stable throughout the Fourth Assembly, with no big increases or decreases in any speciality of the health service.

Unsurprisingly, the NHS is dominated by nurses, followed by administrators. The number of doctors has remained stable – in fact there are slightly more consultants now than in 2011.

The hidden problem, and a problem that might be cause for such lengthy waiting times, is a fall in the number of allied health professionals (like physiotherapists and radiologists) and scientific staff. They don't get anywhere near the attention from politicians as their work warrants, yet ultimately these are the people who carry out diagnostic tests and will determine how quickly someone gets treated. Doctors and nurses don't.

In fact, it wouldn't surprise me if the main cause for longer waiting times in Wales is a lack of hospital scientists and diagnostic equipment to carry out routine and urgent tests, because of the political obsession with doctorsandnurses.

Also, despite well-publicised concerns, the number of GPs hasn't changed very much. The real problem there is their demographics (source). It takes the best part of a decade to train to become a GP, many are nearing retirement age (source) and an increasing number of women GPs (it's close to 50:50 gender balance) – who might take time out or work fewer hours (source) to ensure greater job satisfaction – is going to put pressure on primary care services unless reforms are made to how those services are delivered.

I suppose the real questions here are whether the workforce its well-balanced or too top-heavy in nurses and admin staff in particular? Will these workforce numbers will meet the demands of an ageing population?

Hospital Beds

Bed occupancy rates - source

The number of available beds will, like diagnostic staffing and equipment levels, impact on waiting times. There's no official target for the number of beds that have to be kept free for new patients, but there's an unofficial 82% bed occupancy target set by the Royal College of Surgeons.

Specialities that have met this target include intensive care, surgery, high dependency units, specialist baby care and paediatric intensive therapy. However, even within these specialities there are over-occupancy problems : cardiac and thoracic surgery (92%), neurosurgery (87%) , urology (90%). All have gotten worse over the course of the Fourth Assembly.

Maternity occupancy rates are particularly low (51%) but they are, by definition, not going to be fully-occupied as stay lengths are broadly predictable. Statistically, this does suggest maternity units and specialist baby care units are under-occupied, which brings into question arguments supporting the centralisation of such services.

All this is before considering the specialities with pronounced problems, like acute medicine (90%) geriatric medicine (96%), community medicine (97%) and mental health (87%) - though in the case of mental health, it seems child and adolescent mental health beds are massively under-occupied (69%) compared to adult services.

Delayed transfer of care rates - source

Another related issue here is "bed blocking", known officially as "delayed transfers of care", where a patient – usually elderly or infirm – is unable to be transferred out of hospital because of delays in social service case-handling or because, although it's decided they're fit to leave, there's no bed for them at a care home.

The situation's more pronounced in mental health wards – as you might expect. Although there've been peaks and troughs over the last few years, levels of bed blocking have broadly stayed the same as they were in 2011; so things haven't got any worse, but they haven't got any better either.

Health Spending

Wales spends close to 50% of the devolved budget on health and
social services yet to many it seems that's still not enough.
(Pic : South Wales Argus)

In every single budget the Welsh Government have thrown extra resources at the NHS at the expense of everything else and, yet, some local health boards are still struggled to break even, despite the passing of the NHS Finance Act 2014 (though it'll take time to filter through).

Spending-per-head on NHS services in Wales rose from £1,755.77 in 2010-11 to £1,803.82 in 2013-14 in cash terms (source) – it'll probably be higher still in 2015-16. In real terms, once things like inflation are taken into account, this is likely to be a cut in spending; figures from the Nuffield Trust have suggested around 1-2% - though spending per head is broadly similar to England. Scotland and Northern Ireland spend significantly more per-head.

The biggest areas of spending include mental health (11.4% of spending in 2013-14), circulatory diseases (7.8%), cancer (6.8%), respiratory diseases (6.5%) and musculo-skeletal problems (6.2%).

Within that though, just 0.8% of the NHS budget goes towards child and adolescent mental health (CAMHS; see also - Mental health services for young people criticised), compared to 3.3% for the elderly.

I'm yet to be convinced that the issues in the Welsh NHS are down to money; it's down to poor long-term planning and poor management – something picked up by the OECD recently.

Conclusions

Although health and care services as a whole are running relatively well with no real concerns on the quality side of things, if there's a single issue that's going to see Labour removed from office in May it's their management of the NHS.

The major problems - particularly in treatment capacity and treatment speed - have rumbled in the background for decades and have steadily grown worse, becoming an accepted part of how health services are run here – things like long waiting times, bed blocking and ambulance response times.

Labour's plans for hospital (or hospital department) reorganisations in particular are electoral kryptonite. The outrage has died down somewhat in south Wales, but in western and northern Wales the anger's still palpable, particularly on the emotive issue of maternity and specialist baby services.

On the social care side of things, while there are clear problems, the Welsh Government have taken it seriously – perhaps more seriously than any of the other governments in the UK. They've embarked on a series of significant reforms, but cuts to local authority budgets could undo some of the work they've done there.

The Welsh NHS is stuck between a rock and a hard place. While it needs a sustained period of stability, it's also in clear need of reform to prevent the start of a downward spiral that begins to impact quality of care, not just how quickly that care is delivered. That's a real challenge for all parties, but based on what's happened so far it's becoming clear Labour aren't up to the task.

All signs point towards the situation getting even worse if the status quo is maintained. But if there's another round of botched reorganisations or fiddling by politicians it could send the Welsh NHS towards breaking point. So any case for further major changes by any party will have to be completely watertight.

There are also a number of "ticking time bombs" that will need to be addressed as a matter of urgency in the Fifth Assembly : obesity (as mentioned), dementia care, pressure on mental health services, the GP workforce – which could become an emergency if it isn't addressed in the next 5-10 years – and both local health board finances and accountability.

In many ways that makes it a good election to lose.