Centralising health care

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When organisations engage consultants to tell them what to do, they usually already know the answer; they just need an outsider to boost their credibility.  It’s why consultants are often referred to as people who borrow your watch to tell you the time; as often as not, they simply write down in black and white exactly what you want them to write.

Those paying the outside consultants inevitably have a degree of influence over what they write; and those who have the most influence are those who choose the consultants and write their brief.  In all of this, governments and public sector bodies are no different from private sector companies; he who pays the piper calls the tune.

No-one should be surprised that the report on the Welsh Health service written for the Welsh Government comes down in support of the Government’s changes; that was pretty much guaranteed from the outset.  The danger is that politicians get so involved in trying to discredit both the report’s author and the minister, for largely political reasons, that they lose sight of the underlying arguments.

As far as I can see, there is a high level of consensus (albeit not unanimity) amongst health professionals that there needs to be a shift in the balance between what is delivered locally from a number of generalist units and what is delivered more centrally from a smaller number of specialist units.  That is being driven by a number of factors, including the increasing specialisation of practitioners, the need to maintain specialists’ skills through them seeing an adequate number of cases, the increasing cost of some treatments and equipment, and recruitment difficulties. 

None of those factors have a terribly high level of respect for the rurality of Wales.  But neither is there anything in any of those factors which undermines the argument for most of the more routine cases to continue to be dealt with locally.  The problem is where to draw the line – and what happens when, as many of those believe is now the case, the line needs to be moved?

There is a natural tendency for people to want to retain as many services as possible in their local hospitals – and there is a natural tendency for politicians who want their votes to support them in that desire.  (And it isn’t limited to opposition politicians; some Labour AMs have been equally quick to make the same arguments, even if it’s their government behind the changes.)

So far, the government has simply not been getting its case across effectively.  When opposition AMs – and even government AMs – denounce any and every proposed change as a ‘downgrading’ of one hospital or another, the rational argument for some change quickly gets lost in the shouting and demands for resignations.  The government hasn’t always helped its own case; the concentration has always seemed to be on what’s moving from a hospital rather than on what’s staying; but then, that which is changing is always more interesting than that which is staying the same.

Faced with such difficulties, it’s hardly a surprise that the government sought some outside help to examine the situation and shore up its position.  Nor is it surprising that the expert selected is sympathetic to the government’s position; the majority of other experts in the field would have been equally sympathetic.  So why are they in such a mess now?

I suspect that it’s partly because the move to make changes is to some extent anticipatory rather than reactive.  The search for the ‘killer’ arguments about how the current system is letting patients down is a vain search if the problems being addressed are those of the future rather than the past.  The danger is that waiting for the killer arguments is likely to mean that they become exactly that – killers.  Waiting until there are a sufficient number of excess mortalities to prove the case isn’t really what I want of government.

And yet, without those arguments, it can, and frequently does, look as though the government is acting for financial rather than clinical reasons.  And the e-mails released this week give the appearance of a degree of selection of relevant facts and statistics to support a pre-determined outcome.

Whatever the outcome of this week’s hoo-hah, the underlying problem will not go away.  We need a sensible and rational debate about what local hospitals can or cannot continue to do, safely and effectively – and what requires a degree of specialisation which simply cannot be provided locally.  I’m not seeing much of that debate at present.