Some things are best left to doctors

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It is inarguable that the number of people with a mental health diagnosis has increased. It doesn’t follow from that, however, that Wes Streeting is right to claim that there is ‘over-diagnosis’. There are a number of reasons for the increase in the number of people with a diagnosis, including a reduction in stigma for those seeking help as well as a better medical understanding of some conditions. It doesn’t matter whether a health problem is down to physical issues or mental issues (and there's an argument that many mental health issues have underlying physical causes anyway): as a general rule, identifying more sufferers and providing them with the right treatment and support is surely a good thing rather than a bad one. That some people will be misdiagnosed or wrongly diagnosed is inevitable. It happens with all sorts of illnesses, always has and always will. When cases are numbered in the millions, achieving 100% accuracy is an impossible target.

That doesn’t seem to be the understanding of the English Health Secretary, though. He seems to have in mind that there is a ‘right’ number of diagnoses, and that that number is lower than the actual number currently being recorded. His basis for making that assumption is unclear. Maybe he can explain it clearly and succinctly, but he hasn’t done so thus far. It’s hard to avoid the conclusion that his main driver for making the assertion has more to do with the costs than health – both the direct costs of treatment and the indirect costs of lost productivity from people who aren’t working. It isn’t just him: there seems to be an underlying attitude amongst Sir Starmer and his ministers that many of those who are not working due to poor health are lazy lead-swingers who need to be forced into work regardless of the consequences for their health. I doubt that anyone would argue that there are no people at all in that latter category, but there is no evidence of which I’m aware that the problem is anything like as widespread as the government seem to be assuming. By concentrating his attention on mental health issues, Streeting is in danger of reviving the stigma which has taken decades of work to reduce.

He is, of course, only responsible for the English NHS, and his approach doesn’t necessarily have to be replicated here in Wales, although if Labour MPs are dragooned into going along with him, neither is it certain that the approach will not be more widely applied. But any cuts to benefits or to mental health services implemented on the back of dodgy assumptions certainly will affect people here. His wish to eliminate duplication and waste in the NHS is understandable, but saving money by having sweeping diagnoses made by bean counters and politicians rather than by doctors is surely a step too far.

Being used as the stakes in a high-risk gamble

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Whilst in theory the Welsh Government has the power to determine what steps should be taken to minimise Covid risks, in practice the scope for divergence from England is limited by the tight control of the purse strings being retained in London, the long and porous nature of the border, and the shared media which inevitably highlights what is happening in England and can lead to a degree of confusion when the rules differ. Despite that, the Welsh Government has tried to maintain a safer environment in Wales than that pertaining in England, and has succeeded, by and large, in keeping most of the population on board with its decisions.

It has been clear since the emergence of the latest variant that the desire of Wales (and Scotland) to take stronger action that England is still strong, with the First Ministers of both countries openly demanding tougher action, a demand which Johnson has rejected outright. It isn’t just non-Tory politicians who are expressing their concern – just yesterday, Johnson slapped down the head of the UK Health Security Agency for her entirely sensible advice that people should try and avoid unnecessary socialising. The PM, apparently, is all in favour of unnecessary socialising whatever the risk. Today, senior doctors and NHS leaders have warned that the government needs to take stronger action on a precautionary basis, describing it as “bizarre” to wait until a spike happens before acting.

Whilst the government is entirely correct to emphasise that advisors advise and ministers decide, a decision not to act in the face of such strong advice from so many experts indicates that the government has decided to take a gamble. How much of a gamble remains to be seen. It may be that they end up being lucky: the new variant could turn out to be less of a problem than some think likely. If that happens, they will retrospectively claim that they took the right decisions, ignoring the degree to which luck plays a part; if things are as bad as others fear, the gamble will cost thousands of premature deaths. None of us – not even the most knowledgeable experts – have enough information at present even to make a reliable guess as to the outcome; only time will tell. Johnson might get away with it this time – that would be a good outcome in the short term, but might also simply encourage even more recklessness in the future.

What is clear is that the UK government is being less than honest with the population. Their rejection of the suggestion that all arrivals into the UK should self-isolate until after a second negative test on day 8 (as put forward by Mark Drakeford and Nicola Sturgeon) was on the basis that it would have a detrimental impact on the travel industry, which demonstrates that impacting one particular industry sector is a more important consideration for Johnson than hospitalisations and deaths, let alone increased pressure on the NHS. Presenting sound and sensible public health actions as being ‘restrictions’ on ‘liberty’ not only presses the right buttons with the Tory party’s increasingly influential extremists, but also encourages the public to overlook the fact that our lives are the stake in Johnson’s massive gamble, a gamble which puts profit ahead of people. And, to return to where this post started, as long as Wales is tied to England, no matter how much the Welsh Government might huff and puff, Welsh lives are part of that stake as well.

A level grades are a blunt instrument

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The report last week that the UK Government is being ‘forced’ to fund more places in English universities to train doctors and dentists as a result of ‘grade inflation’ raises more questions than it answers. At a simplistic level, the problem is easily understood – if pupils get higher grades at A level than would have been the case had they sat exams, then more people will meet the grade-based criteria for entry onto the courses. But if those people are suitable to become doctors and dentists under one system, what is it about sitting exams which would somehow have made them unsuitable? If Pupil X gets an A* when assessed by his or her teachers but ‘only’ a B in an exam, why is the same pupil, with the same knowledge and abilities, doctor material in the first case but not in the second? How do we ‘know’ that pupils with an A* grade obtained in an examination can go on to be successful doctors and dentists, whilst those with a B cannot?

Using grades obtained by an adolescent in his or her last year at school as an absolute determinant of his or her future career prospects seems almost designed to waste a lot of potential talent. Clearly, the grades obtained by pupils at A level tell us something about how much work and effort those pupils have expended, how much knowledge they have accumulated, and how likely they are to apply themselves to their work at university, but they aren’t – and can’t be – as definitive as the way in which they seem to be being used. Exams are in some ways a blunt instrument; they are not an assessment method which suits all, and the circumstances in which a pupil finds him or herself on one particular day may not be representative of that pupil’s general character and approach. And although all of us want those providing our medical care to have the necessary knowledge and expertise, it’s not at all clear that the precise grade obtained in A level Biology is a particularly good indicator of that.

We know that there is a shortage of doctors and dentists in the UK, and that the UK is simply not training enough to meet our needs. We also know that this is a problem which cannot be resolved quickly, given the length of time it takes to train people. But neither is it a recent problem: it is a long-running problem under successive governments, whether Tory or Labour, which share an ideological commitment to competition and markets. What this so-called ‘grade inflation’ underlines is that that shortage is not a result of a lack of people wanting to become doctors and dentists, nor is it a question of their suitability for the role. It is the result of decisions by successive governments to limit the number of places, largely on financial grounds. They have made a deliberate choice to train fewer than we need and recruit people trained outside the UK instead, in the process not only rejecting many of those who want to follow careers as doctors and dentists and have the ability to do so, but also depriving other countries of the benefits of their own investment in training. Any government which was serious about providing proper health care for its citizens would start by looking at how many people it needs to train to provide that care and then provide enough places to meet that need, rather than setting a financially-driven cap on the number of places and filling those places through market-style competition. It is yet another example of a government decision driven by ideology rather than need.

A sad ending

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The proposed ban of e-cigarettes has been strongly debated over many months.  The argument over whether they are a gateway to smoking or an aid to quitting is one where the evidence is far from categorical one way or the other.  But given the lack of regulation of the manufacture and content of the devices, the uncertainty of the impact on non-vapers, and the concern that it may be a way of re-normalising smoking, I’ve leaned, on the whole, to support of the Welsh Government’s position on the issue.

It’s puzzled me, though, that it became such a party political issue.  In the absence of absolute clear-cut evidence one way or the other, it seemed to me – until yesterday – that Plaid was the one party in the Assembly which called the issue the right way, leaving it to the decision of individual AMs to decide how to vote.  There are some issues on which taking a stance as a party doesn’t really seem to me to be essential, and suggests a lack of capacity by AMs to reach an informed judgement.

To say that yesterday was a disappointment would be an understatement.  The cheap shot by Leighton Andrews was poor and unnecessary.  For a government which was depending on the support of members of Plaid to pass a key piece of legislation shortly afterwards, folly is an inadequate description.  And it was indeed, as Plaid have said, an example of the arrogance which Labour can display on a regular basis towards opposition parties.

But Plaid’s reaction was no better.  Not only have they thrown out a ban which some of their own AMs supported, they’ve also thrown away a lot of other stuff which was non-controversial and generally welcomed, in a fit of tantrum.

I find it hard to decide which was the most unedifying – the Minister’s cheap shot, or Plaid’s reaction to it.  It’s kindergarten politics rather than a grown-up approach to legislation.  I know that some AMs think that emulating the style of Westminster is somehow a step towards maturity, but it really isn’t.  This is the sort of thing that happens all too easily when people find themselves in a bubble, isolated from the real world outside, where who said what to whom has a level of intense importance to them which is unlikely to be shared by other than the most tribal and partisan of supporters outside the bubble.

It’s a very sad note on which to end the fourth Assembly.

No real signs of an earthquake as yet...

Tweet Last week, Plaid told us that they want to ‘deprive Labour of power over health and education’.  I can’t disagree with that as an aim, although in itself it’s a very negative statement which needs to be backed up by a positive programme outlining what would be different under Plaid.  There’s no question that the record of Labour in both fields has been badly wanting but however frustrating that record might be from the perspective of opposition politicians, merely removing Labour is an inadequate aim in itself.  And as an aim, it differs hardly at all from what the Tories have been saying, which only serves to underline the inadequacy of the negative.  Health and Education need more than a change of the men and women at the top if performance is to improve.

I can also understand why Plaid don’t want to get into debate about who might do what and with whom after the election, preferring to concentrate on putting their own message across rather than speculating about deals and arrangements once the dust has settled.  I’d be saying the same thing.  But that won’t stop me or anyone else from thinking aloud about just what the process might be if Labour is to be deprived of control over these two important fields – and that demands giving some thought to potential electoral outcomes.

The most credible scenario, given current polling data, under which Labour would have no control over either of these policy fields would be an agreement between all the ‘non-Labour’ parties in the Assembly to come to some sort of arrangement under which one or more of the parties formed a coalition and the others agreed, as a minimum, not to bring the government down.  But Plaid have already – very definitively – ruled that one out.  So what does that leave?

There are currently four parties represented in the Assembly.  At present, it looks extremely likely that they will be joined by a significant UKIP group, and it is at least possible that there will be a Green Party AM or two as well.  Given that any sort of Plaid-Tory arrangement has been ruled out, there are only two possible arrangements of parties which could lead to the formation of a viable government after next May.  The first is if the Tories, UKIP, and Lib Dems between them manage to get a total of around 30 seats; and the other is if Labour, Plaid, the Green Party and the Lib Dems manage to get to the same total (scenarios which include the possibility that any one party in either grouping has enough seats to form a government alone, even if that were to be a minority government with tacit support from at least one other party).  (The Lib Dems are assumed to be flexible enough to jump either way, even if they only have one member left.)

Under the first of those scenarios, Labour would, obviously, be deprived of power over both Health and Education (as well as everything else!).  Under the second, they would only be deprived of both if they were to be the junior partner in a coalition, with the senior partner well ahead of them in votes and seats.  These are, after all, the two most important areas of policy over which the Assembly has control, and it’s just not credible that the largest coalition partner would cede control over both.  Indeed, they’d only be likely to cede control over even one of them if there were to be a rough parity of seats between the partners.  On current polling trends, the likeliest result, even if Plaid were to be a part of the government, would probably leave Labour in charge of both.  (And that also means that Plaid’s participation in such a government would be in direct contradiction to what they said that they wanted to achieve – sadly, the Tory accusation of hypocrisy isn’t as far wide of the mark as I’d like to believe.)

Neither of the two scenarios which would lead to a change of control over health and education seem remotely likely on present trends.  It’s a depressing prospect, which serves only to underline quite how big an earthquake we need in Welsh politics if we’re going to see real change.

Generals with maps

Tweet I rather liked the line about the dangers of a general with a map in a combat zone.  I’m not sure that it stands up to scrutiny though – it strikes me that a general without a map might potentially be even more dangerous.

It’s clear by now that the minister is determined to press ahead with a reorganisation of local authorities which will reduce the number of 8 or 9 in total.  It’s also clear that the other three centralist parties represented in the Assembly agree in principle with the push for a reduced number, even if they are quibbling about the detail.

It’s also clear that there are councillors in all the parties who will resist the proposed changes.  Here in Carmarthenshire, in a rare display of unity a few weeks ago, Labour, Plaid, and the Independent Party joined forces to declare that Carmarthenshire should remain a stand-alone authority.  They’re whistling in the wind though – their influence on their leaders in Cardiff is about as close to zero as it can get, and their views will simply be dismissed as self-interest.

It might be true that their protests are based on self-interest, but even if we give them the benefit of the doubt, and assume that they are genuinely seeking to do what’s best for local democracy in Wales, they’ll still be ignored.  That simply isn’t the question being asked; and having the right answer to the wrong question won’t advance their case greatly.

It seems to me that the question being asked by Cardiff’s centralists has little to do with good or effective local democracy at all – it is, rather, about finding the most efficient way of delivering certain key services, and primarily amongst those, education.  Efficiency and democracy are not at all the same thing.  But seeking to judge the latest proposals against that key criterion of ‘efficiency’ (assuming that the term even has a simple agreed definition) raises more questions that it answers.

Firstly, why does the area of Glamorgan and Gwent require four regions, when four or at most five is deemed adequate for the whole of the rest of Wales?  Where is the evidence that requires the population of a region to be less than x and no more than y?

Secondly, why is the sanctity of existing boundaries taken as a given?  What’s wrong, for instance, with splitting Conwy and merging half with Gwynedd and the other half with the rest of north Wales?  Yes, I know, of course, that it’s easier to treat existing authorities as whole units, but if the question is how we find the most ‘efficient’ structure, this is an unnecessary constraint.

Thirdly, why do all services have to be delivered to the same pattern?  I can understand – even if I’m not entirely convinced by the evidence – why fewer education authorities might be an improvement, but why do services such as leisure centres have to be managed at the same level?  It simply looks like a ‘one-size-fits-all’ approach.

Fourthly, given the need for better co-ordination between health and social services, why is the NHS not being included, and aligned to the same boundaries, as Plaid have in fact suggested?

Fifthly, where does this leave the Welsh Government’s drive for city regions?  Whereas the regions have previously included ‘whole’ authorities (for instance, Carmarthenshire in Swansea Bay), the new plan will mean that some authorities (such as Dyfed) are partly in and partly out.

But the biggest question of all, which the minister seems to be completely unwilling even to contemplate, is about the value of democratic elections to these new ‘authorities’.  If the aim is to ensure the most efficient delivery of centrally prescribed services to centrally ordained standards in a consistent fashion, how does electing councillors to regional authorities add any value at all?  How much influence can any elected councillors actually have?

It’s a point that I’ve raised before – if certain services are considered so important that they have to be uniform and consistent in terms of both policy and delivery across the whole of Wales (I’m not at all convinced about that, but it seems that all four Assembly parties are), then why pretend that elected local government has any rôle in delivering them?  Better by far to keep local government local and let it concentrate on those services where there is room for local variation and difference.

Averages don't tell the whole story

Tweet There is an obvious danger that anyone objecting to Cameron’s insistence on continuing intervention in discussion on the Welsh NHS is seen as being a supporter of a service which is failing.  And indeed, some of the responses coming from the Welsh Government do make it appear that they are more concerned with the politics of the matter than with addressing the very real problems that the NHS faces.  The fact that Cameron’s intervention has more to do with politics than with health is no excuse for responding in the same vein.

Part of the problem is that there’s a great deal of heat, but not a lot of light.  Last week, Cameron again drew attention to the difference in waiting times for diagnostic tests, where 30% of people in Wales wait for more than 6 weeks, compared to only 1.5% in England.  In purely numerical terms, that’s a shocking gap between two neighbouring countries, but there’s much more to this than averages can reveal.

From the perspective of each and every individual patient, whether they’re part of the 30% in Wales or the 1.5% in England is irrelevant; the figure for them as individuals is 100%.  And given the small size of Wales compared to England, even on those figures there are almost as many individuals waiting longer than 6 weeks in England as there are in Wales.  If it were really the best interests of patients driving Cameron’s concern, he could halve the total number of people waiting more than 6 weeks in EnglandandWales by eliminating the 1.5% in England, where he does actually have direct responsibility.

There’s another thing about averages as well; whilst they tell the headline story, they hide the detail.  These are averages for all specialities across all locations; there will be a lot of variation in there.  Are there no specialities in particular locations in England where the lists are longer than for the same speciality in some locations in Wales?  I don’t know; but I do know that overall averages will never tell us that.

And how about urgency?  A 6 week target for all tests of all types is nice and easy to shout about, but as a patient, there are some tests that I would want to have immediately, and others that I wouldn’t mind waiting a while for if priority was being given to those in greatest need.  Again, an overall average will never tell us anything about that; yet from a patient perspective, it’s outcomes which matter more than anything.  If Wales could achieve a much lower average (and thus undermine Cameron’s argument) by concentrating on doing the least urgent cases first (if, for instance, they were easier to do), would anyone really think that was the right thing to do?  Fixing the numbers isn't the same as fixing the problems.

Let me stress this: I don’t know the answer to the questions I raise above about the detail underlying the averages.  But I doubt that Cameron does either.  Worse, I’m not sure that he really cares; he’s only after making a political point which has more to do with winning English constituencies in the upcoming election than it does with care for the wellbeing of Welsh patients.

But the underlying problem here isn’t the politics of health, nor the way that politicians use statistics (although it would help if some of them were a little more numerate).  It is that, in Wales as in England, there is a target-meeting approach to managing the health care system, and as long as that continues, the Welsh Government is inviting this sort of criticism. 

Whilst we’d all like to be able to have whatever tests we need ‘on demand’, what really matters to patients is whether we get the tests (and treatment) we need at a time which makes a difference to the outcome for us.  In some cases, that may well be very much less than 6 weeks; in other cases, it could be longer.  Do we want our doctors to be deciding what to do on the basis of meeting a simplistic target to keep the politicians happy, or on the basis of meeting the clinical needs of patients?

Heat not light

Tweet This week has seen the publication of proposals by two of Wales' health boards for changes to the way some services are delivered.  Political reactions have, more or less, been entirely predictable, and based more on political considerations than on any relating to health.  It’s one of those situations where all of the politicians in all of the parties know that there have to be some changes whilst politically they all want to appeal to the sensitivities and sentiment of electors across Wales rather than risk losing votes by saying why they support some change.

That is not to say that the health boards necessarily get everything right, and that there is no scope for debate about some of the detail.  And the lack of trust which has grown as a result of previous attempts to rationalise services – sometimes for financial rather than health reasons – has left a legacy of suspicion about motives and rationales which leave a strong motivation for those opposed to any change.

Having sat through a number of meetings where some of these issues have been discussed, three things in particular have become clear to me.

1. There are people who are inpatients in our hospitals who need not be.  With proper organisation and by putting the funding in the right place, their care could be delivered in the community – usually in their homes – with sometimes better outcomes; almost invariably with more dignity and independence for the patients; and often at lower cost.
2. There are a number of complex cases and specialities, sometimes involving expensive equipment and needing particular expertise, which can be delivered more safely and with better outcomes from a small number of centres than by attempting to replicate services in every hospital in Wales.
3. Medicine is becoming increasingly specialised; specialist skills need to be maintained and developed by handling a sufficient number of cases, and doctors in some specialities are in short supply.

Those three points seem to me to be unarguable; the question is about which changes need to be made to respond to those factors, and whether – as a suspicious public fears – the changes being proposed go further than is necessary simply to respond to those three factors.  That question needs more attention and debate than it is getting from knee-jerk political reactions phrased in emotional terms about ‘saving our services’.

Those proposing the changes are not infallible; and I’m not assuming for one moment that they have got it all right.  But simplistic opposition to any and every proposal is not the best way to get the health service we need and deserve.

'Progressive' means testing

Tweet The clear difference of opinion between the Labour Party in Scotland and the Labour Party in Wales over prescription charges is quite interesting.  In Wales, where Labour is in government, they support free prescriptions; but in Scotland, where the SNP Government is following a similar path to that followed by the Welsh government, the Labour Party opposes the self same policy.  It’s the reverse of the more usual scenario where oppositions promise and governments fail to deliver – and is a curious stance for Labour to adopt.

I’m struggling to see what particular set of principles from the Labour lexicon is being followed in Scotland.

I understand the principle underlying free prescriptions, which is in general terms that there are certain services which should be available to everybody who needs them as and when they need them with no price barrier.  And they should be paid for by a taxation system which taxes according to people’s ability to pay.  It’s clear, and is a principle which I support.

I also understand the underlying principle behind the Conservatives’ position, which is that taxation should be as low as possible, people should pay for as many services as possible, and that free services should be available as a safety net solely to those most in need, with eligibility assessed on the basis of some sort of means test.

The way the leader of the Labour Party in Scotland is posing the question is very similar to the way that the Conservatives have been posing the question over many years.  Why, she asks, should a chief executive on more than £100,000 a year not have to pay for his prescriptions whilst the pensioner needing care has their home help cut.  The question could have come from any number of Conservative politicians with equal facility.  It’s hard to believe, however, that the Scottish Labour Party is really trying to take the place vacated by the meltdown of the Conservatives in Scotland by following the same policies which led to that meltdown.

I’m sure that they’d argue that they are simply being pragmatic; but it looks like the only real principle that they’re following is that they must oppose whatever the SNP proposes; and that’s not much of a principle at all.

Means-testing is a phrase which still carries a certain amount of baggage, and probably more so in Scotland and Wales than in parts of England.  Arguing for more means-testing for health service provision is an obvious position for Tories to take as part of their wish to reduce the levels of the most progressive tax, namely income tax.  But it’s curious to hear Labour politicians trying to argue that means-testing is a ‘progressive’ policy.

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.

Reporting or campaigning?

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The Western Mail’s repeated return to the subject of free prescriptions is starting to look less like news coverage and more like a campaign to re-introduce charges for medicines.  This week’s story highlighted the high average number of prescriptions per head over a year, claiming that it raised “fresh questions about the flagship policy”.  I’m almost tempted to run a ‘spot the difference’ competition by comparing their story this week to one a few months ago.  The questions are not so much fresh as regurgitated.

There was something of a shortage, once again, of critical analysis of what the figures might be telling us.  The average number of prescriptions per head has also been rising in England, despite the high – and increasing – charges for prescriptions there.  That gives a context in which the increase in Wales is not solely down to the fact that medicines are now free – although you wouldn’t know that from any reading of the Western Mail’s story.

But let us suppose that at least part of the increase is down to the fact that prescriptions are free – is that a good thing or a bad thing?  Again context and analysis are everything – and were completely missing from the paper’s reporting. 

It reminds me of a statement by one of the Welsh police forces a couple of years ago that an increase in the number of cases of domestic violence was a good result not a bad one.  It made me stop and think; but the argument was that a greater willingness to report such crime showed that the force was actually being effective in tackling it, and thus creating a climate where people no longer felt that it wasn’t worth reporting.

In a similar vein, if an increase in numbers of prescriptions is because rich people are no longer paying for over the counter drugs, then it’s easy to see why it might be considered a bad thing.  But if it’s the result of less well-off people seeking treatment and taking medicines when they would previously not have done so because they couldn’t afford the medicines, then it’s a good thing – and a clear sign that the policy is achieving one of its stated aims.

It’s a distinction of which readers would be left completely unaware, however, from a report which provided the usual suspects with an opportunity to trot out their usual lines, led as ever by those persistent opponents of free medicine, the Tories.  Their health spokesperson repeats the customary soundbite about millionaires getting free paracetamol (although he varies it a bit by adding bonjela – ah the sheer inventiveness of the man!).

Does anyone know of a single millionaire in Wales who’s ever gone to the trouble of arranging a doctor’s appointment in order to get a prescription for free paracetamol?  I don’t – but then I don’t think I know any millionaires either; they’re not exactly common in Wales in the first place.  It may be a good soundbite, but it’s a deliberately misleading distraction.  They’ll carry on using it though – why wouldn’t they, when they’re being given a free and uncritical platform on which to repeat it?

Paracetamol and millionaires

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Given the high profile of the Welsh Government’s commitment to free prescriptions, I find it hard to believe that any Health Board in Wales would have decided to ban GPs from prescribing certain medicines without consulting the government.  And the calm response by “a spokesman” also suggests that the decision by the Hywel Dda Board did not exactly come as a surprise.

It amounts to the introduction of what Welsh politicians usually like to call a “post code lottery”; which items can be had for free will now vary from one part of Wales to another.  It touches on the long standing issue that there is a lack of consensus about which decisions should be taken nationally and which should be taken locally. 

As a general rule, I tend to favour local democracy rather than central imposition; but in this case, health boards are not subject to local democracy, and this looks like a case of local appointees trying to weaken or undermine a decision taken by electorally-accountable politicians.  Purely for that reason, I’m surprised at the calm response of the government – unless, of course, they are actually looking for a way of back-pedalling on their commitment.

From the figures included in the report, it appears that the introduction of free prescriptions has had no impact on ‘over-the-counter’ sales, which have remained static, but it has increased the number of prescriptions for those same medicines by a significant margin.  It therefore appears, at first sight, as though the extra prescriptions are not for people who would otherwise have purchased the same medicines.  And as far as I’m aware, there is not a single reported instance of a millionaire obtaining a prescription for paracetamol.

But I’d like to understand better where that increase has come from before coming to a conclusion.  Is it the case that people are now going to see the doctor when they wouldn’t have bothered before?  Is it that doctors are now issuing a prescription when they might previously have just said “take a couple of paracetamol”?  What’s the impact on health of removing that option?

From the reports so far, the decision appears to have been taken on purely financial grounds, without considering that health impact at all.

Politicians of principle

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The Lib Dems’ flip-flop on prescription charges is really too easy a target, as Vaughan pointed out yesterday.  Free prescriptions have gone from being an example of wasteful and unnecessary expenditure to being a key element of the party’s health policy.

There is, of course, nothing wrong with any party changing its policy, and I suppose we should all be pleased that the Lib Dems have seen the light.  Keynes famously said that “When the facts change, I change my mind.”; so the question going through my mind is simply this – “Which are the facts that have changed, as far as the Lib Dems are concerned?”.

In 2007, their then health spokesperson declared that “Free prescriptions for all sounds great on election leaflets”, before proceeding to set out why, even though it might be a popular policy, they thought that it was the wrong one.  Presumably, their own election leaflets will look a bit better this year as a result of their change of heart, but surely the policy change can’t just be down to an acceptance that free prescriptions are popular?  Responsible politicians wouldn’t just support something that they’d previously argued was wrong in principle for such an unprincipled reason would they?

Presumed consent

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Clearly, a few feathers have been ruffled over the LCO on presumed consent.  The debate has been succinctly summarised by Adrian Masters; and it is indeed difficult to determine how much of what is being said is being driven by political agendas rather than by debate over the substance.

The comment which best summarised my concern over the way this has been handled was that from Dai Lloyd, who pointed out that the arguments being put forward by the Attorney General could be applied to any and every LCO submitted.  It may even be worse than that – it would also provide a basis for challenging the legality of any Assembly measure, even if there is a yes vote in March which eliminates the need for an LCO.

In that context, I’m not sure that the spat is as helpful to the yes cause as some are suggesting; it’s more a case of highlighting the fundamental flaw in the different approach adopted towards Wales, where only specified powers are devolved, compared with Scotland, where only specific powers are reserved.  That issue doesn’t go away on March 4^th; a yes vote simply moves the potential debate from the two elected legislatures into the courts.

I was also somewhat surprised at the opinion of the Attorney General that it may not be “practical” to have a different system in Wales from that in operation in England.  Surely such a judgement goes way beyond the remit of an opinion as to the legality of the proposal?

Andy and Ben

Tweet I bet that Ben Bradshaw is glad right now that he was reshuffled out of the Health Department in June, given that the Health Secretary has announced today that car parking charges will be abolished in English hospitals, following the lead set by Wales and already followed by Scotland. If he was still at health, he might well have found today's speech by Andy Burnham to be a bit too much to swallow.

When Wales set the pace, Bradshaw claimed it would be at the expense of reducing waiting times.

When Scotland followed suit, he said that it was not a "sensible use of limited resources". He also seemed to be saying that it was not a decision which could be taken centrally, since "In England, hospital car parking charges are decided locally by individual trusts to cover the cost of running and maintaining a car park".

Twelve months on, and the English Health Minister declares to the Labour Party conference that it's not only possible; it's both desirable and a priority for use of resources. Amazing how an impending election concentrates the mind and enables objections to be overcome.

There's a wider lesson to be borne in mind as well. When a Labour Minister says that something can't be done, (s)he is not necessarily telling the whole truth.

Those who can afford it

Tweet I was slightly surprised that the Tories have decided to make the re-imposition of prescription charges in Wales one of their key planks of their Assembly policy. Even some of their own people seem to have been a bit taken aback by the proposal.

It's not entirely clear how much money this will really save. The cost of abolishing prescription charges was put at around £30 million, but the Tories' proposal wouldn't raise that much in reality. In the first place, they are planning to increase the range of exemptions, and in the second, to impose a lower charge – both aspects which would significantly impact on the total of any saving. And that's without deducting the costs of reintroducing the systems to collect and account for the monies involved.

I doubt, however, that they're really interested in the saving; this is more to do with their political message than with financial prudence. After all, much of what they actually say in the Assembly seems to be about demanding increasing expenditure rather than cuts.

The line about "those who can afford to pay should do so" has a certain resonance, there's no doubt about that. And given that around 93% of prescriptions were free anyway, and that that proportion would increase under the Tory proposals, it seems that less than 7% of the population would be affected adversely by their proposal. (Although since that's likely to be the wealthiest 7%, one does rather wonder whether this is likely to affect the section of the population most likely, historically, to vote Tory.)

But, as I've argued before, if the principle to be followed is that "those who can afford to pay should", why pick on (or stop at) prescription charges? Why not fees to see the GP? Charges for hospital treatment?

I can understand them wanting to draw a clear line between themselves and the Assembly government. And at a policy level, there's a refreshing honesty about them returning to their traditional position of attacking both universality and the health service. But what's their game plan for 2011? Do they really believe that they and the Lib Dems will ever have the numbers to form an alternative government in Cardiff?

That's better

Tweet The proposed reconfiguration of the management of the NHS announced yesterday by Edwina Hart goes a lot further than her original proposals. The merger of LHBs and Trusts is a much more radical move than the previous suggestion, and marks a more decisive break with the 'internal market' philosophy introduced by the Tories. No wonder that the Tories' leader is unhappy as one of the most ideological and unnecessary changes ever made to our NHS is swept away in Wales, following the examples of Scotland and Northern Ireland. Only in England will this crazy system remain in place. And it's no coincidence that only in England do Labour rule alone.

Nick Bourne is right, of course, in saying that it is "a total reversal" of the previous stance of the Labour Party and the Labour Government in Wales; but I for one think that is to be welcomed, not condemned. Since when has recognising past mistakes and correcting them been something for which people should be criticised?

The new proposal also deals directly with one of the three concerns that I expressed in my previous post. The split between primary and secondary care providers didn't make sense to me – or to many of those working in the NHS - and I'm glad that the Minister has now come to the same conclusion. I think it is also one of the few occasions on which a government consultation exercise has actually been meaningful, with the proposals being changed in response to comments received, another welcome departure from past practice.

I remain unconvinced that the final number and boundaries of the proposed bodies is based on a careful consideration of what is needed, rather than on what is easily achievable from the starting point. Obviously, I would have preferred to see Plaid's election manifesto proposal implemented, and a commission established to study the whole question. I suspect though that what is now proposed is considerably closer to what the outcome of such a commission would have been.

The Minister is also allowing more time for consultation following the publication of the revised proposals. I very much hope that adequate time will be allowed as well for implementing the proposals, and that lessons will have been learned from previous rushed changes.

The main thing which I and other people locally do still want to see, however, is clarity over what services are to be provided where. Campaigners supporting Withybush Hospital, in particular, remain unclear on the long term plans for services to be delivered from that hospital, and in the absence of such a statement, concerns will remain.

Not healthy enough

Tweet I’ve been spending some time reading the Assembly Government's consultation paper on the proposed Health Service reorganisation in Wales, mostly to try and understand what impact it will have locally. The One Wales agreement included a commitment to ending the internal market in the health service, and the proposed changes seek to implement that commitment. In that respect, at least, I welcome the proposed changes. It’s also good to see a government consultation document which has been written in a style which makes it digestible and comprehensible, with some of the detail available in backing papers rather than incorporated into the text.

That doesn’t necessarily mean that they are the right changes, however. During the Assembly election last year, I argued three things as a candidate, and I inevitably find myself comparing the proposals with what I, and Plaid, said at the time. Apart from anything else, I gave people a very explicit commitment that I would not say one thing before the election and another afterwards, unless I had very good reasons that I was able to explain.

I said then:

• That agreement on the configuration of services locally was a more important priority for action that re-arranging the management deck chairs.
• That there were too many bodies running the health service in Wales, and that a thorough review was needed to determine the right number, but that that was not my first priority. Plaid proposed a commission to study the whole question in detail rather than urgent piecemeal action.
• That it was important to take an integrated view of services – one of the problems with the proposed reconfiguration of secondary care at the time was that it was predicated on the increased provision of primary care for which there was simply no viable plan.
  

Looked at through this prism, I find the proposals at this stage to be more than a little disappointing.

On the first point, we still do not have the clarity that I would like to see on what services will be provided where. Whilst in the short term, the proposed reconfiguration was halted, there are still legitimate concerns about the long term future of Withybush hospital and the services to be provided there; embarking on a reorganisation is likely to divert attention from the questions on which people locally want real, hard answers to the questions which SWAT and others have raised.

We have direct experience of ‘diverting attention’ locally, where five former bosses at Ceredigion Health Trust have claimed thet the merger which created the new Hywel Dda Trust was "rushed and chaotic". They allege that there have been delays, a lack of consultation, and failure to appoint key staff. The experience does not bode well for what looks like another round of piecemeal change.

On the second point, this proposed reorganisation will certainly reduce the numbers of health bodies, but the final number proposed looks to have been arrived at by accident rather than by design.

And on the third, whilst the proposed changes remove the unnecessary division between 'commissioners' and 'providers', they seem to be strengthening the split between secondary and primary care providers, which appears to me to be a potential new source of conflict. The original rationale for having 22 LHB’s was that they would be co-terminous with the county councils in order to ensure effective co-working. Removing that co-terminosity leaves another potential question over the way in which the county councils' social services departments relate to the health providers. (Unless this also presages a re-organisation of local government...).

Overall, therefore, I am unable to support the proposed changes, and have submitted comments accordingly in response to the consultation. Whether people agree with my view or not, I would urge people throughout the area to submit their own views to the Minister.