‘Welsh NHS and social care is a shambles and not fit for purpose’
Dr Iain Robertson-Steel, who recently retired as the director of Withybush Hospital, says new First Minister Mark Drakeford has a major challenge on his hands in turning things around...
THE NHS in Wales has recently passed its 70th anniversary. There is no doubt that the NHS reached the point of near-catastrophic failure in winter 2017 with long delays for beds and unacceptable A&E waiting-times.
Winter 2018-19 is likely to be worse as pressure has been unremitting since last winter.
Patients were put at risk, hardworking staff were driven to the point of near-exhaustion and goodwill was exploited.
The NHS was under extreme pressure in winter 2017, with long delays in A&E, mass cancellations of elective operations resulting in waitinglists growing, and quality of treatment declining.
Massive budget overspends occurred due to a shortage of staff and the employment of locum doctors and agency nurses. The maintenance backlog of the ageing estate became even worse.
The increase in immigration to the UK, 273,00 new residents arrived in 2017-8, with a further similar increase in 2018-19, has put huge pressure on NHS resources and funding, the existing services and hospitals, and GPs have to be spread increasingly thinly.
Discharges of frail elderly patients became virtually impossible and readmissions rates have increased.
Patients became “stranded” in hospital, blocking beds at high cost and resulting in increased delays to discharge and front-door chaos. Unfunded extra beds were created as emergency care spilled into elective care.
Social service departments and staff conversely did not meet the challenge by working longer hours or creating additional resources, there were no “four-hour targets” in social care and the NHS took the blame in the media spotlight.
The blame game was played throughout the winter. Politicians buried their heads in the sand and responded by sending “turnaround” teams to harry the hard-pressed NHS staff and attempt “transformation” and threatening staff through “holding-to-account meetings”.
Sadly, Vaughan Gething and the First Minister were not similarly held to account.
Summer 2018 saw no relief from the pressures on A&E. Primary care and the NHS budget continued to slide and no real practical steps have been taken to make winter 20182019 any better than previous winters.
Social care demand and costs are rising and the response by many councils has been to blame the Welsh Government for reducing their budget, and in turn the Welsh Labour Government blames the Conservative UK government for austerity.
The blame cycle continues and the “solution” will simply be to raise council taxes in Wales and general taxation yet again.
Council tax cannot be the source of funding for health and social care. Residents in Pembrokeshire had a 12% increase in council tax in 2018-9 and there may be an even greater rise in 2019-20.
The bottom line is that the current Welsh Government has been responsible for NHS and social care in Wales for over a decade and a series of ministers have failed to address the core issues and develop fit-for-purpose services for the future.
Government blames health boards for failing to deliver, when the problems faced by hard-pressed and much-criticised boards are beyond their ability to solve.
Unless the Welsh Government tackles the fundamental underlying problems of staffing, structure, budget and “working together”, services will progressively fail.
The failure of the NHS and social care will lie with the new First Minister and the government team.
Failure is, however, not inevitable. A new model of care can emerge which is sustainable and affordable. A new model must be fully costed and funded.
The Welsh Government is great at producing new acts and glitzy initiatives but never costs them or provides adequate funding.
Firstly, the Welsh Government needs to recognise and address the scale of the problem. Wales is a small country with a population of 3.2 million.
The state of the nation’s health is poor and the population is ageing. Wales is economically a poor performer. UK government subsidies are decreasing each year.
Social care is not working in partnership with the NHS. The split created by Beveridge (1942) and Bevan (1948) and the founding fathers must change. A single National Health and Care Service (NHCS) should be put in place in order to make progress.
There should be a maximum of five Health and Care Boards (South and West, South and East, North and Central, Emergency Ambulance, and Specialist Services) and the local authorities and social services should be merged with health boards with a single management team and a combined budget.
All of the structural activities of the local authorities – education, roads and infrastructure – should be put under a single service delivery organisation delivering national standards of service with equity.
Drastic reductions and real cost savings in management staffing and structures could be made if the social care functions and the budgets of the existing multiple local authorities were made part of a single unified health and social care service.
In effect, Wales would have three Health and Social Care Boards serving 1.1 million population.
Government must urgently tackle the shortage of doctors, nurses, health and social care professionals and carers.
Increased recruitment and improved retention of staff trained in Wales for the health and care service are essential. Carers will need to be recruited and trained and paid a realistic wage.
Locality health and care hubs would be established, bringing together health, social care, third sector and local volunteer citizens groups.
There would have to be a maximum of nine hospitals with A&E services across Wales, two district general hospitals for each health and social care board and one teaching tertiary health centre
Sixty per cent of the intake of Welsh health and social educational institutions should be from the Wales population.
There needs to be a standard percapita fixed price for health and social care provision in order to ensure equitable access and fair taxation.
Unless the Welsh Government takes urgent action, and imposes a new model with agreed standards and limits, the population of Wales will not be well served.
Tough though it may be, the multiple bureaucracies, the over-complexity of decision-making and management will have to change, jobs will be focused on delivery of service and non-frontline redundancies will be inevitable.
The current shambles is no longer sustainable or fit for purpose.
The First Minister and the government need to be held to account for 10 years of poor planning and failed management.
The “blame ball” sits with the government, not the NHS boards or county councils and their staff, clinical, social and managerial for “failing to deliver”.
Wales has the opportunity to build a national health and social care service fit for the next 70 years, embodying the principles of the founding fathers, Beveridge and Bevan, based on fair care for all, free at point of need, but not of course “free” in reality, funded from our taxes by the taxpayers.
We, the public will have to accept our responsibilities for our own health and the care and support of our fellow citizens.
If we will not care for our ageing relatives we must pay the taxes required. We don’t need to endlessly consult; we know what we need and want.
The new First Minister, previously responsible for health and social care, needs to review the failed Welsh NHS and imploding social care services, and urgently produce workable long-term, effective, funded solutions. Shuffling the chairs in the circle of the tired old guard will not produce change.
The responsibility sits with him.
THE picture painted by a former hospital director of an Welsh NHS in crisis is nothing short of frightening.
Dr Iain Robertson-Steel, who retired this year from Withybush General Hospital, warns that last winter the NHS “reached the point of near catastrophic failure” – and that this time round things are “likely to be worse”.
With candour, clarity and high concern, he describes a health service in which “goodwill was exploited”, waiting lists grew and the quality of treatment declined.
He has written more than a polemic. He makes a passionate call for the NHS and social care to be brought together, describing how “discharges of frail elderly patients became virtually impossible”. He argues that social services staff did not “meet the challenge by working longer hours” and the “NHS took the blame”.
Dr Robertson-Steel wants to see a “single National Health and Care Service” and says Mark Drakeford, as First Minister, must grasp the opportunity to bring about change or “resign within the year”.
His vision of social care working in partnership with the NHS will receive widespread and strong support, even if his specific recommendations for how this would work in practice may prove controversial.
Critics of the Welsh Government will share the sense of disappointment that runs through his article that “ministers have failed to address the core issues and develop fit-for-purpose services for the future”.
However, he is not defeatist and believes in a taxpayer-funded NHS free at the point of need, argung that a “new model of care can emerge which is sustainable and affordable”.
The issues he highlights concerning recruitment challenges are a longstanding concern and there will be difficulties ahead if it becomes harder to recruit staff for either the NHS or the care sector post-Brexit. He argues that “massive budget overspends occurred due to a shortage of staff”, which forced the hiring of locum doctors and nurses.
Dr Robertson-Steel’s assessment of the state of the NHS in Wales will not make easy reading for anyone in the Welsh Government – especially his claim that turnaround teams ended up “threatening staff”. But the intention behind his intervention is not to trigger another round in a blame game but to spur change. The need for world-class care is inarguable and the challenge is to deliver it.