interviews

The case for change in Wales

NHE speaks to Professor Marcus Longley, director of the Welsh Institute for Health and Social Care at the University of Glamorgan, and a noted expert on applied health policy, about his new report for the Welsh Government on reconfiguring health services in the country.

World-class hospital services depend on four key factors – quality and safety, accessibility, workforce size and quality, and affordability – according to general consensus, says a new report into the health service in Wales.

The report, by a team at the Welsh Institute for Health and Social Care (WIHSC) headed by its director and Professor of Applied Health Policy Marcus Longley, was commissioned by the Welsh Government to review the available evidence on the optimal number, size and distribution of hospital services in Wales.

It has a summary section written for a nonspecialist audience, answering a series of questions in an admirably clear and concise manner (see side panel for a summary), and technical documents that back up these conclusions.

Prof Longley said the problems with the health service in Wales at the moment can basically be split into two: the workforce, and health service configuration.

But the problems are also too longstanding to blame any one decision or organisation or policy, he said.

He said: “This is not new. Going back 10 years to the Wanless report and before that, the diagnosis of the issues has been consistent. What has been lacking is a sufficient response to that, so, whilst the health service and Government have committed themselves to shifting the balance towards the community, and so on, there hasn’t been sufficient progress to deliver what was needed. So, the problem has been allowed to continue longer than ideally would have been the case.”

Avoiding a collapse in key services

His conclusions on the state of the workforce made a splash in Wales because his tone was both frank and alarming: he warned of a coming “collapse” in some services, and a “perfect storm” of reduced availability – due to shorter doctors’ working hours, despite overall increases in the number of staff – and increasing demand. The problems are compounded by recruitment problems in some specialties, and a longer-term trend towards sub-specialisation, the report says.

This has meant that many health boards are having recruitment problems, most notably in A&E, paediatrics and mental health services. Costs for agency medical staff are also rising.

The report says: “The pressure on the availability of key medical staff in a small number of specialties is now so great that the collapse of some services is likely.”

‘Disinvest to invest’

On reconfiguration, the report notes that in some areas, such as diabetes and cancer care, have moved out of hospitals over time. But much more remains to be done, Professor Longley said.

“We’re certainly someway along the path; what we haven’t done is move with sufficient pace. And, secondly, what progress has been made has largely been because we’ve had more money, so we’ve had more money to do new things, rather than the much harder thing – where do we disinvest, in order to invest.

“Now, there was that golden decade of the 2000s, when there was loads more money coming into the system, and we really upped the pace, we’re now in a much harsher financial climate, and still faced with the task of upping the pace. So, now, our inability to move quickly enough has made the problem even more difficult.”

Centralisation

For specialist care, centralisation is often seen as the answer: though Professor Longley warns that the evidence has to be consulted first, and it’s not always as easy as that.

He said: “There are some cases where it’s simple, and where the evidence is overwhelming: stroke would be a good example, major trauma is another, where there’s no room for doubt. But those are, in aggregate even, only a small proportion of what the health service does, and then you’ve got the complication of domino effects: you change one thing, and lo and behold, you’re having to change four things because they’re all inter-connected.

“Those decisions have to be made at the local level, because – and this is another point the report tries to make – ultimately these are decisions people have to make for themselves, or their elected representatives. They are value judgements: what value do I place on quality, as opposed to access, for example, is one of the standard trade-offs.

“We still need to make those difficult judgements. Why is it so difficult to make these choices? Part of the problem, is that the health service by and large hasn’t really engaged with local communities very well. It’s tried to shortcut the process, and said ‘we know what the evidence is, here’s the answer, do you agree’.

Not surprisingly, people say ‘hang on a minute…we want to have a look at this evidence properly’. Given the nature of the process, which is about political and value judgements, the health service hasn’t always been very good at getting into that; it’s tried to stick to the technical, and say ‘the evidence tells us so-andso’, and that really isn’t the right paradigm.”

But people can “absolutely” be helped to understand the complexities of the arguments, he said, if engaged with properly – although he also acknowledged that “the vast majority of the population couldn’t give a damn and will never get engaged anyway”.

But those who do care, he said, need to be treated with respect and given time.

He said: “That’s when people’s views change. They start to appreciate the complexity, and even more importantly, to trust the health service. You quite often have a situation where, at the end of a long discussion, people will say: ‘I don’t what the answer is, it’s really hard, but I do trust you now to make the right decision’. Whereas, at the start of the discussion, they didn’t have that trust.”

Reviewing the data

The evidence itself isn’t always clear cut, of course. As the report says: “It is in the nature of this evidence sometimes to be frustratingly vague, inconclusive, contradictory, or simply non-existent, and not always to point to a single answer.”

Professor Longley told us: “There’s always a case for more research, but it’s never going to tell us all of the answers quickly enough. We particularly need more information on outcomes: that we could do quite quickly. But a lot of this service model evaluation takes time. It’s complex, and it’s never going to give us an answer within the timescale we’ve got to operate in. We’ve got to learn to cope with that uncertainty, make reasonable judgements on the basis of the best available evidence, and fully recognise that’s the world we live in.

“There is no excuse for not collecting audit and compliance data, and the outcomes data – that’s absolutely crucial to knowing where the problems lie. All too often, in the past at least, the health service in Wales has been somewhat dilatory in that. It hasn’t pursued that agenda with the degree of energy and determination that hopefully it now will.”

Time to act

One of the key themes of the review is that people have to make their own decisions, but clearly some changes are politically, financially and clinically unarguable.

We asked Professor Longley what changes he would urge as particular priorities.

He said: “One is to continue the transformation of stroke services. We’re partway down a journey now, with encouraging results already, but there’s still some way to go. They’ve got to stick at that and see it through.

“The other area which would be very interesting to look at I think is this question of the emergency stabilisation and recovery: properly integrating road and air transport.”

The report gives the example of Scotland, where emergency care is centred more on ‘taking care to people’, often via air, instead of ‘taking people to care’.

The report says: “In short, it is the time to the start of appropriate treatment that matters, rather than the time to hospital. Increasingly, these are not the same thing.”

We also asked Professor Longley about international benchmarking, and lessons that can be learnt from other countries. He suggested paying close attention to some of trauma centre lessons from the US and Canada, and access/remoteness issues in Australia, and added: “The Bevan Commission, which advises the minister, has as one of its key priorities at the moment this exact issue of international benchmarking. Which aspects of the performance of the NHS in Wales could we benchmark, and with whom? That’s something we’re likely to see some work on in 2012.”

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