Who would be the new Minister for Health and Social Care? She inherits a system under almost daily criticism, generally acknowledged to be unsustainable without major reform, and facing real terms cuts of about 20 per cent over the next three years.
Her agenda essentially falls into three parts. By far the most urgent is to save money. The usual euphemism – ‘improving efficiency’ – is now no longer adequate, because doing more with the same amount of money (the usual definition of efficiency) is not going to reduce expenditure by the almost 20 per cent that real budgets will be cut over the next three years. In other words, cuts means cuts. Very few NHS managers yet know where they are going to be found.
The second objective must be to force the NHS to implement a new model of care. This needs to move simultaneously in opposite directions. It needs to transfer services out of hospital into the community, to support more people at home, while centralising other specialised services into fewer hospitals, where better quality care can be more easily assured. One of the most visible (and contentious) aspects of this will be ensuring extended opening hours for GP surgeries, a manifesto promise. More profound will be the aspiration to transfer ten per cent of resources out of hospitals and into the community.
The third objective is probably, in the longer term, both the most important and the most difficult. This is to find a way – or probably dozens of different ways – of helping people preserve their health, and to cope much better with the consequences of long-term ill health. The challenges range from the very different problems of obesity and dementia on the one hand, to teenage pregnancy and substance misuse on the other.
Can Lesley Griffiths deliver? Any one of these three challenges would be a tall order: all three together will make for interesting times.
The worst case scenario sees the NHS scrabbling to survive over the next few years by salami-slicing any service that isn’t strong enough to resist, regardless of effectiveness, popularity or strategic fit. Staff vacancies will remained unfilled, whatever the importance of the post. And waiting times, workloads and new services will all take a hit. It’s a pretty grim picture, its only redeeming feature being that the NHS does actually survive.
The best case scenario is one in which a fury of innovation, service re-design and partnership is unleashed, making the leap to a better and cheaper service. As we know, no health care system has ever made such a change, so quickly, and against such odds. No pressure there, then.
If she is to have any chance of success, there are three key arenas to focus on. The first is the opportunity afforded by the NHS reorganisation carried out by her predecessor. This created seven Health Boards which brought together all the services in a locality, ending the nonsense of the ineffective commissioner/provider divide, and bringing primary, community and secondary care (the hospitals) all together in one whole. So far, the change hasn’t gone much beyond the organisational chart on the Chief Executive’s office wall. Now is the time to make it a reality, because this is the way to stop inappropriate hospital admissions and to help people to manage their own conditions, themselves both game-changing innovations.
The second opportunity paradoxically comes from across the border in England. The NHS there is in such a mess, that Wales can now make clear its own alternative vision of the NHS. We no longer need to apologise for perceived failure – we are clearly doing better than England. In particular, we need our own clear, consistent and compelling narrative of how one makes such a great lumbering beast as the NHS embrace painful change. Notions like ‘choice’, ‘competition’ and ‘responsibility’ have been commandeered by English propagandists, and they now almost sound like dirty concepts in Wales. But choice is a defining characteristic of any civilised health care system; competition is a powerful agent of improvement; and responsibility is a concept well known to Bevan. The challenge is to seize these concepts back, define them to suit our needs, and set them free in Wales.
Finally, the Minister has the prime responsibility for the politics. Previous attempts to make the sort of changes described here floundered when Welsh citizens rejected what they regarded as ill-conceived and deceitful changes to their local health services. People need to be persuaded, not just that change is unavoidable, but that it’s brilliant! People should be marching to demand that their local hospital is closed, where care is substandard. Such pressures will be difficult to manage for an administration without an overall majority, and where many of the professions and trades unions will be more focused on defending the status quo than in arguing for change. The only advantage the Minister has is that perhaps people have now been prepared for the worst, and will accept that painful change really is inevitable this time.
So the Minister inherits all the unsolved problems of her predecessors, at possibly the toughest time for the NHS since the mid-1970s. Just as the NHS survived that IMF-inspired pain, so it will survive the current banker-induced crisis. But will it limp out of the ring as a tired and battered 20th-century model, or stride out as a leaner, fitter, 21st-century NHS? Never waste a good crisis, was the advice given to President Obama. Ms Griffiths will perhaps also heed that advice.
Written by Professor Marcus Longley, Director and Professor of Applied Health Policy, Welsh Institute for Health and Social Care
This blog is taken from the recent article by WIHSC Director, professor Marcus Longley, in the Institute of Welsh Affairs quarterly journal, Agenda http://www.iwa.org.uk/en/publications/view/210