Can the Welsh NHS deliver transformation at the scale and pace needed?

You may not have noticed, but in the last few weeks the Welsh Assembly has experienced one of the most dramatic periods in its history.

Before you question whether this simply reflects an absence of intrigue and theatre over the last 17 years, some have been comparing Welsh politics to the plot of Danish political drama Borgen (nope… me neither).

So, what’s been going on?

Despite a stronger than anticipated result for Welsh Labour in the elections and a widely-held expectation that they would, once again, form a minority government, when Assembly Members came to vote on who should be the next First Minister for Wales, the result was a tie between Welsh Labour and Plaid Cymru. Cue twitter storm (#seneddgeddon), media briefings, and back room negotiations.

Just over a week later, and following deals with both Plaid Cymru (the ‘Compact to Move Wales Forward’) and the Liberal Democrats (a Progressive Agreement of joint priorities), the Welsh Labour leader Carwyn Jones was sworn in as First Minister, and formed a minority government. So what, if anything, does this mean for the Welsh NHS?

The agreements, although thin on detail (Carwyn Jones's speech included a bit more), contain quite a bit on health. The Welsh Government will:

• Establish a ‘New Treatment Fund’. Inspired by the English Cancer Drugs Fund, the proposal is for a broader fund covering all life threatening illnesses, and including not just drugs but other treatments.
• Develop plans for the recruitment and training of additional GPs and other primary care professionals. This was a source of fierce debate in the run up to the election period; with stories of recruitment issues for primary care services in rural areas, particularly in North Wales.
• Extend the Nurse Staffing Levels Act, which requires Health Boards to ensure sufficient nursing staff in adult acute services, to cover other areas.
• Reintroduce the Public Health Bill that was unexpectedly voted down at the end of the last Assembly, although without the controversial ban on e-cigarettes.
• Develop proposals to address ‘mental health discrimination’. Beyond prioritising this an issue and increasing access to talking therapies (the areas of manifesto overlap), it’s not clear what this will mean.
• And finally, the government will ‘seek to establish’ a parliamentary review into the long-term future of health and social care. The Liberal Democrats championed this as a way of helping to depoliticise the debate about how the Welsh NHS should be structured and resourced to meet future demand.

Given the areas of overlap between the Labour, Plaid Cymru and Liberal Democrat manifestoes, this isn’t a surprising list. The outlier is the parliamentary review, which is arguably also the most important.

The Welsh NHS hasn’t got a Five Year Forward View, but its budget (which accounts for around half of Welsh Government spend) will be shaped by the spending review deal that flowed from the Forward View – a front-loaded budget increase that is premised on an ambitious £22bn efficiency drive.

With the Welsh NHS facing similar (if not more pronounced) cost pressures, the implication is that they will need to make proportional savings of a comparable (if not greater) size. Without this, the demands on the service are going to out-strip the growth in the ‘Barnett consequential’ (ie the increase in the Welsh Government’s block grant as a result of the increased English NHS budget); and, in a context of sustained austerity, may even start to crowd out other areas of government spend.

As you would hope, the incoming government will inherit a programme of reform aimed at tackling this.

The Prudent Healthcare agenda, championed by the former Health and Social Services Minister, Mark Drakeford, developed a set of ‘principles’, which include the key elements of a reform programme: changing the relationship between patient and provider through co-production; reducing unwarranted variation; eliminating waste and unnecessary treatment; and focusing resources on those with the greatest need.

While there is strong buy-in from the health service, a recent review by the OECD raised concerns that the agenda is too abstract and that, without stronger control or drive from the centre, there is a risk it won’t deliver.

Alongside Prudent Healthcare, there are two recent pieces of legislation, the Social Services and Well-being Act and the Wellbeing of Future Generations Act, that are intended to encourage Health Boards to work with local government, and other public and third sector bodies to map need in their local area, and work together to develop services which reflect this.

So, the broad framework is in place. The challenge, as with other developed health care systems, is whether and how the Welsh NHS will deliver transformation at the scale and pace needed.

A parliamentary review might help with the politics – buying the Welsh NHS some welcome political cover – but the risk is that it delays reform by encouraging people to wait for its conclusions. 

Dan Bristow is Deputy Director at the Public Policy Institute for Wales