Putting the Welsh NHS Back on Track

Since the beginning the Covid pandemic we’ve been told again and again that one of the priorities is to ‘Protect the NHS’. When you think about it, that’s a bit like being told at the beginning of a war that our priority is to protect the Army.

William Beveridge and Aneurin Bevan planned the welfare state in the 1940s to be available “From the Cradle to the Grave”. It has been recently been found seriously wanting. The grand ambitions have run aground not only because of a new virus, but also because the NHS has been failed both by our own Government in Wales and across the other UK nations. It has been whittled down to the cheapest options using the least inpatient treatment.

The Welsh NHS has been emasculated, whittled to the bone, and was unprepared when a pandemic struck.  If you keep cutting any service, the point comes when it can’t cope. Stressed, it is no longer fit for purpose. In fact some of the health management actions in this epidemic made things much worse, decimating care homes by sending them infected cases, and even in hospitals professional staff were often infected by their own colleagues and their patients, in wards never designed to house serious infectious cases.

The Welsh NHS needs a change of direction and cries out for leadership.

Redundancy and Resilience

Before the Second World War, Britain’s railway network – developed piecemeal by numerous private-sector companies in competition with one another – was often compared unfavourably with continental systems that had been centrally planned with much less duplication. Yet during the war, it was realised that this duplication of capacity, so that there were many ways of getting from A to B, was a big asset: if a line built by one company was attacked, then there’d almost always be another company’s line still usable along which the same journey could be made.

Engineers call this ‘redundancy’ – but it’s nothing to do with people losing their jobs. Rather, if any system has functions that are duplicated, then all but one of those duplicates will be ‘redundant’ most of the time – but there to call upon when needed. This in turn brings resilience, the ability to bounce back when under pressure.

The NHS as originally designed had that resilience built in, built as it was on pre-existing private structures and community organisations such as, famously, the Tredegar Workmen’s Medical Aid Society.

But under decades of state control and the attentions of successive governments, both red and blue, this has been stripped out.  Convalescent wards and infectious diseases units have been sold off and often demolished to build commuter housing estates and so prevent further use for healthcare. Managers have less estate to manage but never have pay cuts to reflect the reduction of their workloads. Indeed, managers hate empty buildings and underutilized areas, but the nature of healthcare is that the needs are always changing, and disasters happen.

The lack of NHS capacity and proper planning for pandemic emergencies has made a bad situation a lot worse. As a small country we could probably have done a lot better, and hopefully in the future we will.  We have manageable population of around 3 million and a country which can easily share knowledge and resources and, in emergencies, transport and share staff and kit around, though improvements to our internal transport infrastructure would certainly make this easier still. Instead, we have a Welsh Health service with artificial boundaries and barriers to sharing and co-operation in some cases and unnecessary duplication of scarce resources in others. We have been selling off the family silver for a pittance in a vain attempt to balance the books of individual Health Boards with little consideration of the health of the nation as a whole.

Add to this a deliberate decision not to train sufficient doctors and nurses. Many young people would love to become doctors and nurses but our governments have chosen to outsource the training of medical staff to other countries, importing staff from there (and denuding those countries’ own health services) to save the cost of training them here. A worldwide pandemic where almost all counties are struggling to find medical staff exposes the folly of this policy.

Planning for the Inevitable

Under the instruction of both Labour and Conservative Governments in Westminster, and on Labour’s watch in the Welsh Senedd, the NHS has been diminished since devolution to the bare minimum to give basic emergency care. Hospital wards have been closed and replaced with ‘community care’: specialist nurses based in GP surgeries, for instance, with patients cared for in their homes. This can work well, but in one circumstance it is disastrous.

This is when the problem is a severe infectious disease to which the population has little natural immunity and the NHS needs to treat large numbers of cases in hospital settings.

As a matter of fact, care in the community works well for many chronic diseases. It certainly does not work for virulent infectious diseases, and in fact it can spread them efficiently to the most vulnerable.

We need a few empty emergency wards, some extra convalescent wards, all of which could be used routinely for other uses but re-utilised quickly at short notice.  How about a Welsh infectious disease centre with the proper staff compliment, and every hospital having some isolation cubicles where patients can safely be treated but disease cannot leak out to infect other patients and staff? When we don’t have an outbreak, these specialist staff could tour the country: giving lectures, training and checking readiness. This would probably cost less than the many field hospitals and emergency morgues built in haste and never used.

Keeping a few isolated empty wards, training a couple more infectious disease specialists won’t break the bank, but may save the economy in future.

Unintended Consequences

To save the NHS we are enduring lock downs and serious economic damage where we can least afford it. The income of the people must suffer, the economy must take a big hit or the NHS will be “overrun” by sick people infected by Covid 19, and none of us will get decent healthcare.

Many people have died with Covid. Many others have died or are expected to die because they could not access timely medical treatment for many other diseases such as cancer. Others have suffered severe mental stress and utter despair due to the social and economic wounds of the outbreak.

The economic consequences of lockdown are grave, especially in areas of Wales where hospitality and tourism are big employers. Citizens unlucky enough to develop common serious diseases now, such as cancer and heart ailments may suffer delayed diagnosis and treatment, and add to the mortality and morbidity and distress, simply because the NHS cannot give them decent and timely treatment, as Covid swamps all.

I have seen emails to care homes suggesting that their residents will not be offered hospital admission should they become ill. It is only recently that patients and staff in care homes have been offered tests for Covid, but even then the system is not without problems.

Many of us are aware of friends and relatives who have been forced to use the private sector. Why should a person diagnosed with cancer need to raise money to promptly get treatment to save their life? This should surely be available on the NHS.

We have paid for the NHS through our taxes but may still need to pay again when we get ill. Now thousands wait just for appointments to see specialists and under Covid 19, the waiting lists continue to rise while the health professionals displaced and not able to work may be staying at home drawing a salary. Is it not time to set up telephone and video calls to get these patients diagnosed and investigated?

After the first days of Covid 19, when huge efforts were made in Wales to construct field hospitals for which there did not seem to be either staff or patients, there is no clear health policy except “keep away from other humans” until the vaccines come.

Where are the plans to rebuild general capacity and infectious disease units within the NHS? This would help to stop new diseases spreading in the future, protect staff from infection, and allow control of future outbreaks without stopping treatment for all the other illnesses and injuries.

A vaccine may help but it is not here yet. The virus may become endemic, may mutate and be a player in many winters to come. If the lack of capacity in the Welsh NHS itself is not addressed, if our scarce resources are not husbanded , and short term financial savings allowed to trump future quality improvements, any armistice will be only temporary. Another enemy may yet appear in similar guise and once more expose the poverty of our ambitions to keep our people safe for the long term.

We cannot and must not repeat the “shut everything down” approach when any new infection arrives, just because we discarded the old isolation hospitals, closed the convalescent wards and sold off everything else we could have used for extra capacity.

Instead, as other European countries have shown, a less centralised system involving more local discretion and redundancy, coupled with a requirement set at national level to ensure that spare capacity is available when needed, may be the best way to ensure that when needed the NHS can protect us as it was originally designed to do.

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