Who is in control of the Welsh NHS? It’s not the Welsh government

Llew Gruffudd

It is often argued that the Welsh government doesn’t properly use the powers it has to best effect.

Even within the present constitutional arrangements, there is significant scope for improvements, it is argued.

Scope for improvement yes. Significant improvements, doubtful. I would argue that often those powers are often illusionary. Healthcare in Wales being one example.

Healthcare in Wales, under the present constitutional arrangement, is the responsibility of the Welsh government. Responsibility and control are however not the same. There are too many other non Welsh government forces involved, for the Welsh government to have that control.

Funding

If Wales was in control of its health service, in addition to current administration, it would also involve planning of current and future needs. Pay levels necessary for recruitment and retention of staff. Infrastructure investment for hospitals, investment in the most current equipment.

It can do little of that as it has no control over funding. That is decided by Westminster. Decided, not by Welsh government plans and needs, but by the crude population share measure. Population share of policy and investment in the English health system.

The NHS in Wales is the public number one priority. So too with the Welsh government. Consequently, they maximise the funding to this sector, consistently at the detriment of other areas of public services.

Yet. In spite of this, the NHS in Wales is in crisis.

You often hear that the Welsh government has given, say, £20 million more to the health sector, but invariably short of what is needed. So what does that achieve? Either a percentage improvement, or a waste of £20 million as it failed in its aims. A bad policy decision, or lack of money?

Social Care

Integral to the success of the healthcare sector, a successful care sector would take significant pressure off the Welsh NHS, free up hospital beds and allow much more community based treatments.

The care sector is the responsibility of local authorities in Wales. The Welsh government made considerable policy changes to integrate the health and care sectors.

Now one thing you have to say about the Welsh government, is that they do a lot of policy. They also do a lot of reports and a lot of consultations.

If only it led to improvements.

Policy making

A major impediment to the Welsh government’s policy making in this sector, is that social care is largely carried out by private providers.

Local authorities, on behalf of the Welsh government, buy social care from the private sector. Over 65% is privately provided. With 80% of the workers in the private sector.

This means that social care policy is dictated, not by government plans, but by commercial decisions of the private care owners. A care home closes, an increasing event. That is a commercial decision, but the repercussions are through the health care sector. Not just the considerable trauma to vulnerable residents, but a reduction in capacity in residential care. A reduction not easily rectified.

And the problem is set to get worse. The same problems prevail throughout the care sector. Many of the providers are small businesses, but an increasing number of large providers are becoming involved. Large medical insurance companies and hedge funds. Their loyalties are to investors and promised returns, inevitably that means taking money from frontline services. This is invariably workers wages and lower standards of service.

GPs and the NHS

GP practices. Generally the first point of contact of the public to NHS services Often called The Gateway to the NHS.

GPs are private practitioners. They work under contract to the NHS. The contract is renewed annually. This means that with less than a year’s notice, the GP contract can be terminated and thousands of Welsh patients are left without a GP.

This could be because of unsatisfactory contract terms, or the partners , or sometimes sole practitioner, giving up the practice, often to then become locums at another practice.

It is the responsibility of the regional health board to relocate patients, often paying a premium to neighbouring practices to take them on. In the process, a detrimental effect on the patient/doctor ratio of that practice

It is unlikely to improve. The constant battle between the government with limited finance and a GP sector who argue that they cannot provide a service without increased finance, is not easily resolved.

It is a complicated service. A basic payment per patient plus extras and bonuses for ‘additional’ services such as blood tests, health checks and blood pressure tests. Some provided by some practices, others not so much.

The provision of GP services is moving even further from government control by the growing influence of private medical companies. GP practices, not owned by GPs. but by private enterprise.

A movement started in London and encouraged by Tony Blair as Prime Minister has had consequences. A group of GPs were encouraged and supported by government policy, to become entrepreneurs. They took over the ownership of multiple GP surgeries in London.

Blurring the lines

AT Medics as they were called, they became the first medical company of its kind. Blurring the lines between business and medical care. In 2021 ATMedics owned 49 GP practices. Paid themselves £5.2 million in dividends and turned a profit of £7.6 million.

That year, 2021, AT Medics was bought by Operose. Operose is a subsidiary of a large American medical insurance company Centrene. Centrene owns 80 GP practices in England.

Although Centrene has not yet entered Wales, there is every likelihood that it will. Not that Wales is immune from this practice.

E Harley Street Primary Care Solutions, a private medical company based in Leicester, presently owns GP practices in Cardiff, Newport and the Gwent valleys.

There is concern that these privately owned practices are lowering standards in the search for profits. One concern being the increasing employment of the less qualified and lower paid practitioner associates in place of qualified doctors.

The nature of the system lends itself to this predatory action. With GP practices owned by GPs and free to dispose of their ownership in this way. It also puts the GP sector another step away from government control.

Dentists

Dentists again private practitioners, although whereas contracted GPs work exclusively for the NHS, dentists do not. While many dental practices have a quota of NHS patients, paid for by the NHS, many do not.

With GPs, the problem is the closure of practices. With dentists they can just refuse to treat NHS patients. It is well documented that large areas in Wales are without NHS dental treatment. It is not that the dental practice is overloaded, for it is common practice for dentists who are removing NHS patients, to offer them ‘a financial plan’ to pay for their treatment.

Dental treatment in Wales is not free at source, other than exceptional categories, payment already exists. The ‘financial plan’ method effectively removes dentistry further from the NHS for large parts of the population.

Eye Care

Other than the most serious conditions, eye care in Wales is provided by private specialists. It is a means tested service, with only particular groups qualifying for NHS paid for service, mainly the initial test. Eye care hardly qualifies for the free at source NHS for the majority of the public.

The consequences of government policy

These issues are due to the chosen course of government in purchasing NHS services from the private sector. Whether it be social care, GP services, dentistry, eye care. The majority purchased from the private sector with NHS money, public money.

This, coupled with the government policy of encouraging ‘the competitive market’. Tony Blair’s philosophy that the competitive market brings efficiencies.

It would appear that the opposite is the result.

A diminishing NHS and an expanding private sector.

NHS money, increasingly funding private dividends and bonuses.

As one disillusioned doctor put it, ‘the NHS should be about treating sick people, not increasing bank balances.’

PS.

To finish on a positive note.

If you eventually reach a hospital, either because of sickness or incapacity, it is because you are in an emergency, or you have made it through the ‘Gateway to the NHS’ and survived the seemingly unending waiting lists.

However once there, you are in the hands of fantastic, skilled staff, who carry out fantastic treatments and procedures. All for free as a patient. As a taxpayer, that’s a different tale.