Debunking the Welsh Government’s favourite lie

A freedom of information request demonstrates that many of the Welsh NHS's issues can be improved by better management, not simply more cash

Bore da all,

First off a note to all free subscribers that you are running out of time to take advantage of the January offer to get the paid version of this newsletter a big discount. More details here.

Today’s issue will be focussed on debunking the misnomer that it is inevitable that Wales’ health service will underperform. This uses Cardiff as an example of how things can be done differently. But first let’s take a look at something that was raised last week.

In the last newsletter we talked about the commission looking at how Wales could be set up in the future. Within it I agreed with the report’s co-author Prof Laura McAllister who  said that the changes the report called for (devolution of justice, policing, rail etc) were very unlikely to be taken up under the current Tory Government. 

I want to draw attention to a comment made by Nick on that newsletter. He agreed with that assessment but made the point it hasn’t always been the case that the Conservative Party have been completely unwilling to countenance more devolution. 

Nick said: 

I think it is interesting to note that the Wales Acts of 2011 & 2017, both of which significantly enhanced devolution, occurred under UK Conservative Governments. 

Furthermore, devolution in England to metro areas has, with the exception of London, happened entirely under the Conservatives with Labour, despite doing electorally well out of the arrangement, being slow to adopt support for decentralising power. 

This is an example of how fast UK politics can move. The Tories have only become truly hostile to devolution since Brexit which then was turbo charged when Boris Johnson came to power. 

But I think any assumptions that Keir Starmer’s Labour Party are going to make all the changes recommended by the report would be misplaced. Sec of State for Wales Jo Stevens has already gone on the record to say that policing is not on the agenda at all but they would “look” at justice. 

This underlines the issue of how devolution has been enacted from the very beginning. The question never appears to have been “what do we really want devolution to achieve and what is the best way to make that happen?”.

No one can look at how devolution is currently set up and think that it is designed to succeed and it has been clear from the start there will be issues. When I was researching for my book on Welsh indy I spoke to Professor Robert Hazell, professor of government and the constitution in University College London’s Constitution Unit. Speaking to me in the autumn of 2019, he said:

“I led the work on devolution in Wales in the Constitution Unit’s very early days. I wrote the unit's report on an Assembly for Wales, which was published in 1996, which predicted that an assembly without legislative powers would struggle if it was dependent on Westminster for all its primary legislation. This is because they probably wouldn't find enough legislative time in Westminster because Westminster would have other priorities. And it gives me no satisfaction to say that that prediction was proved right.”

The fact that UK Labour are now saying that they will “look” at justice but will not be considering policing speaks to the fact there is currently no real appetite within the UK wide party to really enhance Welsh devolution. The promise to look at justice is partly a little nod to try and keep their Welsh colleagues happy but mainly it is the fact they need to offer something to the Scots too keep them happy and it would look strange to give Wales nothing. 

If you are seriously considering devolving justice, how can you not also at least consider devolving policing? They are two areas that are inextricably linked. It all speaks to a decision making mentality of “what is the minimum we can do to be seen to be doing something” as opposed to “what do we need to do to make this work most efficiently”. 

Nick, who I should thank for inspiring half of this newsletter, added in his comment that “there has been little dispersal of power from the Senedd to the local level in Wales”.

It is actually really interesting to look at how, on a superficial level, 25 years of devolution in Wales has mirrored England/the wider UK. Some examples are:

• Large city in the south east that sucks in people, talent, money and investment

• Public transport poor everywhere but particularly as you move away from the capital

• The north of the country feels totally forgotten by and therefore deeply resentful of the south east (both the north in Wales and England are entitled to this grievance in my opinion).

• Perception of an overpowered central executive unwilling to disperse responsibilities to lower levels of government.

I hear this view said a lot in Wales and I think there is merit in part of it but other areas are weak. I have great sympathy for the view that devolution so far has been a monumental missed opportunity and that successive Welsh Governments have shown a lack of ambition when it comes to doing things differently to fix Wales’ problems. How local government has been devolved for a quarter of a century and yet we still have 22 different local authorities for a population the same as Greater Manchester is crackers. 

But I am not convinced that it is devolution that has seen Cardiff become the main economic powerhouse of Cymru. While I have no doubt that having the seat of government in Cardiff has led to more money and attention on the Welsh capital, I am unpersuaded that this wouldn’t have been somewhat the case if devolution had not happened. Cities around the UK and the world have proven very successful and inevitably they tend to outperform the areas surrounding them. 

I am not making the argument that devolution alone caused Wales to mirror the UK, I just think it is an interesting observation. I would genuinely be really interested in people’s thoughts on this because I am still trying to form a clear view. 

The Welsh Government’s most consistent lie debunked

Listen to any exchange in Senedd and one thing is guaranteed:

• The Tories will challenge the Welsh Government about an undeniably terrible statistic whether that be about the economy, schools or health. 

• The Welsh Government minister will retort that “that is a bit rich because the Conservatives in Westminster have cut our budget”.

• Nothing changes as a result.

But a recent investigation shows what a cop-out this is on behalf of the Welsh Gov. Yes, the Tories have undoubtedly decimated the budgets of the Welsh Government over the last 10 years. However the Welsh Government response implies that it is therefore impossible for them to fix the things they are ultimately responsible for.

THIS SIMPLY ISN’T THE CASE!

It is well within the Welsh Government’s gift to improve the performance of Welsh public services without spending more money and we can prove it. Let’s look at ambulance waiting times.

I recently put in a Freedom of Information request to the Welsh Ambulance Service looking at the number of lost handover hours there were in Wales. This means the length of time ambulances are waiting outside of A&E before they can drop off patients.

The amount of time ambulances are having to wait outside of A&Es in Wales has grown at an alarming rate in recent years. In December 2023 over 22,000 hours of paramedic time were lost because hospital emergency rooms were too full to discharge them from the ambulance. This is up from 5,300 in December of 2016.

This has a huge range of negative impacts such as paramedics leaving the profession or losing their skills, slower response times to emergency calls not to mention the horrific experience of the patient in question.

To be clear, this is not an issue with the ambulance service. They simply can’t hand over patients into A&E because hospitals are too full. If you doubled the amount of paramedics and vehicles you would just end up with a longer queue outside of emergency rooms. This is an issue with the health boards and hospitals (I am talking about how they are managed, not the individual performance of healthcare workers doing their best in difficult situations). 

But the point I want to make is that this isn’t inevitable as exhibited by looking at two of Wales' seven (yes we have seven…) health boards - Cardiff and Vale in the south, and Betsi Cadwaladr in the north.

Take a look at the graph below which shows the lost hours in these two health boards. Cardiff is almost as low as it has ever been whereas Betsi is obscenely high, especially compared to eight years ago. 

Now it is worth saying here that as Betsi is Wales’ biggest health board, its total hours are likely to be higher than any of the others. But it is the direction of travel that matters here. If we look at the graph below we can see that of all the health boards in Wales, Cardiff is the only one which is bucking the trend:

So how is Cardiff doing it? How is it below 2016 levels whereas every other health board is double. Having spoken to contacts within the health board and conversations with senior managers (plus a really fascinating tour around UHW) it is remarkably simple. 

In C&V, the wait ambulances face is no longer considered "an A&E" problem but a responsibility that the whole hospital has to take on. This means that other departments, which in other health boards are insulated from the issues in emergency rooms, are expected to find ways to accommodate patients or free-up capacity so that paramedics can get back on the road where they belong.

A good example of this is over the aims for ambulance waits in hospital. The Emergency Ambulance Services Committee (the seven health board chief execs that make up the ambulance commissioning committee) have an agreed aspiration to eliminate delays over four hours. 

However Cardiff and Vale have an internal ambition of one hour and work towards that. When the health board recently issued a black alert, the highest level of alert which means they are close to being overwhelmed, it was because a handful of patients exceed the four hour wait. Contrast this with other health boards where waits of this length are routine occurrences. There is a very different tolerance to long ambulance waits in Cardiff and Vale compared to other health boards and this translates to better performance.

This tells us that long ambulance waits aren't inevitable in Wales. With good management it is possible to get them down. While budget cuts may have triggered their increase, this doesn’t mean that we can’t change the way we do things to create better outcomes for patients. 

You could perhaps argue that the success of Cardiff and Vale is an advert for the fractured, multi health board system we have in Wales. One area has, through its own ingenuity, found a way to do things better which it may not have been able to do if it was part of a larger, more unyielding organisation. But if this is the set up then good practice must then be applied across the other organisations. This is where the Welsh Government needs to be far more proactive. If they insist on not grasping the nettle and rationalising Wales’ convoluted health system then at least make sure that no good idea is left unadopted across all the health boards.

I hope that was insightful. I am still straightening out my own views when it comes to devolution and would really value your thoughts in the comments. 

I am away on holiday for the next couple of weeks having booked a trip to travel in the footsteps of Charles Darwin and journey round the Galapagos Islands. But don’t worry, I have scheduled a couple of newsletters for the next few weeks. 

Take care 

Will