Wales' biggest problem that no one knows how to fix

Our politicians have failed relentlessly and things are only going to get worse. A deep dive into who is to blame for the state of the Welsh NHS

Well, here it is: the first proper Will Hayward Newsletter (still not sure about that name).

Firstly thanks for joining me!

I imagine that the standard format of the newsletter will change a bit over the first month or so while I work out what is best. On that note, if you have ideas for how you would like it to be set out or what issues you would like me to look at, let me know. I am writing this for you after all.

One of the reasons I pitched this newsletter in the first place was this inescapable feeling I have about how bad things have become in many parts of Welsh society. Be it our health service, schools, economy, appallingly high poverty rate or our bloody trains, no one can look at Wales and say things are working well. 

But more important in leading me down the path to this newsletter was the fact that our politicians in both Cardiff Bay and Westminster seem utterly incapable of doing anything substantial to fix the situation. 

Actually, it isn’t just that they are incapable of fixing it, it is the fact that they either relentlessly act like there isn’t even a problem (see the UK Government on trains) or pretend that they don’t have the tools to fix it (see the Welsh Government on… literally everything). 

For the last five years I have covered Welsh politics. A common theme during that time has been an incompetent political class (that’s a generalisation, there are many exceptions) who have dreamed small, delivered less and tried to hide their failures in the long grass of complicated stats and an opaque constitutional set-up. 

But the most offensive thing isn’t that things are bad, or that those responsible seem to be incapable of making the lives of people in Wales better (which literally is their job), but rather that we in Wales seem to just accept it. 

How often do we hear people shrug their shoulders and make statements like “Well, Wales has always been poor” or simply accept that they will have to wait four years for a hernia operation? We have been bludgeoned into apathy here in Cymru and that in turn enables our politicians to continue to fail us. This is compounded by opposition parties here in Wales who are so pathetically anaemic in their opposition to the Welsh Government and so utterly lacking as a credible alternative that there is nothing pushing the Welsh Government to be better at what they supposedly do.  

The solution to this is a more informed public. This is where this newsletter comes in. If we don’t understand what Wales’ problems are, how they were created and why they aren’t being fixed, how can we possibly make things better?

So where to start? Given that statistically it is likely that more than one in five of you reading this are on an NHS waiting list, let’s begin there.

“The doctor will see you… in 2025”

Take a look at this chart. It shows the amount of people on Welsh NHS waiting lists over time.

There are few things to look at here:

1. Two-year waits are going down. But it is glacially slow. At this rate it will be half a decade before they are eliminated (by way of comparison England has none).

2. All the other waits are going up. This includes waits for a first appointment which exceed 50,000. This in turn means that many of these cases are far more serious and complicated when they get around to them meaning longer time in hospital and more money. Not to mention the human suffering. 

3. This was not caused by the pandemic. Yes, the pandemic caused that big spike you can see. But the numbers were tracking up before this point. In January 2019, there were 267 people waiting over a year for a first appointment, in January 2020 (months before the lockdown) the figure was 1,115. We must not accept the lie that Covid took a healthy health service and made it sick. It already had a lot of underlying health conditions.

4. IT DOES NOT HAVE TO BE THIS WAY. What is easily missed on this chart (but I think is the most important part of it) is that it isn’t inevitable that we have these waiting lists. You may have missed the subtle arrow I put on the chart. It marks November 2012 when the number of people waiting over a year for a first appointment was zero. The figure now is 52,000. 

This isn’t going to get better

This is an issue the Welsh Government can’t get a grip on and this isn’t changing any time soon. Keir Starmer has made no guarantees of increased health spending in England and this therefore means no consequential for Wales. But beyond that we have the issue of an ageing population. Let’s look at the age profile of Wales at the moment compared to other parts of the UK.

Though we are talking a maximum of seven percentage points here, this makes a real difference in terms of pressure on the health service. But it gets more concerning when we look at where we are headed. Old age dependency (the ratio between those aged 70 or over and those aged 20-69) will have changed in Wales from 1:5 in 2000 to a projected almost 1:3 by 2038. 

So that’s more old people and fewer people to pay for, or care for, them. Like I say, the task the Welsh Government is failing at isn’t going to get easier. 

Underfunding by the UK Government

The go-to rationale for Wales’ struggling health service according to the Welsh Government is that they are under-funded by Westminster. It is by now virtually an automatic response. Somewhat bravely for a party that has run the health service for over 20 years they actually get quite angry if you have the audacity to question their record. Here is Mark Drakeford losing his mind with the Welsh Tory leader when asked about ambulance waits. 

But does he have a point? There is no doubt that Wales has had to absorb some pretty brutal cuts from Westminster. We hear the UK Government say that there is “record spending” on the NHS and this is true but it means nothing when you take into account age and population change. Have a look at this graph from the Wales Governance Centre:

The line at the top shows that Wales’ health spending is up over 30% on 10 years ago (I have missed out the Covid years because spending was wild then). But if we take into account inflation, an increasing population and the greater need (the dotted line at the bottom) we can see that we had almost a decade of brutal cuts. 

Where the Welsh Government are failing 

So we know that the Welsh Government has been dealt a pretty tough hand by a UK Government that has really cut their overall budget in real terms over the last 10 years. But this by no means lets them off the hook for the state of our NHS. Let’s take a look at some of the issues that lay firmly at the door of Drakeford, Morgan, Gething et al.

1. Not spending the equivalent on health that England does

This graph shows what the Welsh Government have done with the cash they have received from the Barnett formula based on how much England spends on health. Basically, if they are above the blue line they are spending proportionally more on health than in England. 

As you can see, for the first 10 years of devolution they passed on more than they received. However when the coalition came to power in 2011 there was a really steep drop. While the UK Government ringfenced NHS funding, the Welsh Government cut it to protect other services. This led to some high profile issues and they reversed that decision a few years later. However, this is the time that the Welsh waiting lists started to creep upwards. 

Don’t pay to much attention to the sudden drop in 2020. This is mainly down to the fact the UK Government spent obscene amounts of money on a contact tracing system in England that was as expensive as it was useless. 

2. A convoluted and insane structure

The Welsh Government has controlled the NHS in Wales for decades. It therefore has to own the fact that governance in the health service is a complicated and convoluted mess. 

A population roughly the size of Greater Manchester has seven health boards (each with their own individual press office, chief exec etc), three NHS trusts, Public Health Wales, the community health councils, the National Delivery Group and NHS Wales Shared Services Partnership. This is not even taking into account social care or the fact that the health board areas do not correspond to council boundaries (of which we have 22) or police forces.

This has created really unnecessary complications. The health boards are, for all intents and purposes, different organisations. To move staff between them is like moving a shelf stacker from Lidl to Aldi. 

The boards also measure data differently. I once tried to find out how many nurses had left the Welsh NHS and was unable to find this basic piece of workforce information because of the hodge-podge way the different parts of the health service collect data. 

3. Betsi Cadwaladr Health Board

Where to even start with this mess? The north Wales health board could (and probably will) take up an entire newsletter one of these days. 

To sum up in just the last eight years we have seen:

• Eight chief executives

• Patients having an “unnecessary amputation”

• Members of the finance team deliberately misrepresenting accounts

• An amputee needing to be 'carried to the toilet' by his wife after being discharged without a care plan

• Clinicians 'possibly working outside the limits of their competence'

• £122m of expenditure not being properly accounted for

• Incorrectly recording Covid deaths in the early days of the pandemic

• The independent board forced to resign by the Welsh Government only for one of the newly-appointed members to also resign just a week later

• The health board liaised with suppliers to deliberately edit documents before they were sent for auditing

• Almost 1,700 mental health patients wrongly discharged from support services during the pandemic.

But the amount of times that the Welsh Government have tried to distance themselves from an issue they are undoubtedly ultimately responsible for is embarrassing. 

What can be done about the Welsh NHS?

At the moment, the beleaguered health minister Eluned Morgan has put together a team of “outsiders” to provide fresh eyes and ideas on what can be done about Wales’ health governance. While there is no doubt that huge parts of Welsh governance lives in a bubble, and that fresh ideas are a good thing, I am incredibly sceptical that there is the political nous, will or courage to pull off meaningful change. 

This is where the opposition parties in Wales need to step up. They talk a good game. Andrew RT Davies recently tweeted that the Welsh Conservatives would “properly fund” the Welsh NHS (which he did on the back of one of my articles demonstrating historic underfunding from Tory-run Westminster). 

But when I asked how they would do this if they ran the Welsh Government the answers were embarrassing (including cancelling projects which were completed over 10 years ago and building the M4 relief road).

Realistically, if the Welsh Government was going to meaningfully increase NHS funding they would need to either cut education or housing (that is where a lot of the extra cash goes) or increase income tax.

I actually went to the Tories, Plaid and Lib Dems asking how they would fund/run the NHS differently and will be covering their responses in an upcoming newsletter.

A mess which is getting worse and no one will take responsibility for

I feel I should probably apologise for making this first newsletter so utterly depressing. But we must not allow ourselves to fall into apathy when it comes to our health service. The issues are serious, long-term and entrenched. But, most importantly, they are fixable. 

We need to increase public understanding of this issue. Only then can we ask the right questions and apply pressure to our politicians. 

Thanks so much for reading. I would dearly love to have your feedback and if you have issues you want covered in this newsletter let me know. My email address is will.hayward@walesonline.co.uk.

Please do help spread the word about the newsletter. It will really help me and enable me to keep doing this kind of journalism.

Take care 

Will