Institute of Welsh Affairs

Wales' Acute Hospital Waiting Times

John Osmond asks why NHS Wales high acute hospital waiting times have failed to be more of a priority for the Welsh Assembly Government.

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Why isn’t the Westminster Government following Rhodri Morgan’s example and abolishing prescription charges in England? The same question might be put to the Scottish Executive.

The response you’d get is this. Set against reducing waiting lists, it simply can’t be justified as a priority. To do so would be to take resources away from sectors where people are dying in the queue before they get treatment in order to give free prescriptions to people who can afford them. When tackled on the question Alan Milburn, the English Health Secretary before he stood down this summer, used to refer to a close friend who had died while waiting for cardiac surgery.

To extend free prescriptions to everybody in England would cost around £300 million a year. In Wales it is going to cost £30 million by the time charges are completely phased out in three years time. In the context of this year’s overall Welsh health and social services budget of £4 billion, £30 million may not sound very much. Yet focusing our attention on free prescription charges and away from waiting times suggests a skewed sense of priorities.

This becomes more apparent when we compare the Welsh and English record. Latest figures for people in Wales waiting more than a year for hospital in-patient treatment, at the end of August 2003, was 12,863. In 1999, the first year of the Assembly, the figure was 7,303. However, the killer statistic is the equivalent number for the whole of England at the end of August. This was the tiny number of just 31, brought down by nearly 100 per cent compared with a year earlier, from 18,200 at the end of August 2002.

Of course, any number of stories can be told using statistics. The 12,863 Welsh waiting time figure is partly so high because it includes patients waiting for tonsillectomies. There have been delays to patients waiting for this treatment because single use instruments are needed in the operations to protect against a possible risk of vCJD and these instruments are in short supply across the UK. If the waiting list figure is adjusted accordingly it falls to 8,826. This is not such a bad comparison with 1999. However, it is still 1,523 higher, and extremely high when compared with the position in England. And remember, England has a population of 49 million compared with Wales’ three million.

The sense of priorities involved is underlined by the fact that the Assembly Government has no up-to-date targets for tackling waiting lists. Targets were set at the beginning of the Assembly’s life, in 1999, including one that said that nobody should have to wait for in-patient treatment for more than 18 months. By 2001 this had not been met, and since then targets have been quietly dropped in Wales. England by contrast has a target of nobody waiting for in-patient treatment for more than nine months by Spring 2004, and six months by 2005.

The whole issue of Wales’s lengthening waiting times compared with England has been examined in detail in the past year by a high-powered Assembly Government review team. It was advised by Derek Wanless, the business and finance expert who earlier had produced a report on NHS spending needs for the Chancellor Gordon Brown. The Wanless report, which came out in July, found that excessive emergency admissions to Welsh acute hospitals are clogging up bed space and directly causing the lengthening waiting lists. At the other end of the process patients are not being transferred quickly enough out of acute hospitals into social care.

The report revealed the astonishing statistic that Welsh GPs refer 40 per cent more emergency admissions per head to acute hospitals than occurs in England. This is the main cause of Wales’s high demand for emergency services. In turn, as the Wanless report put it, this is “driving out the ability of the NHS in Wales to meet the demand for elective activity.”

The report does not explain why Welsh GPs behave so differently to their English counterparts, except to say: “At present there is often no perceived option other than the District General Hospital available to GPs seeking help with medical emergencies.” The Audit Commission, quoted in the report, suggested that: “Primary care practitioners often feel that admission is the only way to access Trust services.”

Health Minister Jane Hutt is due to provide a detailed response to the Wanless report very soon. Part of this should be to commission a study on why Welsh GPs refer so many of their patients to acute hospitals and why so many consultants are prepared to receive them. Such a study ought to be a priority concern for the Assembly Health Committee as well, and also the newly established Wales Centre for Health which was set up by the Assembly Government in 2002 to investigate such issues.

We know that we have higher illness rates in Wales than in England. We know, too, that the Welsh, typically over-preoccupied with their health, often judge their doctors by the access they can give them to consultants. But it is hard to conclude that factors such as these can explain a 40 per cent referral rate difference between Wales and England. In any event individual GPs and practices vary hugely in the number of referrals they make. So much of the explanation must lie with GP behaviour patterns. The challenging question, of course, is how they can be changed.

Abolishing prescription charges, perhaps Welsh Labour’s most successful election pledge last May, was an easy hit. But more than 80 per cent of prescriptions were free to those most in need already – young people, pensioners, and people suffering from long term illness. The best justification for the move I’ve heard is the claim that it will encourage the long-term sick back into employment since they will no longer lose the benefit of free prescriptions. But where is the evidence for this? And should part of the health budget be used to tackle a problem outside the confines of the health service?

Meanwhile, we have more than 8,000 people waiting more than a year for in-patient treatment, each with their own case history of distress and anxiety. Why has this not been more of a priority for the Assembly Government? Why has the Health Division in Cathays Park failed over the past five years to get to the root of the problem, now clearly spelled out by the Wanless report? Why were waiting times not a headline concern for any of the parties in last May’s elections?

Most people reading this will have their own experiences to verify the urgency with which the issue ought to be addressed. Alan Milburn, quoted at the outset, is a case in point. I have a less dramatic, but nonetheless poignant example. My mother, now approaching 90, is partially sighted in one eye and has been told that she is developing glaucoma in the other. Naturally she is worried about her vision. The other day she received a letter saying she had an appointment with a specialist – in 15 months time. Arguably she would be better off not having been diagnosed in the first place. Certainly, she would be suffering less anxiety.

It is hard to refute the argument that Welsh waiting times would be lower if there had never been devolution. Can you imagine the fuss Welsh politicians would have been making over the past five years if waiting times were steadily dropping in England while the Welsh statistics stubbornly increased. As it is Labour MPs at Westminster have been reluctant to attack a Labour Government in Cardiff while the Opposition in the Bay has been abysmal on this issue.

The Assembly Government is doing good things in steering NHS Wales to becoming a primary-care led service. But the benefits from that will only accrue in the longer term. In the meantime we should acknowledge more immediate priorities, and first among these is reducing our excessive waiting times.

John Osmond is Director of the Institute of Welsh Affairs