Devolution: Is Wales better or worse off?

As the scale of the crisis in the NHS in Wales becomes ever more apparent, the First Minister of the Welsh Assembly has been forced to concede that Wales can’t cope in its existing format. Rather than continue to witness the needless spectacle of Welsh patients dying as they await major surgery on home soil, the First Minister has finally come down on the side of common sense. He would rather see Welsh patients treated over the border in England than have to wait as happens all too often under the current format. Border? That is as much a nonsense term now as it was in 1997 before the devolution vote. In practical terms, there is no border between Wales and England. There are road signs proclaiming a physical demarcation but they are just signs. The need for autonomy sometimes makes us lose sight of reality. A cultural border is fine as long as it doesn’t impinge on the health, education and employment of those living on the wrong side of it. Ironically, it has also just been announced that Welsh pubs will be allowed to open later to show the televised games featuring the England football team in the World Cup. We can’t have it both ways.

The NHS is either national or it is a fragmented bunch of regional variants. The latter clearly doesn’t work, so isn’t it about time we returned to what the NHS always was; A national health service? The current system is crying out for some uniformity to address the growing “post-code” lottery in which the quality of your healthcare is dictated by where you live. It is also impossible to ignore the wider political point here. Wales achieved a “Yes vote” in its devolution referendum in 1997 by the less than convincing margin of 50.3% in favour versus 49.7% against. Was Wales better off before devolution? Government expenditure now accounts for two thirds of Welsh national income. Quite simply, that is about as dependent as you can get and is a long way from independence, autonomy or even just standing on two legs unassisted. The Welsh have always been famed for their love of the committee and devolution has only served to indulge their passion. Since devolution in 1997, results of secondary school leavers, the NHS and joblessness have all got worse, not better. Aside from the growing North/South divide, Wales has become obsessed with its cultural needs at the expense of its Maslowian needs. Health, education and employment  have all suffered at the expense of the national obsession with its culture.

In England, patients still have to pay for prescriptions and hospital parking. Unsurprisingly, the Welsh were cock-a-hoop when their Assembly Government voted to dispense with such charges. But we need to be more realistic. Like it or not, both hospital parking charges and prescription charges provide vital revenue with which to sustain to ever increasing costs of top quality healthcare. Neither does it follow that the NHS in England is perfect because we know from Lord Francis that it still has plenty of room for improvement. Standards of care being delivered on one side of the fence are one thing but the health of patients in the general population is quite another. Welsh patients exert a massive strain on health services. According to the World Health Organisation (WHO), “Childhood obesity is one of the most serious public health challenges of the 21^st century. Overweight children are likely to become obese adults. They are more likely than non-overweight children to develop diabetes and cardiovascular diseases at a younger age, which in turn are associated with a higher chance of premature death and disability". So what has that got to do with Wales?In Wales, around one in five under 13 year olds are overweight or obese and that figure is rising at an alarming rate. Treating those people in later life will be costly. So what is Wales doing to help itself? The WHO states that, "Social and economic development as well as policies in the areas of agriculture, transport, urban planning, environment, education, food processing, distribution and marketing influence children's dietary habits and preferences as well as their physical activity patterns". Increasingly, these influences are promoting unhealthy weight gain leading to a steady rise in the prevalence of childhood obesity. Unless children are taught the rules, they have less chance of playing the game on a level playing field.  With a decent education comes the information to make the right choices in terms of diet and exercise. It would appear that Welsh children have been badly let down. Granted, that education must also reach out to their parents at home, but Welsh schools have a huge role to play and their current stategies appear to be failing. The WHO also states that, "People should engage in adequate levels of physical activity throughout their lives. At least 30 minutes of regular, moderate-intensity physical activity on most days reduces the risk of cardiovascular disease, diabetes, colon cancer and breast cancer".Clearly, all of this advice applies to all countires in the UK but Wales in particular has a big problem having recently been ranked as second only to the USA in the international obesity stakes. 

As I write, the NHS in Wales is in debt to the tune of £100 million and rising. The recent decisions to dispense with a succession of community hospitals has culminated in the unsavoury spectacle of ambulances queueing to unload their patients at General Hospitals too full to accept them. As predicted, this has since resulted in needless patient death. It would not appear to be a shortage of ambulances! We are obviously short of bed space for the elderly and the acute mentally ill. These two cohorts are alone are impacting massively on available bed space at hospitals in Wales. A friend of my family recently had an acute mental illness which necessitated detention under the provisions of the Mental Health Act. He was initially kept on a gynaecological ward due to a lack of appropriate bed space! There are countless similar stories throughout Wales and so it was refreshing to hear the new CEO of the NHS state his intention to re-open and make more use of community hospitals. 

In terms of those habits which exert the biggest strains on any health service, smoking and alcohol consumption invariably take centre stage. By the age of 13, 27% of Welsh boys and 26% of Welsh girls admit to having been drunk at least twice. The Welsh 13 year olds were the worst of the 40 countries included in the study. In the 15 year olds, these figures double. It is therefore little wonder that the adult levels of hazardous levels of alcohol intake and binge drinking are so high. Over half of the men aged 16-54 admit to exceeding safe limits with between 32 and 39% of the same age group admitting to binge drinking. The figures for Welsh women are not much better so the impact of alcohol on Welsh health is huge and is being fuelled from a disturbingly young age. Alcohol accounts directly for 1.5% of all hospital admissions in Wales. Alcohol consumption in Wales was also found to to be the cause of 18,000 violent crimes per year. Of the 15,300 annual referrals for the treatment of alcohol misuse in Wales, 1,600 were for patients aged 19 or younger!

Smoking is a big problem in Wales. To give an idea of how far Wales has got to go with smoking, Sweden and California have both reeached levels of just 17% of the population smoking. The current figure in Wales for adults stands at 25%. That is 1 in 4 compared to 1 in 6 being achieved elsewhere. But why the fuss?In the words of the Chief Medical Officer of Wales “Smoking is the largest single preventable cause of premature death and one of the main determinants of health inequalities. It accounts for more than half of the difference in risk of premature death between social classes, with striking differences in prevalence by social position and by geography across Wales. There is a wealth of evidence showing that our current level of smoking is a major cause of lifelong nicotine addiction, avoidable illness and premature deaths”. Figures from 2005 show that 37% of mothers smoked at some stage during their pregnancy or in the previous 12 months and 37% of households with children contained at least one smoker. In Welsh 15 year olds, 19% of boys and 28% of girls smoked every week. By 2005, smoking in Wales was causing 6,000 deaths per year. That does not include the cost of treating them before they die or the effect of their smoke on those around them.

Asthma, arthritis and heart disease are all examples of the chronic diseases which currently affect 25% of the entire Welsh population. These are diseases which can’t be cured. With better public information and education though, they can be reduced in terms of the extent to which they impact on the Welsh health service. Wales has much to do in terms of health outcomes. Only by doing so will it begin to reduce the current strain on health services. There is only a finite budget for the health service in Wales as there is for the whole of the UK. If the current levels of State dependency persist, it is difficult to see how the current health service can continue in its existing format. 

It is currently free at the point of access for every man, woman and child. For that to continue, every man, woman and child must do better in the health choices they make. For that to happen, the Welsh Assembly Government has got an almighty job to do because the habits which exert the greatest impact have been passed down from father to son over several generations. I would suggest the Assembly Government would do well to go to a country like Sweden to find out what they are doing which is working so well - apart from having a national diet almost devoted to fish!

The biggest contributors to heart disease and stroke are high blood pressure, high cholesterol, diabetes and smoking. Obesity frequently leads to diabetes. Diets rich in saturated fats so beloved of the Celtic nations result in raised cholesterol. Too much salt and too much alcohol are well known to raise blood pressure. A basic lack of exercise is the final piece of this health jigsaw and the Welsh are currently doing badly across the board. By all means improve the health service offering to the patients, but let us also recognise the need for patients to take more responsibility for their own health. For once, Government has a huge role to play but do they really understand the scale of the challenge? I certainly hope so.