Renewal for the NHS in Wales : An Interview with Janet Finch-Saunders, AM
Having already spoken to Siân Gwenllian and Rhun ap Iorwerth about the NHS, it seemed right to seek a balancing political opinion before drawing some conclusions. But I didn't expect to find myself sat under pictures of Mrs Thatcher, Theresa May and the Queen (the first listed causing me to shift in my seat with time-worn tribal discomfort) talking to a Conservative AM who has such an informed and impassioned view of what North Wales' healthcare needs to revitalise it.
Aberconwy AM since 2011 (she took the seat from a post-coalition Plaid Cymru and has held it since), in conversation Janet Finch-Saunders is warm and engaging, and, on health at least, has views that are hard to fundamentally disagree with.
The NHS in Wales is undoubtedly stressed; underlined very recently when a group of accident and emergency hospital consultants wrote to First Minister Carwyn Jones to state that safe care in their departments is being undermined to "an unacceptable degree". In North Wales Betsi Cadwaladr University Health Board has its own well documented problems, and whatever the genuine statistical progress claimed, speak to clinical staff quietly and they often still feel over managed and run ragged.
Settled under Mrs Thatcher's piercing gaze, as expected the conversation with Janet Finch-Saunders started with Betsi Cadwaladr UHB.
FtM : How do you see the situation currently with BCUHB?
JFS : "We are not seeing the improvements at the coalface after nearly thirty months in special measures."
"If you speak to the consultants, patients, nursing staff then there seems to be a lack of communication still causing serious problems. There are still evident pressures for patients, shown most clearly in the time it takes from referral to go through the process to get where you need to be to be treated."
Why do you think that is? Why is it so pressured?
"We do not have enough hospital beds - there is an emphasis on community based care, which is fine if the infrastructure is there and the district nurses, physios, GPs to deliver it."
"Communication is an issue too in coordinating community care. I have seen it myself."
"The law in Wales mandates integration of health and social care, but it is not yet in place practically, there is buck passing and awkwardness about working together."
"And Mental Health has big issues locally - there is an inadequacy to the support. I know myself from supporting a family member, fighting their corner, it is difficult just to navigate around all the different aspects; we asked for 'a family tree' of how the mental health team works and we can't get one."
It sounds like complexity is part of the problem?
"Sometimes with government, and maybe health boards, local authorities, there is a tendency to appoint people to deal with specific issues, and that just continues. I believe in the end there are too many managers."
"(When special measures started) I'd have liked someone to come in and streamlined a lot of the roles and analysed the management structures. When I was on the Health & Social Care Committee it was very obvious there was a problem with workforce planning across the Health Boards - add to that all the specific negative press that BCUHB has had and I am not sure locally it is easy to recruit the right people."
So there are problems with recruitment, retention, communication and lack of community infrastructure?
"Yes, and staffing is a particular concern. When my father was in hospital - at times the staffing was running at 50% and he had complex needs as did lots of the other patients, and you need the right number of staff in those situations."
What has led to this?
"We have asked for years to have a root and branch, thorough review of the NHS in Wales. Carwyn Jones has been very reluctant to do that - so instead they throw money at the problem in a piecemeal way. So you see things at BCUHB that should have improved - so you see orthopaedic waiting times, for hips and knees, deteriorating markedly."
And the recent waiting list initiative?
"If they can suddenly do that - why did they allow the problem to build to a crisis?"
"The time from first referral to when the problem is dealt with - from my own experience if that is too long other secondary issues can develop. My husband started with one bad hip and waited three years, by which time the other was affected by the way he had been walking to protect the first. He was also prescribed high levels of strong painkillers with toxicity side effects. I can't help think the whole thing is crazy."
"Likewise the waiting list initiative is dealing with symptoms not the cause, and is a sticking plaster not a needed operation."
"I have an 82 year old lady as a constituent who waited 102 weeks in pain for her hip operation. She was very active before, and therefore very limited by the pain."
"There are local options to improve things - two years ago the consultants identified a new way they wanted to work to improve things, a model that would save money and allow more operations to take place - and I went to see people on their behalf, and it has still hardly moved down the road. The money should be spent on long term solutions like that, not one off actions with the money going out of Wales.
And when you wanted a root and branch analysis, would that have been seen as a Conservative initiative, or as a cross party process?
"We'd have loved it then to be a full cross party project."
And locally, how would you have tackled the BCHUB crisis?
"I'd just like to have seen a more hands on approach - even if it meant the health minister being based here some of the time until the problems where resolved. With the Welsh government there is too much reliance on "marking your own homework" - after a long series of chief executives, as a businesswoman I can't accept that."
"And, in the end, we just need to be treating things quickly before a wait leads to deterioration or other negative consequences."
You supported the idea of a Bangor Medical School?
"Yes, not necessarily all our group (Conservatives in the Assembly) agree with that, but from meetings with the BMA and talking to local doctors to me it is an essential step to attract and keep the doctors we need here."
Is there a democratic deficit? In 2015 only 48% knew the Assembly controlled the NHS? That must limit democratic scrutiny?
"Yes - there is a frustrating confusion. But it is run by the Welsh Government, and the other opposition parties should work with us to hold them to better account, but Kirsty Williams (Liberal Democrat) is in the government, and Plaid Cymru often work closely with Labour."
"I think we have to fundamentally question why the Welsh Government can't run a successful health service in Wales. Why not?"
"I am not sure that the Welsh Government is yet mature enough or has the full set of skill sets needed to govern effectively. We deserve better standards. I think at times what would a competent businessman come up with as a model, how would it differ? (She was not talking about privatisation, but streamlining and creating more effective structures and processes) I think we need a better economy too, well paid, high skilled employment, to also help fund services - and Labour don't seem to know where to start to do this."
Janet Finch-Saunders was often quite animated whilst speaking, there can be no doubt she means what she says. Add that to her family experience, which she touched on several times, and her views have both a sound rational and emotional basis. She is particularly strong at highlighting the system's failings. Listen, and you could convince yourself it is all Labour's fault.
But, despite the differing political hues of the government controlling the service, the problems with the NHS locally are seen, to differing degrees, all over England and Wales. Why is this?
Perhaps, starting with simple and robust military derived models, low on management with maximal resources spent at the clinical frontline, over a generation the management (and delivery) of health care has become expensive, convoluted and complex.
Then, stepping well beyond the bounds of this specific conversation, you have to consider how over the last ten years staff pay and growing patient demand have come to the fore. Pay problems lead inexorably to manpower issues - in health better recruitment and retention of staff are the fundamental steps to better delivery- and there are pay concerns in Wales and England alike.
By 2020 real pay (after taking into account inflation) will have fallen by at least 10% in a decade for nurses. For GPs looking back from 2015 their real income has fallen in the order of a quarter in the preceding ten years. Seniority payments have been, or are being, stripped out and NHS pension contributions have also increased significantly for many clinical staff. When governments talk about efficiencies in healthcare they are too often seeking to pay the staff less rather than working with them to innovate.
Poor pay makes it hard to recruit, but In Wales - after a long period of relative stasis - NHS staffing numbers have increased, but the demand pressures these staff meet are remorseless and may very well continue to outpace the current planned level of investment. Demand grows with an aging population and greater expectations across the age ranges; it is not going to slow anytime soon. If demand is not matched by increasing staff, then work pressures inexorably grow on those already employed.
With staff increasingly poorly paid and definitely overworked, hospitals and community services find themselves firefighting and often relying on expensive, temporary staff to fill the gaps that develop; this has been a key factor in Betsi Cadwaladr's ballooning spending deficits. The whole system then becomes overstretched, continuity is lost, communication fragmentary - with results exactly as described in the interview above.
Finally, however you look at it, overall resource levels are also an issue that needs examining.
Four years of significant real term increases up to 2016/17 mean health spending in Wales is £64 per head greater than England; but this excess spending is still insufficient when you allow for Wales' older, poorer population. During a decade of austerity social care spending has been much better protected in Wales, but demand still pressures budgets with knock on effects.
But, if you look wider afield and make comparisons with similar European countries, the Welsh (and English) NHS is simply under-doctored, poorly provisioned with beds and underfunded. In this context it should be no surprise that across Wales the organisation is stressed and chronically misses its own targets.
Whether problems have a greater balance of structural, manpower or resource factors is a mute point for patients - to them it manifests in delay. For acute care this is distressing and potentially catastrophic, for more chronic problems the longer someone waits the more they suffer and the more cost incurred by them, their employer, family or the state. A delay in the health service can often manifest as a very significant cost elsewhere. As Janet Finch-Saunders has stated, this is crazy.
It looks like time for a fundamental rethink. Big questions about the balance between primary and secondary care, how social care and health interact, the provision of emergency / out of hours care, and the level of resource that should be committed by society need to be honestly addressed - and that will require deep rooted political engagement.
A timely and seemingly laudable Welsh Government commissioned 2018 report has called for a revolution in Wales' healthcare. You can read it here. But Labour may not have a strong enough mandate in the Assembly for the level of radical reform laid out and needed, and even if it does then it is still too limited in the actions it can currently take to raise the needed revenue.
The Welsh NHS cannot wait for the next Assembly election in 2021 outcome for action. Creating meaningful change without enough resources to underpin it is an impossibility; so to have sufficient impetus there may need to be a more united political front to seek proper funding tied to real reform.
As mentioned in the interview above, a few years ago the Tories did consider co-operation over a health service review. As talking to Rhun ap Iorwerth evidenced, Plaid have often been a constructive opposition. Now Labour clearly needs help, even if it is unsure of that requirement itself - and it would be the Welsh Assembly's coming of age as a legislature if a wide-based foundation for co-operation on health evolved. Either way, if something doesn't happen quickly, behind the headlines patients will continue to suffer.