Renewal for the NHS in Wales : An Interview with Rhun ap Iorwerth, AM

The twentieth anniversary of the 1997 Welsh Devolution Referendum was a muted affair in many quarters - objective performance in health, education and the economy since the momentous vote suggesting that greater self-determination has not yet brought the full dividend hoped for.

In North Wales the NHS is a particular concern, with Betsi Cadwaladr University Health Board in special measures since 2015, and facing a stark choice between containing an ever widening deficit and maintaining service levels; an organisation seeming to be perpetually hobbled by overspending on agency and locum staff. The potential need for harsh cuts to prevent further financial deterioration is worrying - as the current level of overspend is not exactly paying for first rate performance, as clearly evidenced by the BBC NHS Target Tracker.

For Betsi Cadwaladr (and elsewhere in Wales) it appears staffing is key, and it is a lack of numbers of permanent staff - doctors, nurses, allied professionals - not the quality or commitment of those already in post, that is the core issue.

Earlier in the summer we spoke to Arfon AM Siân Gwenllian about Plaid Cymru's campaign for a North Wales Medical School, designed in part to address this staffing shortfall; in July, when Labour Health Minister Vaughan Gething responded to her report, it appeared that this was an unlikely aspiration. Step forward to October, and the budget agreement between Plaid and Labour spells out the framework, and the necessary finance, for the foundational stage of such a project, which could in time revolutionise North Wales' health economy.

Following up and extending our earlier piece on the medical school, a further detailed conversation with Rhun ap Iorwerth about Plaid's wider health policy provides some insight into how the 'Party of Wales' would tackle the broader NHS crisis that Wales (and much of the UK beyond its borders) is facing.

Representing Yns Môn, Rhun ap Iorwerth has been in the Assembly for four years, and has been Shadow Health Minister for one. He speaks with authority and confidence, but also is an attentive listener when a question is being asked or a statement he has just made tested. I met him in his Llangefni constituency office and, prompted by a short initial inquiry, it was the progress with the 'North Wales Medical School' project he mapped out first:

"I now call it a 'centre for medical education' rather than a medical school - in a way I agree with them (Labour) as a medical school is not something you can open overnight. What is important to me is not what is written above the door, but that what we need is somehow to generate more capacity, to teach more doctors, and to teach them in a part of Wales where we know we have a serious recruitment and retention problem."

"The money set aside in the new budget equates to an agreement in the budget, and that agreement can now be used to drive policy. We have a way forward now - with medical students learning in North Wales potentially anchored in Bangor from day one."

The overall project may have a broad agreement in principle, but there are differing views on the detail of implementation - which will no doubt be the focus of further campaigning and negotiation. Once all that is settled Rhun is determined that the new centre for medical education will make the best of its location:

"There are a number of models worldwide - in New Mexico, Ontario, New Zealand and Australia - where the medical schools teach a specific approach to medicine, to be delivered in a rural area such as this. You could imagine the centre in Bangor developing a similar expertise in delivering healthcare in less urban areas."

"The new centre will also be attractive to students who don't want to go further afield - it is the European Model to study at the university closest to home."

Pressed on the point, he sees the Welsh language and the new centre organically connected:

"The Welsh language would almost naturally be an important part of it - if you have a centre that specialises in delivery of medicine in a bilingual area, then that becomes a specialism within the school."

This development has been won through the work of the Assembly's Health, Social Care and Sport Committee (of which ap Iorwerth is a member, their report on Medical Recruitment can be found here), through campaigning and through negotiation. When he spoke, there was no evident triumphalism in Rhun ap Iorwerth about the resultant investment; he quite humbly sees himself as having played a necessary (and ongoing) part, and remains concerned point by point with how things develop from here. The approach looks very much like convincing evidence of detailed, constructive and professional political opposition.

That his attention has been focused on medical education (rather than that of nurses or other health professionals) is due to the recent channel followed by the systematic, sequential work of the Health, Social Care and Sport Committee. We finished with this specific topic by talking about the recent drop in Welsh students applying to medical school, then Rhun started to offer wider perspectives:

"The number of applicants from Wales fell 13% in a year, as opposed to a 1% drop-off in England - the cause is probably multifaceted. It must be linked to the drop-off in STEM subjects, but the attractiveness for bright young students of going into medicine has been dropping off and we can only guess at the reasons for that - perhaps bad press for the NHS is important."

"To create new interest I'd love to see more activity in schools, in a much more structured way, from primary school age on with a two pronged strategy - one teaching people to learn more about health and look after themselves from an early age, and then telling them what the opportunities are in health-based professions. More than half of doctors have decided that is what they want to do by the time they are nine years old!"

"I would like to get to the point where we can make medical, nursing and other allied health professionals education free in Wales. That would be a real signal to people who are looking to make careers in the NHS that they would be valued. It makes no sense, for example, that someone has to pay £45,000 (in tuition fees) to train to be a doctor when we are desperate for doctors. It doesn't make sense to me at all. When we see the drop in people wanting to go to medical school - how many people have looked at the simple maths of it?"

"I argued for the retention of the bursary for nurses, and got a positive response from (Health Minister) Vaughan Gething for another year straightaway. So, for now, we have bursaries for nurses in Wales, but not in England, and that is a really positive signal."

"I would always encourage anyone who wants to spread their wings to do so, but the reason why public money goes into training doctors, nurses and other health professionals is to train them for our NHS, and we need to bring the spend and the outcome closer together. You are more likely to work where you train, we know that, and you are more likely to work where you come from - if we can bring the two together you are offering people something that will help them commit to the Welsh NHS long-term."

The NHS in Wales - in its systems, capacity and existing staff - is undeniably stretched and stressed. Having talked about recruitment and retention, the question insistently begged as to what Plaid would do in totality with health if elected in 2021. The 2017 Plaid Cymru General Election Manifesto had commitments to 1,000 extra doctors and 5,000 extra nurses over ten years - with the numerical statements there has to be a strategic intent as to how the NHS might be run differently, to avoid the current impasse recurring. Where would Plaid start, and how would they initiate and sustain change? Rhun's response was illuminating, but still ultimately came back to the importance of staff:

"If we inherit things as they are now then it is really difficult, but in the short term we would try to put in motion the things that are going to help in the long term. We will have to somehow free up money within the system, I am not convinced that money is being spent as well as it could within the NHS. There are constraints though. We can't just say we will increase the NHS budget. "

"It appears the NHS has become very much about firefighting and there's less room for creative thinking about its future. If you look at Betsi, which you could argue is directly managed by the Welsh Labour Government at the moment, it has become about getting on top of a number of very acute problems, on waiting times and recruitment on finance, and I'm not seeing an NHS that has the freedom to be creative at all."

"In a sense the NHS is in a position (in Wales) where it has to buy its way out of problems - so with agency staff and use of locums they can just about manage their workforce filling gaps by chucking money at the problem, and this is still increasing at a hell of a rate. In my conference speech this weekend (Plaid had just had their annual conference when we met) I have stated I'd like to stop profiteering from agency staffing, and to run it on a not for profit model. That is the kind of creativity we could inject into the NHS."

"It feels as if it's totally stifled now by firefighting and rigidity."

"There is a desperation in Wales for solutions that (already) exist, you can pick the models almost off the shelf. Investing in infrastructure - genuinely looking at those areas that are clogging up the system; for example we have been talking for a long time about the Danish style diagnostic centres. When pilots were attempted in Wales workforce was too much of an issue."

"The workforce is at the heart of everything. Good ideas are very difficult to implement without the staffing."

"So we will free up the NHS through investment in workforce."

"We have to get beyond the vicious cycle of workforce shortages and firefighting. The best recruitment and retention tool for the NHS in Wales is people knowing it is sustainable. Not achieving this is one of the biggest threats we have; from bad press and then people feeling that it is not a valued service."

"When we talk about workforce pressures people often think about the effect on patients. Issues that can lead to longer waiting times for example, it is the patient having to wait for a long time that is the problem. But I am also concerned about the effect of these problems on the workforce, and it's a spiral - the workforce that is left when there are problems in recruitment and retention having to deal with the issues of long waiting times, they take the flak and have to work harder and for longer hours."

"Once Wales' NHS is shown to be sustainable, an organisation where staff are made to feel they are valued, where they know they are listened to - being able to tell us what is making life difficult for them and getting the right response - word will get around, both to current NHS staff working elsewhere, and people on the outside thinking of working within the NHS."

"We will create a new bond between the Welsh NHS and its staff."

There was implicit criticism of Labour's approach in these statements - a barely obscured narrative of needing to act following a failure in management - which jarred with the sense of (albeit arms length) collaboration over the medical education centre. This contrast prompted the question as to whether Plaid is rightly condemned for being a too close, 'critical friend' of the Labour Party. It was the one of only two points in the interview where Rhun looked momentarily perplexed - he thought for a few moments before replying:

"Much of it is perception, anybody who watches in detail what happens in the Assembly or watches what we do, and how we hold government to account - for example on health - will know we do this harder than any other party. But there is a perception, perhaps because we were in government with Labour in the past, perhaps because of the recent compact, that somehow we work hand in glove with Labour."

"It is not true at all. We are 100% opposition to Labour. The recent compact was not coalition-lite. But if the perception exists we must address it."

"I am confident that we are holding the government to account as firmly as we can, and I have no question that Plaid Cymru is the best generator of ideas, and not just in health."

"We have a total commitment to furthering the cause of Wales, and looking at everything from a specifically Welsh angle - and not being shackled by other parts of our parties, as with Labour or the Conservatives; it gives us a real advantage, an intellectual freedom. A huge number of people put ideas into Plaid, and we are not afraid of running with them. You can see the impact of this in our last manifesto, which was a pretty impressive document."

"For health - the problem that Labour have is that they've been running the NHS in Wales for eighteen years. For them to admit that we have seriously fundamental problems within the NHS would be to admit that they are the ones that caused those problems."

"In normal democracies governments come and go. They are judged on their record, and a new government can come in and redesign with honesty and a fresh outlook."

"If this does not happen it creates its own issues. Specifically in North Wales, Betsi Cadwaladr is Labour's. They created it, and they have created the environment within which the NHS in Wales operates. I think we need some fundamental change in thinking within the NHS, and Labour are struggling to admit that because they are the ones that have got it wrong. That is why we need a fresh start, meaning an election and a new government that doesn't feel it has to just be incremental, and that can make some real change."

Given the evident need for change you might wonder why electoral breakthroughs, such as Leanne Wood's victory in the Rhondda in 2016, have been so far limited. Just before I met him, Rhun had recently written on Nation.Cymru that Plaid have a vital need to gain the electorate's trust, I asked him what was necessary for that to happen, and he responded emphatically, with a touch of wry humour:

"The real answer is, and it is a tricky one, is governing."

"In 2007 the SNP only just got over the cusp, they didn't get a majority - they then ran a minority government. But from that, to win the trust of the country, they were able to show that they could govern well. And that is what Plaid Cymru needs, the chance to govern. Then going a couple of steps back, we really need to persuade people that we could govern well. That is our overarching challenge."

"Most people would see that across education, the NHS and economy Wales needs something different. We need to put together a sensible, innovative, exciting and well thought out programme - that is exactly what the SNP did just over 10 years ago. A programme that pushes people to the tipping point of saying 'you know what, we will give them a go'."

"We have the ideas. We need to persuade people we should be trusted to run the government."

Which left time for the sense that 'Plaid Cymru is a party for Welsh speakers', or has too narrow a range of interest, to be addressed, giving Rhun his second fleeting pause for thought before responding:

"It is strange, now. Our leader Leanne Wood isn't a Welsh speaker, and represents a largely non-Welsh speaking area. We have to persuade people that 'we speak your language' - whatever that language is. Of course the Welsh language and our heritage is important to us, but listen in the Assembly and much more of our input is in health, and education, and the economy and universal credit - we are a political party that is proudly based and revolves around Wales, its past, present and most importantly future."

"Yes, we serve the areas we (already) represent very, very well - and our MPs at Westminster punch well above their weight. But essentially we believe Wales (as a nation) could be better."

"We need to stop floating as a country. In a small country we can be more responsive, more nimble with solving problems. We can manage change in country the size of Wales. Across all public service there is a feeling we have a government that just tries to manage, tweaking this and that. Wales is beyond tweaking - the NHS, the economy and what we need to achieve sustained growth - it does not come from tweaks, but promoting innovation, bringing industry expertise in, creating efficiencies to enable creativity."

"Labour will not run Wales forever. I want it to change tomorrow, but I will do my damndest for 2021. We will need to be brave."

On health Rhun ap Iorwerth is not suggesting a radical re-envisioning of the NHS, but investing and trusting in its people, then creating the necessary resource and intellectual space for innovation and creativity to do its work. He shows positive signs of offering a very safe pair of hands for the project.

More generally Rhun ap Iorwerth expresses a dedication to understanding a problem and solving it collectively, using the valuable knowledge of those involved, rather than imposing a dogma. It seems a very pragmatic and necessary approach. There has been a similar direction and momentum in each of our series of three Plaid interviews - taken together they leave common, limiting preconceptions of Plaid Cymru trailing in tatters and rags. Siân Gwenllian, Rhun ap Iorwerth and Aaron Wynne share characteristic intelligence, openness and integrity; the question as to where the political impetus might come from to achieve the original hopes of greater Welsh self-determination has at least one credible answer.