Published: 02/09/2004, Volume II4, No. 5921 Page 10 11

Targets, the controversial medicines prescribed for the English NHS but not taken in Wales, have really made a difference.And if you do not believe that, says Lyn Whitfield, all you have to do is compare the two organisations.

If critics ever want to know what the English NHS would be like without New Labour's targetsetting, modernising and partprivatising regime, they might get a few clues by looking across the river Severn to Wales.

Since the last general election, the maximum waiting time for inpatient treatment in England has fallen from 18 months to less than nine, with the service on course to hit six months next April.

A maximum wait of 13 weeks for an outpatient appointment also seems set to be delivered.

However, in Wales maximum waiting times for both inpatient and outpatient care are over 18 months.

Wales has targeted some procedures so that, for example, nobody waits more than 10 months for cardiac surgery and there are short waits for cataract surgery.

And Welsh first minister Rhodri Morgan and health and social services minister Jane Hutt have also insisted that a 24-hour access target (rather than 48 hours) for primary care shows devolution can deliver.

But in terms of performance against the headline total waiting list and time figures, the performances of England and Wales have diverged dramatically.

'If you have something seriously wrong with you, you can die waiting, ' says University of Wales Institute in Cardiff senior lecturer in Welsh governance and modern history Russell Deacon. 'The situation in Wales is just terrible. You can wait two or three years'.

Why the massive difference?

Two arguments often put forward are that Wales has a sicker and older population and that its health service is under-funded and short of capacity.

But it probably doesn't have a greater burden of ill health than, for example, the North East of England, where the population is ageing faster says last year's Audit Commission report, Transforming Health and Social Care in Wales.

It also said the Assembly has increased health expenditure by 30 per cent and, with more beds per head of population than England, may actually have too many beds rather than too few.

'The healthcare system... is a vicious circle in which both entry and discharge points are blocked, ' the report argued. 'Waiting lists, delayed transfers of care and deficits are symptoms of the vicious circle, rather than its cause.

'Policy and resources have been aimed at the symptoms... and this actually exacerbates the problem [by fixing] resources in the acute sector [and] drawing them away from the non-acute elements of the patient pathway, preventing balance across the system.

'It is not too little capacity that is the problem, but rather that existing capacity is under chronic and unnecessary pressure.'

This is hardly a new conclusion.

Derek Wanless' Review of Health and Social Care in Wales also found that long waits, deficits and delayed discharges were 'symptoms of deep, underlying problems needing to be faced'.

As a vision of the future, the Audit Commission endorsed Wanless' recommendations, which include getting individuals to take more responsibility for their own health, service reconfiguration, greater financial discipline, better workforce planning and more use of IT.

All of this will sound very familiar to English ears. Health thinktank the King's Fund chief economist John Appleby recently told HSJ there has been 'no magic bullet' for getting lists down in England (pages 12-13, August 5).

Instead, he says, success has boiled down to 'having targets and having targets that ministers and the Department of Health are really keen to enforce', extra resources, close attention to patient flows, 'the whole modernisation agenda' and some changes in clinical attitude.

The fact that waiting lists and times have generally continued to lengthen in Wales suggests that some of these must be missing across the border.

British Medical Association Welsh council chairman Tony Calland groans at the mention of the word targets.

NHS Wales director Ann Lloyd says there has been action to tackle Wales' underlying problems. Since the Wanless and Audit Commission reports last year, four task groups have been set up to look at engaging individuals in their own care, optimising service delivery, improving performance and involving people in service change.

Wales's 22 local health boards have drawn up Wanless implementation plans with trusts and local government, and£30m was set aside for implementation.NHS Wales three regional directors have been looking at the configuration of secondary care.

However, opposition politicians argue this is not enough. Welsh Liberal Democrat leader in the National Assembly Mike German says: 'We have not seen decisive action. The money the government should have used for reform has been frittered away.The minister needs to get a grip.'

Mrs Lloyd can't answer political points, but says new waiting time targets were set this summer and points out that since April, patients have been given a 'second offer' of treatment at another hospital, if their local service can't deal with them within 18 months.

She also says the centre monitors local services through the targets in the service and financial frameworks, which outline agreements between health boards and trusts among other measures. The 'balanced scorecard', which records trusts performance across a range of management measures, will allow local communities to see how their services are doing.

Overall, there is a sense that while Assembly ministers initially focused on improving health and reducing inequalities, they are now paying more attention to health service performance.

This has been welcomed by the NHS Confederation in Wales. Its spokesman, Kevin Sullivan, says England and Wales are converging in that 'there is now a growing recognition that a health service and an illness service are two sides of the same coin, and that success depends on focusing on both.'

But this is another way of saying that Welsh lists are longer because, until now, getting them down has not been a political priority.

One managerial source, who does not want to be identified because waiting lists are now a 'red hot topic' in Cardiff, says the Assembly, still a very new body, was 'politically na´ve' in choosing to focus on ill health.

But he also says they were able to do so because, until the Welsh press started to run stories contrasting the English and Welsh health services, there was little electoral demand for change.

'We are prisoners of our history, ' he says. 'Any suggestion of change tends to be met with the question 'what would Aneurin Bevan say?'

There is a very real ideological attachment to the NHS, which is why politicians use the rhetoric of Old Labour and have shied away from change.'

Dr Deacon agrees. 'The NHS is a monopoly provider and there is still the idea in Welsh Labour that it should remain so, even though it is a dinosaur, ' he says.

'In England, there has been a lot of political pressure on government to get lists down, but here [Welsh secretary] Peter Hain can just say it is the Assembly's problem, and [in the last Assembly elections] there was no pressure from the electorate.'

Since April, 1,300 people waiting more than 18 months have been given a 'second offer' of treatment elsewhere, but 465 have declined. Mrs Lloyd has been tasked to find out why. Travel in rural areas may be one problem, but there is a suspicion that some people simply think they should wait their turn.

The Audit Commission describes the challenges facing the Welsh NHS as 'daunting'.

Dr Calland says the impetus for this has to come from the Assembly. 'They have to grasp this in the very near future, otherwise the health service in Wales, which is already an emergency service, will collapse as Wanless warned it would, ' he says.

The wait goes on

While waiting lists have fallen dramatically in England since the last election, in Wales, the outpatient waiting list has risen (from 177,600 on 31 March 2001 to 237,193 on 31 July 2004), almost 50,000 have been waiting more than six months and more than 7,000 for 18 months.

The inpatient and daycase waiting list has risen (from 65,600 to 74,936) and almost 1,500 of the people on it have been waiting for more than 18 months.

However, there are some qualifications.Wales counts more outpatient referrals than England, 'inflating' its figures by about 30 per cent, including referrals from accident and emergency departments and other consultants, and self-referrals, whereas in England figures only include GP referrals.And very long waits are coming down. In March last year, more than 5,000 people had been waiting more than 18 months, and NHS Wales chief executive Ann Lloyd says it will meet a new target to eliminate them by the end of the year.