It is generally considered that the NHS in Wales performs much worse than the English NHS. The Daily Mail is always saying so and many other commentators too.
So when Theresa May recently asked – “If the Labour Party have got all the answers, why is it that we see funding being cut and targets not being met in Wales, where the Labour Party is responsible?” she probably thought this was a good way of answering the criticisms of her government’s record in presiding over the current winter crisis.
Normally, as someone who worked in Wales for nearly 40 years and who is aware that satisfaction with the health service is actually higher in Wales than in England1, I just shrug my shoulders, knowing that this is just stupid politics. The conservatives in England run their health service in their way and the Welsh labour party (which is allied to but separate from, the labour party in England) runs the health service in Wales as they think best. Therefore it is fair game you would think that one should criticize the other, regardless of any truth behind claim and counterclaim. But because Wales is tiny compared with England and struggles to get its voice heard, all the publicity goes one way, from England about Wales and not the other way around, and always infers that Wales is doing very badly.
So for once I want to redress the balance a little bit, and explain how Wales does things differently, and in my view better.
Firstly there is no privatisation programme in the NHS Wales as there is in England. Virgin doesn’t get a look in for hospital or GP services so profits aren’t creamed off. There is no contracting out wholesale for mental health services. There is minimal Private Finance Initiative so there are no problems with costs to private providers causing hospitals to go bankrupt. There are no big debts to pay off in the future. As we have seen this week with Carillion, private companies do not always run their empires with competence or honesty.
There is no contracting out to private GPs, or attempts to de-stabilize GP practice. The back end services that GPs rely on to service their practices (pay and rations) remain in public ownership and work well, while they do not in England.
There are no prescription fees in Wales. This is partly because there was a very large proportion of people in Wales who were too poor to pay them so it made sense to scrap them altogether. There is free parking at almost all Welsh hospitals except those that had contracts in place before the rules were changed (very few).
There was no cancer drug fund in Wales (it has now been watered down in England because it made a mockery of attempts to make sure everyone got fair access to drugs). All the stories in the media about how a few individuals people were dying because of the lack of very expensive drugs were very sad, but I make no apology for saying that scarce resources should be directed to where they will make the biggest difference, according to best scientific evidence. Saying that Offa’s dyke was a “wall of death”2 was absolutely crass – see my previous blog https://scepticalgp.wordpress.com/2014/06/02/offas-dyke-and-the-line-of-death/.
Wales uses an opt out system for consent for removal of organs after death, so that there are more organs available for transplanting. Many of those go to England. England is now considering following suit.
But most of all the Welsh government has a consensual attitude to NHS workers, works well with the Unions and tries hard to attract and keep its workforce. There was no junior doctors strike in Wales, nor any other dispute. The Welsh government has been successful in attracting young doctors to train as GP’s in Wales and all places this year have been filled, unlike in England.
Of course there are problems in Wales but considering that there is no level playing field, Wales does surprisingly well. Comparing Wales to England is hardly comparing like with like. Wales is much more rural, and much poorer than England. It has different challenges that have to be addressed by the Welsh devolved government. The GDP per head in some areas of Wales is lower than parts of Bulgaria and Albania and in 2009 West Wales and the Valleys had a GDP per head rating equivalent to just 68.4% of the EU average. If you need to do comparisons, Wales should be compared to a similar region in England such as the northeast.
This matters because there is a linear relationship between greater poverty, and the amount of ill health. The cost of treating the population is higher per head. There is also the legacy of ill health from old heavy industries like coal, slate, and steel.
Secondly, the demography is different; Wales has a much higher proportion of elderly folk who are more likely to have expensive health needs. There are the older people who have always lived in Wales, but there are also a disproportionate number of non-Welsh retirees, usually from England who come to retire to Wales, because house prices are cheaper and it can be a very nice place to live. Wales is not given more money specifically for these people. They replace younger fitter Welsh people who go over the border to England to work because of lack of opportunities in Wales, and who do not use the English health service in the same way. There are also people on the borders who choose to register with Welsh GPs because they can get free prescriptions, but then object because they have to use Welsh hospital services, even though Wales does not get any more money to pay for them.
So the money that Wales gets from the Westminster government for its health service has to go a lot further.
The money for the Welsh parliament comes in a block grant from England according to the Barnett formula. It is higher per capita than in England but not nearly so high as in Scotland, which is altogether richer. Wales can then choose from this amount how much to spend on its Health service as compared to education and other calls on its funds.
So going on to Theresa May’s question, why is it that we see funding being cut and targets not being met in Wales, where the Labour Party is responsible?”
This “funding being cut” statement refers to the fact that between 2009-10 and 2012-13, health spending was cut in real terms by about 3.6% in Wales, while the English health budget was increasing, albeit at under 1% a year in real terms. During those times Welsh government made a decision to cut the funding of the health care sector in order to protect the social services budget, This was specifically because cutting social services leads inevitably to inability to discharge people from hospital, especially in Wales where fewer people can pay for social care themselves. It was an attempt to stop the very things that are now plaguing the English NHS – inability to discharge patients, blocked beds, inability to admit fro A&E, people waiting on trolleys, ambulances piling up outside A&E, and so on. They were then pilloried mercily for spending less on Health. But the strategy did work to some extent and there were fewer bed blockers in Wales as a result.
However, since 2012-13, health spending in Wales has increased from £6bn to close to £7bn in 2016-17. The Wales Audit Office notes an average 2.9% annual increase in real terms during this period.
This tops spending increases in England, which have averaged 2% per year since 2013. In fact, Wales now spends £64 more per person on health than England, according to HM Treasury. However the overall amount Wales has had from the Treasury has dropped from £16bn available to spend in 2009-10, to about £14.5bn by 2016-17. This means a squeeze on all budgets.
The idea that Wales NHS performs worse than England is because of specific problems with targets such as waiting times for operations and diagnosis.
In 2016 England did better on hernia, pneumonia and heart disease diagnosis, and waiting times for some important procedures and operations such as hip replacements are shorter than in Wales. While that is important for patients, it is not a deciding factor in the effectiveness of treatment. Within reason, waiting times are not always bad. My own personal feeling about waiting lists for surgery is that it all depends on when surgeons decide to put patients on the waiting list. In my view it is very easy to decide on a knee operation far too early, before there is significant disability, and as any operation carries some risk this can mean that patients are actually worse off if they do get a complication when they were managing OK without an op. So these targets are only a small part of whether a service is doing well or not. And on other key procedures such as heart bypasses and kidney transplants, the waits were shorter in Wales. Wales is currently doing worse on hitting the 4 hr. wait for seeing patients in A&E, but every country is having problems for these and they have been disregarded in many analyses. Cancer diagnoses were similar in the two countries, so it is unlikely that waits for diagnostic tests are making much of a difference overall.
Finally, all the evidence is that in the round, there is virtually no difference in the performance of the four nations of the UK. In 2005 a report came out from the Nuffield foundation comparing the four health systems (2), in Wales, Scotland, Northern Ireland and England. It wasn’t reported at all in the press, but it said in effect that the gap between the NHS in England and the rest of the UK has narrowed in recent years, so that now no country is consistently ahead of the others, despite all the hype about how England has improved with increased competition and privatisation.
So one has to realise that the Daily Mail and its mates just want to make a political point that the Conservatives run things better than Labour do, using Wales as a scapegoat. What a surprise! Of course that is a matter of opinion and many would beg to differ.

1. http://www.bbc.co.uk/news/uk-wales-27616963
2. http://www.telegraph.co.uk/health/nhs/10760842/Offas-Dyke-is-line-between-life-and-death-says-David-Cameron.html
3. . http://www.nuffieldtrust.org.uk/our-work/projects/funding-and-performance-health-care-systems-four-countries-uk