Daniel Jones is a Junior Doctor writing here about the challenges the Welsh NHS will be facing in future.     

 The Welsh NHS is in crisis! At least it always appears so.

Then again, which part of the NHS in the UK isn’t in crisis? Hasn’t the NHS faced crises even before devolution? If we get out of this one, when will the next one just come along?

It is a predictable feature of media reporting of the NHS that it always appear to lurch from crisis to crisis. The reality is that it has actually delivered consistent and enormous improvements in health and wellbeing of the UK population since its creation. It is easily one of the best healthcare systems globally^[1].

Nevertheless, this most recent decade of its history where it has been the biggest pot of public spending in the midst of a Westminster austerity agenda has seen it undoubtedly struggle. The health budget has seen real growth of 4% per year over its 70 year history and yet this decade it has been about 1% a year or -0.9%  a year in the case of Wales where the Welsh Labour government controversially cut health spending in real terms^[2]. Social care funding has been cut across the UK.

This has translated into an arrest of the performance improvements that we’re used to and even going backwards on some performance measures. The time you wait for an ambulance or to be seen by a doctor in the emergency department continues to get longer and longer UK wide and in Wales specifically, the time you spend on an operation waiting list continues to grow and grow.

Challenge is a better word for this than crisis and it is not the only challenge that the Welsh NHS faces in the coming years and certainly none of these challenges can be solved by simply putting more money in.

This article will explore current and future challenges that our healthcare and social care systems face and what we can do to meet them.

Demographic change & Funding

Wales is not about to be hit by a demographic time bomb but we can accurately predict that its population will increase to 3.26 million by 2041. Of particular note is that a significant proportion of this expansion will come in those who are over 65: 232,000 extra (36.6% increase) by 2041^[3].

This all means increased demand on health services and, by looking at the current and likely needs of these individuals (more on this in the next section), we can estimate the quantity and nature of the extra demand. For example, we know that these extra people will be more likely to access healthcare and require more medications, we know they will be more likely to need social care services and we know they have a relatively high chance of at least one hospital admission.

After no small amount of number crunching by the Health Foundation and Institute for Fiscal Studies^[4] we now know that to meet this additional demand and carry on providing current levels of provision that Wales will need to grow its NHS budget by 4% per year for the next 15 years, representing hundreds of millions of pounds.

The good news is that the bulk of this health funding has been promised by the Westminster so long as it is faithfully diverted straight to the Welsh NHS budget by the Welsh government then this challenge will be met. In terms of how it will be funded, it will undoubtedly require a rise in taxes which, at present, has not been detailed but a specific NHS tax has been touted.

The bad news is that there is currently no extra funding pipelined for social care and that additional health funding has been recommended so the NHS can actually carry out capital investment, grow its capabilities and adaptability and deal with its workforce issues. Without this funding (likely to be at least £400 million), certain parts of the NHS and our social care services will inevitably continue to struggle.

Disease profile

The changes in our demographics, lifestyles and habits will inevitably change the disease profile of our future population. Unfortunately, this is universally predicted to be an increased number of people suffering with multiple chronic diseases. This raises additional challenges beyond the increased costs explored in the previous section.

The current system of secondary care (scans, procedures, specialist clinics etc.) mainly taking place in district general hospitals will not be able to cope and we will require a shift in it taking place alongside primary care in the community and even in patient homes themselves. With general practices already linking up together throughout Wales the framework is there to happen.

Our district general hospitals meanwhile, as they shift their outpatient services to the community, will have to shift their emphasis on to emergency care and general inpatient care which have perhaps struggled the most in this decade. Even with a growing population, if our emergency and social care services are properly funded and staffed then we will likely be able to admit fewer and fewer inpatients.

Meanwhile, our tertiary care (complex surgeries, major trauma, advanced procedures, rare disease experts etc.) will have to become more centralised into our large, teaching hospitals which will refine their focus and gather leading experts together in order to improve clinical outcomes and patient access to these services. With enough commitment, we may even see a day when Welsh patients no longer have to travel to specialist units in England.

However, all of this is a resigned attitude to this additional disease burden but these diseases are all largely preventable. Indeed, much will be caused by lifestyle factors such as obesity, alcohol consumption, poor diet and smoking that can be targeted. Prevention is famously cost-effective, alleviates the pressure and most importantly is the best situation for the patient themselves.

Prevention requires a bold investment in primary care and public health, the kind of investment that the NHS could make were it to have the extra funding available. It would however be an investment that would pay dividends.

All of these changes will require a political will which in it’s most recent statement, the current Welsh government claims it has^[5]. Time will tell.

Obesity

I reserve this for its own section because I think it deserves special attention. Obesity is a problem that is set to hit Wales harder in future: not only will the current percentage of adults overweight or obese (58%) likely gradually increase in the next decade, but with 27% of children currently being overweight or obese, our population is set to become much unhealthier as they grow up^[6]. With the metabolic conditions associated with it, (let alone the stigma and restrictions it can introduce into people’s lives) obesity is set to generate a high personal cost for many and a significant additional cost to the NHS in Wales.

Yet, this too is preventable and it can actually be done by bold state interventions that don’t require substantive investment. We know from our experience with smoking just how successful these can be, we have several proposed policy interventions such as sugar taxes or advertising restrictions that have predicted benefit and we also know that the public would support such interventions.

A committed legislative agenda could prevent thousands of people in Wales becoming obese in the coming years: great for them and great for the NHS. We could also see similar positive impacts with action on other lifestyle issues too such as minimum pricing on alcohol.

Inequality

Inequality is a classic double edged sword in healthcare: not only do disparities lead to worse health for those on the low end but those on the low end also tend to have the worst access to healthcare as well in spite of the NHS model. Both of these phenomena get worst as the level of inequality worsens and we are still dealing with the consequences of the explosion in inequality that occurred under Thatcherism.

Whilst current inequality has stabilised, it is not getting any better and there are substantiated fears it could get worse. A salient reduction in the level of socioeconomic inequality we have would be a policy agenda that would deliver substantive benefits to the health of the population and economy, helping to alleviate NHS burden^[7].

However, failing that we can at least ensure that the NHS in Wales is as equitable as possible.  This means that the funding and development of health and social care must be done with disparities in mind and we know that this is best done in an integrated, patient centred way.

With the Welsh government about to establish regional health boards covering all of Wales there is now an opportunity to ensure that hospital trusts, local authorities, GPs, public health workers and most importantly patients in a given region get around a table with a common pool of resources to hand and equity on the agenda.

Health and social care worker shortages

Wales is estimated to have 0.6 GPs, 7.1 nurses and 1.9 hospital doctors per 1000 people in the population¹. Whilst the latter two figures outperform England, we are below the European average and even the figures for Europe could be argued to constitute a shortage^[8]. Indeed, healthcare worker shortages appear to be a global problem and one which will worsen over the coming decades.

The NHS has managed to recruit these staff numbers before as has social care but it remains a daunting task. Certainly, this is a problem that cannot be addressed with a short fix and will require a serious investment in recruitment and retention.

The recent decision to increase healthcare worker pay in line with the rises in England and making minimum pay a living wage is a welcome start from the Welsh government. The recent medical school opening at Bangor and the refusal to impose the new junior doctors contract in Wales are also welcome.

However, we can and must do more in this regard with a comprehensive workforce strategy and we will likely need more inventive long term solutions such as increasing our use of technology as well as the use of non-medically trained personnel such as physician and surgeon associates or healthcare assistants.

Increased capability

The final significant challenge that faces the Welsh NHS is not a new one: it has historically been the victim of its own success and will continue to be.  The more success we have in keeping people alive and healthy, the more success we have in managing people’s medical conditions and the more technological advances in medical science we make then the more the NHS can offer.

However, we do not have the resources to offer everything we could and never have. Healthcare rationing always has been a difficult task and will likely become more so as our capabilities increase. The best way to meet this challenge is to continue to anticipate it. We must continue to accept that we have to ration and are sure that are our rationing decisions are robust.

The current model sees the All Wales Medicines Strategy Group use cost-effectiveness comparisons (favouring cheap interventions that prolong high quality of life) and is generally excellent but it is not perfect, we must also try and capture what we as a society want and that means greater public and patient involvement. If we do that then hopefully our general public will have an NHS that achieves what they want it to do within its means.

Conclusion

I have outlined several challenges which I think NHS Wales will encounter in the future but there are some that I have yet to mention and inevitably it will face new challenges I have not anticipated. If we are to meet them head on then we will need to be adaptive and to do this we need a welsh government and a NHS that have the leadership required.

^[1] https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and

^[2] https://www.nuffieldtrust.org.uk/files/2017-01/4-countries-summary-web-final.pdf

^[3] https://gov.wales/statistics-and-research/national-population-projections/?lang=en

^[4] https://www.ifs.org.uk/uploads/publications/comms/R143%20executive%20summary.pdf

^[5] https://gov.wales/docs/dhss/publications/180608healthier-wales-mainen.pdf

^[6] https://gov.wales/statistics-and-research/welsh-health-survey/?lang=en

^[7] http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

^[8] https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0187-2