Health and Devolution: The Next Decade
A Fabian Health Policy Seminar
12.30 – 13.45, Wednesday 14th July 2010

Dr. Brian Gibbons AM (Former Minister for Health and Social Services) with responses from Professor Gwyn Bevan (London School of Economics and co-author of Funding and Performance of Healthcare Systems in the Four Countries of the UK Before and After Devolution) Carolyn Lester (Lead for Health Inequalities, Public Health Wales) and chaired by Denis Campbell (Health Columnist, the Guardian/Observer).

On Wednesday 14th July, the Fabian Society convened a number of high-level panelist’s and delegates in Cardiff to discuss the lessons from health care provision in Wales since the devolution of power. The seminar aimed to discuss how the experience of developing a unique national means of delivering healthcare could inform both future planning in Wales but also how this might be transferable to planning and provision in both England and Scotland. The event was kindly supported by sanofi-aventis.

The panel was led by Dr. Brian Gibbons AM (Former Minister for Health and Social Services) who was joined by Professor Gwyn Bevan (London School of Economics and co-author of Funding and Performance of Healthcare Systems in the Four Countries of the UK Before and After Devolution) Carolyn Lester (Lead for Health Inequalities, Public Health Wales) and chaired by Denis Campbell (Health Columnist, the Guardian/Observer).

The session was held under Chatham House rules to allow maximum participation and openness from both speakers and delegates.

The discussion was opened with a brief overview of how the Welsh Assembly, often through trial and error, developed its own unique National Health Service since devolution. It was noted that the essence of devolution was to allow different parts of the United Kingdom to do things differently in line with there own perceived needs.

The Welsh Assembly’s early approach to the NHS was initially framed, conceived and operated within the Conservative spending limits of the post 1997 General Election. This meant that in the early years of policy there were not significant resources available to invest in new health care practices. This meant the Assembly was forced to address health challenges in different, innovative ways given the realities of fiscal constraints.

This was coupled with issues in the early years in the spending formula, which resulted in resources often being allocated in a manner that meant per capita spend was highest in the healthiest areas and lowest in poorer areas where the health outcomes were worst. Professor Peter Townsend was subsequently enlisted to develop a more effective needs based formula that ensured resources were allocated to those in greatest need.

In the early 2000’s, the Labour pledge to stick to Conservative spending plans expired and investment began to flow more freely into health services across England, Scotland and Wales. From these very early days of additional investment there was an aversion to development in a similar manner to England, where private provision and markets were being integrated in the NHS to drive up standards and improve performance.

This was for several reasons; firstly, there was no significant tradition of private medicine in Wales meaning that if NHS Wales had developed in that direction it would effectively have meant that “it would have to have been invented”. Additionally, even if this had been implemented there were substantial barriers to a market for private medicine developing. The demography and ethnology was also arguably against such development given that the country had a history of chronic illnesses and an aging demographic meaning that the health care system was not necessarily an attractive investment for the private sector. Equally the geography of Wales didn’t lend itself to the type of duplication necessary to have a market based health service. Therefore, the Welsh Assembly did not feel that anything that began to move towards a market would be appropriate on either ideological or pragmatic grounds for Wales.

The development of the NHS in Wales was accelerated in 2003 when the Welsh health authorities were abolished and replaced with 22 local health boards. This was decided based on the fact that there were 22 local authorities and it was felt that representing the cultural and minority differences across Wales in healthcare provision was crucial to meeting the needs of patients. An important ambition of the new health authorities was the integration of health and social care in order to address the high levels of inequality in Wales. However, it was argued that the new structures did not translate to a positive public perception of healthcare provision in Wales. Many areas experienced lengthening waiting times and the media began to feed a narrative that the health service was underperforming – especially in comparison to what was happening in England.

Following the 2003 Welsh Assembly Elections, Labour held an outright majority in the assembly, thus allowing them to drive forward their healthcare agenda. There was a pressing awareness that the NHS in Wales had to begin to deliver not just a public health agenda but basic ‘bread and butter’ NHS services. This was driven by extensive media coverage as well as Welsh MPs sitting in Westminster who were acutely aware of improvements to the English NHS.

This led to the announcement in the middle of the second Welsh Assembly term of ‘Designed for Life’ - a 10 year strategy for health and social care in Wales. Designed for Life aimed to provide an evidence based strategy linked to innovation and a consistent commitment to best practice which would provide a health and social care service ‘fit for the 21st Century’.

The new blueprint for reconfiguring healthcare in Wales quickly became the primary political issue for the Labour administration – which had recently become a minority administration due to the defection of a Labour AM. ‘Designed for Life’ enjoyed cross party support in the assembly, but it was argued that implementation at a local level proved to be politically more difficult. It was suggested during the discussion that at a grass roots level numerous local campaigns - some based on quite accurate concerns – were mobilised on a “political opportunist basis”. It was therefore conceded that the ambition of trying to drive Designed for Life forward so it would be completed for the 2007 assembly election was too ambitious in retrospect.

The NHS in Wales has since been reorganised into 7 local health boards that are driven by a national advisory board, which in turn is chaired by the Health Minister and the delivery end of that chain by the Chief Executive of NHS Wales.

As a closing comment to the summary of where the NHS in Wales currently stands – and how it got there - it was argued that the NHS in Wales was ‘socialised medicine by Beven-ite principles… and corrupted as little as possible by the private sector.’

The discussion then moved on to more detailed projections of how the Welsh system could develop in the future and the comparisons that should be drawn between Wales and the systems of Scotland and England. 

One participant argued that there was the potential for Wales to deliver far better health service outcomes than in its English counterpart. It was argued that the NHS in England was such a mammoth structure that reform and delivery was inevitably more problematic. However, with smaller structures and fewer geographical differences, Wales could potentially lead in innovative health solutions.

In discussing lessons that Wales might be able to learn from England, one member of the panel argued that initially controversial money incentives for good performance in the English NHS had worked surprisingly effectively in England but had not translated into similarly good results in Wales.

It was argued that measurable metrics in the comparative NHS systems of England and Wales showed Wales was doing worse than its English counterpart. It was stressed that there was a vital need to have consistent data across devolved nations so we can compare and learn from best practices. In turn, it was commented that it was crucial to develop diverse policies across devolved nations to ensure we can learn and innovate.

It was argued that Wales had a fantastic opportunity to avoid the potential mistakes that the English may now be making in healthcare provision. It was argued that it had been shown worldwide that choice and markets within healthcare systems have been ineffective. With a Welsh aversion to opening up to free markets within the NHS, it was claimed Wales may be pursuing the correct approach and should be confident in doing so.

As the discussion progressed it was noted that although there were lessons to be learnt from a devolved approach to healthcare, it would still take many more years to show how differing approaches have impacted upon health outcomes.

The discussion went on to examine how the Welsh Assembly has approached tackling health determinants. It was noted that this was a mixed picture, but that overall, Wales did not come out strongly. It was, however, shown that the approach of the Welsh Assembly to health determinants had improved markedly and that a strong evidence based approach had wielded rapid improvements across Wales. This, coupled with the regeneration of many deprived communities in Wales had led to a discernible improvement in health determinants.

The panel debate then opened to discussion with assembled delegates. Attendees were keen to discuss further what lessons Wales could learn from the English approach to the NHS since 1997. It was suggested that although lessons should be shared across devolved nations, Wales was now on the ‘front foot’ regarding healthcare provision – a fact shown by falling waiting times. It was argued that Wales may lack some of the market inspired efficiencies of the English system, but that provisions such as free prescriptions and free hospital car parking were preferable to patients and the Welsh public and seen as a desirable trade off for longer waiting times.

In a short summary of the discussion, one speaker noted that one of the key lessons was that in the early years of devolution, the Welsh Assembly had spent considerable time and money on things they felt should work, rather than using an evidence based approach and implementing things that were proved to work in practice.

In looking to how the Welsh system could continue to evolve, one participant suggested that more democratic involvement in the NHS could be a unique Welsh solution to problems arising. It was argued that engagement would build a community sense of protection of services. Looking to the future, concerns were raised that Wales would be particularly badly hit by public spending cuts being proposed right across the United Kingdom. It was noted that drastic improvements brought about by ‘Designed for Life’ depended on significant capital investment and that any public service spending cuts might particularly affect the capacity to fully roll out the scheme as was intended.

The Fabian Society will be continuing these debates at a similar discussion in Edinburgh in September, to look at what issues can be learnt from Scottish healthcare provision and devolution. If you would like further details on this event, please contact Genna Stawski on This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 02072274914.

                     This meeting was kindly supported by sanofi-aventis