Tuesday, 4 September 2007

Neurosurgical Boundaries

For some months before the Assembly elections, Plaid AM's in particular, and most especially Dr Dai Lloyd, were running hard on the campaign to retain the neurosurgery unit in Swansea, rather than agree to the then Labour government's proposal to centralise and merge it with the unit in Cardiff.

Superficially, that campaign was successful, and the Health Minister has announced that both units will remain open. Cause for great rejoicing – in South Wales. For the Law of Unintended Consequences then came into play, and it turns out that this looks like rather less of a success from the point of view of patients in North Wales.

To date, most North Wales neurosurgery patients have been treated at Liverpool’s Walton hospital, but the Health Minister announced that, in order to justify keeping two units in Wales, patients from the North would in future have to travel to one of the two units in the South for their treatment – adding a significant amount of time and inconvenience to their journeys.

There are, as I understand it, two arguments which have been deployed in support of the proposal. The first of those is that, to maintain the skills of people in a highly specialist area, and to justify the numbers being employed, they need a number and range of cases which can only come from a larger population than is to be found in the immediate catchment area of the two South Wales units. The second is to do with providing services for Wales within Wales.

It seems to me that the first part of the first argument – number of cases – is (at least in part) a financial rather than a medical argument. (It sounds very much like the argument which was at the heart of the proposals for centralising some services which proved so unpopular for Labour during the election campaign.) There will always be a pull between providing specialist services locally and providing them at the lowest possible cost per head. Taking the decision as to where this balance lies is surely one of the proper roles of political debate, since it boils down to deciding how much to spend and on what priorities.

The second part, though (the range of cases), is much harder to deal with. The smaller the unit, the more rarely certain types of problem will be seen. It can be overcome to some extent, of course, by sharing staff, and by staff sharing their time between different units, but there are costs (time as much as money) associated with that. This is less of a political question, and more of a medical one; politicans need to be willing to listen to expert views before reaching decisions on this.

The second argument deployed, however, is wholly political in nature, and is the one which interests me most. It is effectively that such services should be supplied wholly within Wales for Welsh patients. Even as a committed devolutionist, I find myself asking ‘why?’.

I understand an argument about local provision of services – it is natural that people want all services provided as close to where they live as is possible within the resources available, and within the standards set for those services. I can certainly understand an argument for setting up a third unit within Wales (subject to the issues around numbers and types of cases mentioned above), and Llandudno would seem to be well-placed for that.

But I don't understand the argument that says that such services should always be provided within Wales, regardless of cost implications or the inconvenience to patients. What exactly is wrong with a situation where the Assembly Government effectively ‘buys’ certain services from hospitals across the border where that provides a better service for the people of Wales? (There’s nothing, incidentally, which prevents this working the other way as well – why should some people on the English side of the order, by the same token, not be able to access services from Welsh hospitals, if that provides a better service?)

Transfer of comparatively small sums of money in both directions across the border to pay for services accessed by citizens in no way undermines devolution, or the move for greater powers for Wales. On the contrary – I can see it relieving potential concerns about the impact of greater devolution on services. There are real dangers for public confidence if people believe that greater devolution = more centralisation in Cardiff.

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