1.  INTRODUCTION

  1.1.  Since the Black Report[1], whose conclusions have recently been reinforced by the Acheson Report[2], the factors adversely affecting the health of populations have been well documented. It is government policy to redress the inequalities of health which result. Whilst many of these require action over social factors such as education, housing and employment, those trying to deliver health care currently have to deal with the adverse consequences of decades of neglect. This logically involves spending more per capita on the health of deprived populations. It is the contention of this Memorandum that this is not happening and that current practices are generating just the opposite effect.

  1.2.  We believe that North Glamorgan NHS Trust is uniquely placed to document this assertion. It serves the most disadvantaged community overall in Wales for acute, community and mental health services. It is the only "pure" Valleys Trust, undiluted with pockets of more affluent catchment areas. Yet its resources are insufficient to provide services comparable even to those elsewhere in its own Health Authority Area (Bro Taf) let alone elsewhere in the Principality. All the assertions made in the following paragraphs are derived from official statistics.

2.  MEASURES OF NEED

  2.1.  The accepted indicator of deprivation is the Townsend Score which reflects many factors including unemployment, lack of car ownership, non-owner occupied households and overcrowding. The all-Wales score is 1.6, the score for Merthyr and Cynon is 3.4 (itself the highest score in Wales) and the Gurnos ward, in which Prince Charles Hospital is situated, is a staggering 9.0[3].

  2.2.  Other more specific indicators support this rather generalized measure, viz:—

—  Unemployment is in excess of 11 per cent (All Wales 6.7 per cent) [3,4].[4]

—  Physical health status is the lowest in Wales [4,5].[5]

—  Mental health status is the lowest in Wales [4,5].

3.  EFFECT ON HEALTH STATUS

  3.1.  The Merthyr and Cynon Valleys, by comparison with other catchment populations in Wales have:—

—  The highest overall mortality rate [4,6].[6]

—  The highest number of years of life lost for those aged less than 75 years [6].

—  The highest death rate from strokes [6].

—  The highest death rate from respiratory disease [6].

—  The second highest death rate from cancers [6].

—  The third highest death rate from heart attacks [6] (highest within Bro Taf [3]).

—  The second highest level of Limiting Long-term illness in Wales[3,4].

  3.2  This pattern of illness places greater than average demands on the health services. For example, after correcting for catchment population size, by comparison again with all-Wales:

—  We have more new accident and emergency attendances than any other trust [4]

—  We are third in Wales in the number of new out-patient attendances [4]

—  We have the highest rate of in-patient hospitalisation [3,4]

—  We are fifth highest in the number of day cases treated [4]

4.  DEFICIENCIES IN PROVISION

  4.1  One might suppose that the combined evidence of a severely deprived population and the evidence of the consequential low health status would result in the successive Health Authorities responsible for this area's funding trying to remedy the situation. Just the opposite seems to have occurred.

—  Despite having the lowest mental health status in Wales, there is no local High Dependency provision for dangerous patients, no adult day hospital (the only Trust in Wales so deprived) no EMI day hospital in the Cynon Valley and no separate hospital-managed rehabilitation service

—  Despite having the highest proportion of its children on the "at risk" register, the Trust has the lowest number of Health Visitors per unit of population[7]

—  Despite having the highest incidence of death from heart attack in Bro Taf, there is only one cardiologist. Every other trust in this Health Authority Area has two or more

—  Despite having the highest number of deaths from stroke per unit of population, there is no stroke unit

—  Despite having the highest number of deaths from respiratory disease per unit of population, there is only one physician responsible for adult respiratory medicine

—  Despite having twice the number of diabetics than the Health Authority average and a Royal College of Physicians recommendation, there is only one diabetologist where two are needed.

5.  IS IT THE FAULT OF POOR MANAGEMENT?

  5.1  Although we would naturally deny such an assertion, official figures also refute it. Despite being a "last chance" 4th wave Trust (because of its manifest unpreparedness under Mid Glamorgan Health Authority's stewardship) the Trust:

—  has met its financial targets

—  has earned high commendation from its auditors for its systems improvements

—  has never closed its doors to emergencies

—  has over performed on all its major contracts every year

—  has managed the highest per capita number of accidents and emergencies

—  has the lowest in-patient and day case waiting lists in Bro Taf and one of the lowest for an integrated trust in Wales

—  will meet its waiting list reduction targets.

  5.2  This has been achieved despite being burdened with mostly old buildings, and estimated £25,000,000 backlog of maintenance when the Trust was set up and an independently assessed recurrent deficit of £2-3 million in annual funding. What has NOT happened, is the introduction of so-called "developments" which would in fact amount to no more than remedying the glaring deficiencies listed above.

  5.3  This demonstrates that the problems lie outside the control of the Trust's managers.

6.  WHAT ARE THE ROOT CAUSES?

  6.1  We discount any deliberate malignancy on the part of Purchasers and recognize that our funding difficulties are not unique. The historic underfunding of the NHS is a big factor, but one which impacts particularly hard when there is no "fat" to trim. The recent injection of additional funds is obviously welcome, but the impact has been diluted by being used to reduce the overall deficits rather than being targeted to where the need is greatest.

  6.2  This is not to say, however, that there are not attitudes to the problem and its resolution, which may be partly subconscious. Furthermore, they may flow from a deliberate well-meaning but misguided attempt to make longer-term strategic health delivery improvements at the expense of the immediate problems. It would take a long essay to discuss these attitudes and their basis in detail and this section will focus on just two: the alleged minimum effective size for a comprehensive District General Hospital (DGH) and the influence of socio-economic mix.

  6.3  The idea that it is not possible to provide a quality DGH emergency service for population units smaller than 400,000-500,000 was promulgated by the Royal College of Surgeons of England, and was in conflict with recommendations from the Royal College of Physicians concerning the continuing need for generalist physicians to staff smaller DGHs. Under pressure, these bodies with the British Medical Association then produced and published an agreed view[8]. At the moment the Academy of Medical Royal Colleges has asked them to redraft it because of a failure to consider adequately the problems posed for other specialties such as pathology and anaesthetics (personal communication, Professor L Strunin, Vice President of the Academy of Medical Royal Colleges). Yet its reliance on opinion rather than evidence has not prevented its authoritative tone from influencing thinking at Health Authority level where the wisdom, truth and inevitability of their thesis seems to have taken root and be influencing decisions.

  6.4  This model may well be appropriate for urban areas of England but that is far from saying that it is universally applicable. If it were applied to Wales there would be only seven DGHs instead of the current 16. The result of the recently concluded reconfiguration exercise has demonstrated that Ministers have implicitly not accepted this model as universally appropriate in Wales.

  6.5  Even if it is an appropriate model for the major conurbations such as Swansea and Cardiff (where most of Bro Taf's population reside) its extension to the surrounding Valleys is not only unjustified but unacceptable. Geographical imperatives decree that the patients in the Merthyr, Rhymney and Cynon Valleys would find it next to impossible to travel to the Royal Glamorgan Hospital at Llantrisant and would gravitate instead to the University Hospital of Wales.

  6.6.  This would result in the provision of a locally accessible DGH for well-off residents of Cardiff with cars and good transport connections but for the impoverished residents of the Valleys, without cars and inadequate transport links, a need to travel 25-30 miles for quite routine investigations such as an MRI scan or many operations such as those for middle ear disease, vascular disease and head and neck cancer, not to mention all casualties other than minor ones.

  6.7.  Such a strategic vision is morally and socially indefensible and unacceptable to any political Party. And yet, there is undoubtedly a (possibly unconconscious) attitude that any successful attempt to bring the services provided for the residents of the Merthyr, Cynon and Rhymney Valleys up to the standards acceptable elsewhere, will make it more difficult to achieve the ultimate aim of "hub and spoke" arrangements which will downgrade the local provision in the interest of economy and "better" care. The result is to exacerbate the current unsatisfactory situation and make it "inevitable" that a centralist solution can eventually be sold as better. On geographical grounds alone the Colleges' option is unacceptable for the Valleys. These communities need appropriate numbers of medical and other staff to provide locally accessible comprehensive secondary care: rationing by location is unacceptable.

  6.8.  If the continued existence of DGHs which serve smaller populations is to go hand in hand with the provision of a high quality service, the inevitable corollary needs to be clearly understood. Small DGHs cost more per head of population than large DGHs to achieve the same level and quality of provision.

  6.9.  To take a simple example, if the UHW NHS Trust is persuaded that there is a need for half an additional haematologist, the only practicable solution of employing an extra whole one will result in employing seven instead of six and a half—a temporary over-provision of 8 per cent. If North Glamorgan NHS Trust find themselves in a similar position, they will have to employ two instead of one and a half—an over-provision of 25 per cent—and so on.

  6.10.  The second factor is more subtle. Almost all DGHs serve an economically mixed population. The better off within it tend to under-use the services, so that the less well-off can get a bigger proportionate share without disturbing the notion of the equity of overall per capita funding. The higher the proportion of the less well-off, however, the less effective such a trade-off becomes until, in the limit, as we have argued, when all the catchment population is "less well-off" no such internal trade-off is possible.

  6.11.  The development of Health Improvement Programmes is a positive step in attempting to redress health inequalities but fails to deal adequately with the problem because it is Health Authority Area based. Where there is a large segment of the relatively affluent amalgamated with the deprived, resources are again diffused instead of being focused. It is imperative, therefore, that the use of per capita funding, adjusted by a suitable weighting factor for need, which is currently used to distribute from the centre to Health Authorities MUST be applied with some rigour to the distribution from Health Authorities to Trusts and other Providers. There is insufficient transparency at present to assess whether this is even attempted in any way. In parenthesis, we suggest that the existing formula is far from representing reality anyway.

7.  WHAT NEEDS DOING

  7.1  One solution to the health problems faced by Merthyr, Cynon and Rhymney Valleys would be the adoption in Wales of Health Action Zones, as introduced into England. There can be no doubt that if such zones were introduced, North Glamorgan would be first off the starting blocks as an area of greatest need.

  7.2  However, we believe the problems and its solutions are not just parochial and deserve wider attention. We would suggest that:

(i)  Welsh Office Ministers should say explicitly what they have already indicated implicitly, namely that planning and funding should not be based on any English notion of ideal DGH size.

(ii)   Welsh Office should make it clear to Health Authorities that it wishes to see evidence that their financial allocations to Local Health Groups and to Trusts (whether by contracts or not) have taken realistic cognisance of health inequalities and that they have a reasonable plan to measure their effect in reducing them.

(iii)  Welsh Office should develop guidance for Health Authorities on the extent to which funding needs to compensate for the diseconomies of small size. We do not believe that Health Authorities have the expertise to do this and some degree of uniformity throughout the Principality is essential. They should also encourage greater transparency, so that the basis for Health Authority financial allocations is clear to all parties.

8.  CONCLUSIONS

  8.1  More money, though welcome, is not the only answer to the problem of the health inequalities in Wales. Better focused targeting is needed and can be achieved by relatively minor changes in the way central government's policies are translated into local action.

  8.2  The transfer of responsibility to the Welsh Assembly is a good opportunity to refine these and make a new beginning.

  8.3  The circumstances of these Valley's Health Services provided a unique insight into the failures of past policies and we would welcome a Parliamentary delegation to see the situation at first hand.

Professor MDA Vickers
Chairman

15 March 1999

2   Acheson D Independent inquiry into inequalities in health. London: Stationery Office, 1998. (Acheson Report.) Back

3   Bro Taf Health Authority Profile, 1997. Back

4   * Digest of Welsh Local Area Statistics 1999. Back

5   Welsh Health Survey, 1995. Back

6   * An Atlas of Health Inequalities between Welsh Local Authorities, 1998.

*(These report figures by Local Authority Area. Merthyr is a Local Authority in its own right but Cynon, although served by North Glamorgan Trust, is part of Rhondda Cynon Taff (RCT) in which the more affluent Taff improves RCT ratings overall. As in all the aspects in which Cynon can be separately identified, its situation is either equal to that in Merthyr OR WORSE, we have taken the view that the figures for Merthyr can be taken to represent Cynon as well.) Back

7   District Audit Report on Health Visiting, July 1998. Back

8   Provision of Acute General Hospital Services: report of a joint working party of the Royal College of Surgeons and the Royal College of Physicians British Medical Journal 1998; 318: 151. Back