The Socialist Health Association (SHA) is a very useful source of information, analysis and comment. It is an affiliate of the Labour Party, but recently came close to losing that relationship, which is not surprising seeing that their aims are well to the left of Starmer and indeed any Labour government: https://sochealth.co.uk/the-socialist-health-association/ . They have a clear commitment that health is not just a question of care and treatment when needed, but ensuring that people’s environment provides ongoing support for a healthy life as stated in one of their aims ‘To demonstrate the relationship between environmental conditions, poverty, inequality, access to transport, and ill health, and to work for improvements in economic, housing, transport, nutritional, industrial, and environmental conditions’. The Association changed their name from ‘Medical’ to ‘Health’ to emphasise this point. SHA Cymru has been active for decades and produces information, analysis and comment that is relevant to our discussions: https://sochealth.co.uk/the-socialist-health-association/sha-country-and-branch-organisation/sha-wales/socialist-health-association-wales/ 

The point of starting this discussion with SHA is to emphasise that considering health and the NHS in Cymru is not just about waiting lists and hospital treatment, but considering the health and support needs of people throughout their lives, and it is useful to have at least one socialist body make this case, even though its reports are aimed at influencing Labour Party election policy. Having said that, it is clear then that as ecosocialists we follow through on this link with health and all aspects of our lived environment when considering the importance of all demand and policy areas. It is hoped this has come through in our two other workshops so far. In this discussion paper the focus will be on defending the NHS as a public owned and controlled service, free at the point of all medical need including mental and chronic as well as acute, how that is supported by public health services and how social support and care should enable people.

Austerity has deeply damaged the health and support services in Cymru. Public Health Wales produced a report in 2020 that showed that whilst Cymru life expectancy increased in the ten years to 2010 by 2.6 years for men and 2.0 years for women, it only increased 0.2 and 0.1 respectively for the following ten years. Moreover, the class way of death worsened with mortality worsening in areas of greatest deprivation from 2011. Throughout this period the People’s Assembly Wales was  probably the only organisation that produced regular analysis of just how deep these austerity cuts were and in their last and the most recent report in 2022 ‘…shows that between 2009 – 2020 the cumulative effect of cuts to the Welsh budget and directly to welfare spending in Wales amounted to a loss of around £3.5bn a year or a real terms cut of 22% over 2009.’ The NHS in Cymru is still struggling to overcome the consequences of these cuts coupled with the huge impact of the Covid pandemic. A recent analysis by the BMA reveals in stark graphic form just how NHS target after target are not being met. Local Councils are key providers of social care and support and public health and other public protections that affect the health of their populations. However, the regulation they provide has been one of the main areas of austerity cuts with regulation and planning being cut across Cymru by 60%. Social Care, whilst protected by statute, has been under pressure to make ‘efficiency savings’ the catch all euphemism for cuts. 

In terms of staff GPs have since 2012 a 127,000 increase (4%) in registered patients but a nearly 30% decrease in the number of GPs and a 100 less practices. Spending on this key level of primary care, which provides 90% of NHS patient support, has fallen from 11% to below 8% as a proportion of the Cymru NHS budget. Leading to attempts to push patients toward chemists and charging providers. In nursing 78% of respondents in an RCN survey reported that ‘the number of nursing staff was not sufficient to meet the needs of patients safely’. In terms of social care a recent survey revealed that 33% are finding it difficult to manage financially and 26% thought it likely they would leave the sector. Filling vacancies remains a problem across the sector. The RCN estimates there are 2000 vacancies for registered nurses in Cymru in 2024. One consequence is expensive agency nurses are used amounting to over 6% of staffing and the role of nursing assistance is stretched.  

Overall the picture is of an NHS, care and support service that is permanently on the edge of a crisis and in many cases is being sustained by the commitment and indeed unpaid work of staff. The picture yet again, is a range of many supportable targets and legal intention, but acute inability to deliver, largely due to 15 years of austerity. The recent crisis with the Princess of Wales Hospital in Bridgend and the first period of the Covid pandemic, revealed just how close to breakdown the service can come. In this situation acute medicine has to take priority, and it is the long term health needs and prevention which take the hit. In the case of elective surgery an increasing number of people are using what savings they have to ‘go private’ even maxing out on their credit card with unimaginable interest rate payments. For people in this situation, it starts to become very difficult to defend the NHS and argue against privatisation. 

The Cymru NHS budget for the current 2024/25 financial year is just over £11bn. The additional £600.00 penciled in the draft 2025/26 budget amounts to an increase of just over 5% but taking account of NHS inflation which is significantly affected by an aging population and the level of deprivation in the country, is about 1.5% in real terms. This hardly starts to address the level of crisis identified in this paper, let alone start to overcome the effects of austerity and the Covid pandemic.  

What needs to be done – demands and policies. 

Devolved powers have enabled some beneficial policies in Wales such as provision of free prescription services, an early banning of smoking in public places, free car parking at hospitals, an end to PFI and less marketisation. Other benefits such as free transport for older people, thus reducing social isolation, also impact on people’s health and well-being.

However, these policies mean little if adequate and needs based funding is not available in Wales for the NHS, together with social care and support. Welsh led Labour Governments and members of the Senedd failed each year to resist round after round of austerity cuts. NHS spending in Wales is beginning to recover but councils and primary care are still struggling. 

Evidence above indicates that Covid costs and consequent ‘catch up’ costs are not being fully covered.

These following demands and policies would start to both defend and address the health and support needs facing people and the NHS in Cymru. 

1. Faced with future cuts in budgets MS/AS should refuse to implement them and prepare for collective support and resistance across Cymru with this type of programme of demands and policies. 
2. A comprehensive needs-based review of all public sector funding to be instituted immediately.

3. Privatisation, competitive tendering and PFI to be totally abolished and all NHS, care and support provision, including social care, to be returned and retained in public ownership. 

4. Health and Social care services to be fully funded to the highest possible international standards and free at the point of need and publicly provided.

5. Legal limits for professional staff – patient ratios to be set

6. All employees to be trained to the highest level and employed on trade union negotiated salaried contracts – the longer term including all doctors and consultants.

7. More investment in training of doctors, and greater investment in primary care provision through GP led community health centres to avoid hospital admissions wherever possible. Multi disciplinary primary health care teams on local/community level to be integral part of this provision. 

8. Prevention and support need to be recognised as a key part of the public service in Cymru.

9. Seamless delivery of health and social support ensuring the maximum possible personal independence of the person being supported based upon the principles of independent living for the future: https://www.rofa.org.uk/independent-living-future/

10. Care and support to be provided in or as near to a person’s home as possible, appreciating that there will be circumstances where specialist services are only available at a distance.

11. Welsh Government to oppose and refuse to support or recognise any trade agreements that cover services including the NHS and social care

12. Increase democracy in health and social care services – strengthen bodies like CHCs – not abolishing them as has happened in Wales – , establish local patients groups, and social care forums, and increase democratic control by local and community councils. Clearer role and core funding where needed, for the third sector.
13. Health boards and their relevant professional leads should have a statutory duty to report to local authorities in their areas about local health issues – so Cwm Taff would report to BCBC regularly and provide an annual report on the state of health and care in BCBC which would be subject scrutiny.  CHCs are a good idea but, for whatever reason, never really caught the public imagination.  
14. Health and social care users need advocacy support when they need to raise concerns about the service. Wherever possible these concerns should be raised as part of a dialogue rather than being escalated to formal complaints which often leads to an adversarial (unfortunately) response.]