Welsh Institute for Health and Social Care Blog

Pro Chancellor, I present to Congregation Dr Tony Jewell.

Tony has been the Chief Medical Officer for Wales since 2006.  In this role, he leads the medical profession here, is the medical advisor to the whole of the Welsh Government, and champions public health and the clinical contribution to improving the NHS.  He is, in short, the physician for three million people.

But Tony is far more than just a consummate doctor and civil servant.  He is a man who passionately believes in social justice, and in the capacity of all people and communities to defeat the scourge of ill health. 

His whole career shows this.  He was one of the first medical students to choose to include Sociology and Political Science as part of his medical undergraduate studies in Cambridge. After graduating he took time out to work as a sheet-metal worker in a car factory in Coventry, before proceeding to the London Hospital for his clinical training.

 After qualifying as a Doctor, he joined the newly-established GP vocational training course in East London.  This was at a time when general practice in the East End was in crisis – poor quality GPs, predominantly single-handed, with shop-front, lock-up surgeries.  Far from the easy option which he might have chosen.  He subsequently went into partnership and established a Health Centre in one of the poorest parts of the East End.  Later, as the Trades Union Representative on the Tower Hamlets District Health Authority, he was one of the principal supporters of the Health Inquiry that looked at the reasons for the poor health of that community.

But Tony’s desire to improve health and tackle the obscenity of gross inequality took him after, ten years in general practice, into public health.  Again, far from an easy choice, because it meant going back into training for his new speciality.  He trained in the East Anglian region, acquiring a powerful reputation as a highly-effective, passionate and action-orientated crusader for public health.  This was recognised in successive appointments as Director of Public Health for increasingly larger areas, and ultimately as Clinical Director and Director of Public Health for Norfolk, Suffolk and Cambridgeshire. He also served as a highly-respected Chair of the Association of Directors of Public Health.  He was appointed Chief Medical Officer for Wales in 2006.

Chief Medical Officers are senior civil servants, and therefore have no public political views.  But before taking this vow of silence, Tony was a prominent member of the Central Council of the Socialist Medical Association.  As its Chair at the time noted, ‘If ever the discussion got bogged down and did not appear to be leading anywhere I learned to ask Tony to summarise the position and give a steer for action. He never failed to deliver’

During the last five years, Tony has certainly left his mark on Wales.  He has worked tirelessly behind the scenes to shape policy to reduce inequalities, such as through work on child poverty. He has been the principal architect for the development of the Public Health System in Wales with his vision of a Public Health Service, Observatory and Institute.  He has also led calls within the UK to protect children from passive smoking.  Within the Welsh Government he has been a tireless advocate for Wales to act as a global citizen and work with others in sub-Saharan Africa and elsewhere to improve health. 

The sort of personal commitment to health which took him to the East End and into public health in the first place, lives on. He has recently completed the Cardiff Half Marathon, and is known by his staff at Christmas Parties to promote the benefits of Fruit Salad rather than Plum Pudding with Cream and Brandy.

Above his desk, overlooking Cathays Park are pictures of the four people he regards as the architects of the NHS in Wales: Lloyd George, Aneurin Bevan, Julian Tudor-Hart and Archie Cochrane.   But despite the best efforts of Tony and these distinguished predecessors, health inequalities continue to blight many of the communities in Wales, including plenty around this University.  Despite rising life expectancy, you can still expect to die five years earlier in some parts of Wales than in others, and to have even more years of poor health before you die.  In his open letter to the First Minister, at the start of his most recent annual report, he wrote:  ‘I must again draw attention to the pernicious inequalities in health outcomes across the country… We need to ensure that the gains are distributed across the socio-economic gradient… Health gain in Wales needs to be fair’

Tony Jewell’s life-long contribution to improving primary care, to the health of the people of this country, and to tackling health inequality, are outstanding.  For all these reasons, Pro Chancellor, I present to Congregation for the award of Doctor of Science, Dr Tony Jewell.

Text of oration given by Professor Marcus Longley at the awards ceremony this morning.

It’s very hard for any large organisation to change something which it doesn’t routinely monitor.  And that usually means reliable, valid data, taken seriously. 

Can we therefore answer the following questions about NHS Wales: 

• How good is the ‘average’ patient experience?
• How common are neglect and disrespect?
• Which are the best and worst services, in terms of what patients’ experience?
• Is the patient’s experience getting better?

 I don’t think we can.  Parts of the service can, because they do routinely ask a representative sample of their patients some intelligent questions about what they’ve just experienced.  But most don’t.  And we certainly have no overall picture. 

Why is this?  Is it too hard?  It certainly does take some staff time and expert resource, and there have been many poor examples of patient surveys… but the good practice shows it can be done. 

So is it because it doesn’t matter? Or it matters less than the other things we do measure?  Those are rhetorical questions. 

The Welsh Government’s commitment to ‘absolute transparency on performance’ is an excellent token of intent.  What will the NHS need to do to be absolutely transparent on its performance in this crucial area – the care patients’ experience? 

It will need to avoid the obvious pitfalls.  For example, it can be difficult to get full answers from patients on some of these issues because of their gratitude for having been treated at all, low expectations, a wish to ‘move on’, poor questioning, or even a concern that if you’re critical you’ll be made to suffer. 

Let me offer four simple steps for 2012 to make performance on the patient experience absolutely transparent: 

1. Gather common data routinely right across Wales, from a representative sample of patients, using intelligent questions, immediately after their episode of care is over.  Properly validated telephone or postal surveys are two obvious ways to do this
2. Include measures of both process and outcome in the questions
3. Agree some smart performance indicators, so we know what ‘good enough’ is, and where we’re going
4. Publish the results each year.

 That would make the year 2012 something of a watershed for NHS Wales.

 Written by Professor Marcus Longley, Director and Professor of Applied Health Policy

A PowerPoint presentation, which includes material on the subject of this blog, is available in our Resources section.  The presentation was given to the Assembly’s Health and Social Care Committee on 24 November 2011.

Why do people get so angry when a small local hospital or residential home is ‘threatened’ with closure?  Is it because people particularly want to be looked after in an antiquated, poorly-maintained, under-used and possibly sub-standard facility? 

Probably not.  It might be because they don’t realise that it’s sub-standard – public services are often very reluctant to wash their dirty linen in public.  It might be because they don’t understand what the replacement service involves – services are often inept at explaining change effectively.  It might even be that the service has got it wrong – has failed to understand the difficulties people will face getting to the new service, for example.

But underneath all these obstacles to change lies the peculiar importance of such services to our communities and our collective psyche.  Health and social care are about much more than treating sick people and caring for the vulnerable.  They are intensely political phenomena, in the sense that they have been created and maintained by politicians, responding to their electors’ fears and hopes, and can only survive if they continue to do so. 

The NHS is perhaps the greatest tribute ever paid by this country to our shared sense of mutual responsibility, and our recognition that we are all potentially vulnerable.  We find it deeply offensive that sick people might be turned away from a hospital, or given second rate care, simply because their wallets are empty.  And we all recognise that there, but for the grace of God, go us: personal calamity can reduce us all to poverty and dependence.

So health and social care are the ultimate high-minded insurance policy: we protect ourselves, and we feel good at the same time.

But things need to change, and we need to change the face of health and social care.  The way we deliver services is still dominated by models and assumptions that date from the 1960s.  District General Hospitals and Residential Homes for the Elderly were once a wild aspiration; now they cant cope with technological advance and client choice.  Cottage hospitals need to be reinvented, and people increasingly want high quality, tailored and reliable care in their own homes. The trick is to preserve the original values, while changing almost everything else, if services are still to be available for an ageing population.

People oppose change for all sorts of reasons: because they don’t understand it, and because sometimes it’s simply wrong-headed.  But they also oppose change because they don’t trust those proposing it, and because the current infrastructure has become an integral part of our perception of ourselves.  For many people, grey-suited public sector managers, who understand the price of everything and the value of nothing, pull the strings of service modernisation.  Who would trust them?  Local hospitals and care homes are tangible expressions of the values which underpin the services – they actually exist.  Anonymous bureaucrats, proposing invisible, and often remote alternatives… not very reassuring, is it?

If you doubt the strength of this concern, just look at the ‘save our hospital’ signs outside almost every small town in mid Wales.  (In an excess of enthusiasm, one local resident has even painted ‘save our toilet’ on another well-loved public facility!)  And yet what these services really need is people marching to demand their closure and replacement by something fit for the new century.

So we have paradox: people want to preserve something second rate, because they care so much about it! 

Trust and understanding – the two go together – is the only real key to this problem.  Wales has a big advantage here.  Being small and relatively homogeneous, with strong communities and shared values, should foster trust and cooperation between citizens and their public servants.  The experience of recent attempts at service change often shows that such partnership can’t be assumed: it needs to be worked at.

Written by Professor Marcus Longley

A version of this article appeared in the Western Mail on Monday 7th November 2011