Fear in West Wales

Yesterday’s news that Hywel Dda Health Board plan to close three community hospitals, cut services at three others and close A&E at Prince Phillip Hospital, Llanelli is generating inevitable outrage. Changes and closures in south west Wales have long been on the agenda, so Hywel Dda’s proposals are not unexpected.  Similarly, protests about “service reconfiguration” are long standing with the hostile reaction to the latest news being entirely predictable.  Hywel Dda is just the tip of the iceberg, however, with similar cuts / reconfigurations expected for most of Wales’s health boards soon.  There will be yet more cuts headlines and no doubt many more petitions, marches and angry debate in local newspapers.  It promises to be an autumn of discontent for Health Minister Lesley Griffiths.

In some ways the reaction to changes in hospital services are irrational and bizarre.  In any one year, a relatively small proportion of the population uses hospital services – 10% of people 16+ were inpatients in 2010 and 9% were day patients. Presumably many of these attendances (though almost certainly not all) were for care that it would be difficult to provide outside of a hospital setting, so this 10% might be expected to be those who would get most concerned.  Even so, 10% is a small proportion of the population.  A much higher proportion – 32% – attended an outpatients department, but at least some of that outpatient care could be provided from non-hospital settings, so again, it’s hard to imagine that it is concern about having to change where a patient attends outpatients is motivating people to pick up their placards.  It’s attendance at casualty departments, at 17% of the population, that gives us a clue.

What is driving otherwise-placid people to protest on the streets is fear.  Fear that, if they or someone in their family has a suspected heart attack the ambulance – when it comes – will transport them 100 miles away. Fear that, if they undergo chemo-therapy they will do so a gruelling journey away, far from friends and family.  Fear that they will be unable to visit a dying relative because he or she is too far from home to visit after work when there is no bus.  Fear of giving birth alone in the house because the maternity ward is out of reach.  The fear of not having access to health care is very deep-rooted – many people can themselves remember or have family members who remember life before the NHS, when a visit by the doctor could leave a family in severe hardship for weeks.

That nearly one in five the population has felt concerned enough about their health to pitch up at A&E in the last 12 months tells us something. Presumably most of them are not attending for the pleasure of an 8 hour wait surrounded by other ill people.  NHS experts will tell us that many A&E attendances are ‘inappropriate’, meaning that people could have got treatment (or sometimes just reassurance) elsewhere in the healthcare system such as from their GP. But still they turn up with their ear infections, wonky bandages and fevers. Why? Because they are afraid their child’s ear infection could be meningitis, because they are too worried to wait for a 48 hours for a GP’s appointment, because they want to be seen and treated straightaway.

Aneurin Bevan famously argued for a national health service that was ‘in place of fear’ (and you can buy the book here).  Whilst the fear of not being able to afford health-care may have gone, the fear of not having access to health-care remains. People hold the NHS very dear indeed, and it is a brave Minister and health board member who tampers with it, no matter how much change may be needed.  That said, if there are to be changes in the NHS (and I am NOT arguing here either for or against change), those advocating the changes need to recognise that they are not only dealing with the rational case for reconfiguration, whether cost, safety or anything else, but very deep emotions about health and care, in which fear is key.  Unless they understand and address that fear, there will never be change, whether for good or ill.

Statistics on use of hospital services from Welsh Health Survey 2010.  

Victoria Winckler is Director of the Bevan Foundation.