It’s four months since Plaid Cymru took power at Cardiff Bay, promising a 100-day blitz of initiatives to transform the NHS in Wales. “So far, they seem to be on top of getting things done,” says Helen Howson, director of the influential Bevan Commission think-tank based at Swansea University. “There was a lot of despondency before, the feeling that we were going round in circles. I’m not saying we won’t be going round in circles again, but there’s a new energy and a new enthusiasm.”

New health secretary Mabon ap Gwynfor has been busy enough, announcing plans for a string of surgical hubs, beefed up partnership working with councils, better workforce planning and a mandatory annual funding shift from hospitals to primary care. There will also be a “root and branch” review of NHS performance and a new deputy minister for public health.

In its supplementary budget, the new government also promised to restore the outgoing Labour administration’s targeted funding for cutting waiting lists, which expired in March, along with £25 million to jump-start surgical hubs and £20 million more in capital spending.

But as the 100 days expired in the dog days of August, Plaid’s uphill slog had, if anything, got steeper. After falling for a year, waiting lists have surged again, A&E performance is going in the wrong direction and the troubled Betsi Cadwaladr health board in North Wales remains, well, troubled. Then, in July, came a harsh lesson in the realities of minority government: amid a row over education funding, the Senedd blocked the supplementary budget, leaving the promised waiting list money on hold, at least until the autumn.

While none of this is Plaid’s fault, ap Gwynfor’s long list of promises—including a risky-looking pledge to “eliminate” two-year waits “within months”—have become even harder to deliver.

Wales had been making real progress in reducing waiting lists, explains Nesta Lloyd Jones, assistant director of the Welsh NHS Confederation. “Overall patient pathways have been reducing considerably and the number of people waiting longest for treatment has fallen dramatically from its peak,” she says.

The sharp reversal since the funding stopped—including a 60% surge in two-year waits—“is not a coincidence” says Professor Jon Barry, consultant surgeon at Swansea Bay and director in Wales for the Royal College of Surgeons (RCS). Hospitals got extra funding to run clinics out of hours or on weekends, he explains “and I got through a lot of patients”. But “chucking money in” is “not a durable solution… because if you keep working people harder and harder you get more burnout”—a problem already showing in RCS member surveys, he warns.

Barry, a member of the government’s elective hubs taskforce, argues that hubs are a more sustainable solution than piling up surgical overtime or using expensive private hospitals. “A surgical hub means a separation of our emergency and elective streams,” he explains. Hubs can be a department within an existing hospital, a separate facility on the same campus or a standalone unit—what’s important, Barry says, is that “those beds are only there for elective patients—you have dedicated beds and a dedicated workforce.”

Experience from England “shows that hubs work”, Barry says. But while England has 125 and Northern Ireland six, Wales’s only operational hub is an orthopaedic unit at Neath Port Talbot hospital; planned hubs at Llandudno and Llantrisant have been hit by delays. This “glacial pace… is a frustration for all of us”, he says, especially as Wales has “enough infrastructure and the right workforce” to “deliver the hub model with what we’ve got”.

Ministers want the hubs to become “centres of excellence” in areas like orthopaedics, ophthalmology, general surgery, ear, nose and throat, and gynaecology—“the biggest pinch points in terms of our waiting lists,” says Barry. Location will be politically sensitive: north-south travel in Wales is notoriously difficult and there’s unlikely to be enough money to replicate each hub in both halves of the country.

But hubs alone are not “a silver bullet”, Lloyd Jones warns. “They must be supported by sufficient multi-disciplinary workforce capacity, modern digital infrastructure and sufficient social care capacity to ensure strong patient flow across the wider health and care system.”

That sounds expensive. It’s the age-old public service dilemma: reforms which save money in the long run come at a short-term cost that ‘here today, gone tomorrow’ politicians are usually unwilling to pay.

“If there’s no more money coming in, the only way can do this is to work differently,” says Barry. That could mean concentrating emergency care on fewer sites, he suggests, giving the example of Royal Glamorgan Hospital and University Hospital Cardiff—just nine miles apart.“Hypothetically, you could take the emergency unit out of Royal Glamorgan and, overnight, you’d have a de facto surgical hub… Those beds would just serve the elective population. That doesn’t cost as much money as a shiny new building on a mountainside in Wales.”

Earlier this year, Howson had an NHS-funded knee operation carried out a private hospital. “I was in one day, had the op, and out the next,” she recalls. “I asked my consultant how they could do six operations in a day when the NHS can only do two. He said, ‘Some of it’s money but mostly it’s mindset. If two is the standard, why would you push yourself to do four or six?’”

As well as “getting the mindset right”, surgical hubs “mustn’t be isolated”, Howson says, but “work together as part of a national co-ordinated system… But you also have to look at how to reduce flow into the system.”

With that inflow increasing year on year, it’s like to trying to drain a bath with the taps still running on full, Barry explains. “But there are other things we can do. We could get people in Wales to stop smoking, lose weight, exercise more, and we can frontload primary care to stop people needing to come to hospital”.

And a lot of people on waiting lists may not actually need an operation, he says. For example, in his own area of surgery, there’s “good evidence” that patients with asymptomatic small inguinal hernias don’t need an op, he explains. “They need reassurance and if anything changes, [to] come back and see us.”

Wales’s older and sicker population means “we probably do need more resources”, Howson says, but with John Healey unlikely to sending bags of cash down the M4 anytime soon, “we ignore at our peril that 85% of health is created outside hospital – only 15% comes from fixing people once they’re ill.” She believes ministers are finally listening: ap Gwynfor “is really going in there on this,” she says. “But, inevitably, it will take time.”

Meanwhile, the Welsh NHS needs to get more efficient at what it does. Health boards have already made “substantial savings”, says Lloyd Jones, particularly by reducing agency staffing, but NHS leaders are hampered by “short-term funding arrangements which make it harder to plan services effectively and invest in the transformative changes needed.” Such changes will also need the kind of cross-party co-operation which was not much in evidence before the Senedd recess.

While no one has the stomach for an English-style re-organisation – “we would lose three years, wouldn’t we?” says Howson—there’s a clear need to bring the NHS in Wales together, “to share our learning, our skills, our resources, at national level as well as local.” For politicians, working through seven health boards, focused “on competition as much collaboration”, can be “so, so frustrating”, she explains.

“What we really need is clearer purpose, sharper accountability and stronger national coordination, as well as greater freedom for people and places to improve care,” she adds. There should be enough there to keep Wales’s new ministers busy for quite a while to come. //