This article first appeared on the Nuffield Trust website. It's the second in a new series called 'Fact or fiction?', where experts from the Nuffield Trust give their take on the data and evidence behind some of the current perceptions of what is happening with the NHS. The Nuffield Trust is an independent evidence-based research organisation.
Despite being a devolved issue whose political fate will not be next determined until Welsh Assembly elections in 2016, the NHS in Wales has become a key battleground in the UK general election.
Claims about the Welsh NHS fly back and forth between politicians in Westminster and Cardiff Bay: Labour politicians can barely appear on national media without being questioned about their record running the NHS in Wales; the Prime Minister has renamed Offa's Dyke 'the line between life and death'; and Welsh NHS staff and patients find themselves at the centre of a fierce debate almost every week at Prime Minister's Questions.
Critics say that the Welsh NHS is falling behind under Labour, with people waiting longer for both urgent and routine care, and the service affected by real-terms cuts to the NHS budget. Labour and others point to the difficulty in making comparisons between the two nations and the greater protection of social care spending in Wales.
Last week, the Nuffield Trust published analysis for BBC Wales as part of their health check week looking at how the Welsh NHS compares to England's. It's a complex subject and well worth reading the full analysis, as well as the report we published last year with the Health Foundation, which compared the performance of the four UK health systems.
So, is it fact or fiction that the Welsh NHS performs poorly compared to England's?
Making comparisons: A health warning
Firstly, a word of warning. Comparing health systems is notoriously tricky, as local factors can vary hugely from country to country. It took a group of six academics two years to compile our report comparing the four healthcare systems of the UK. Thinking about England and Wales, there is an inherent unfairness in comparing a country of 54 million people to one of 3 million people.
Context does matter, and it is irrefutable that the Welsh population is older, sicker and more deprived than the English population—so its NHS has to work harder. Comparing Wales with an English region is likely to be fairer, although still not straightforward, which is why we used the North East of England in our Four Countries report.
With this health warning in mind, we can draw some conclusions from looking at the comparable data on waiting times, hospital admissions, delayed discharges and funding in Wales and England.
What do we know?
1. Welsh patients have grounds for real concern over lengthening waiting times
Since 2010, Welsh performance on waiting times for planned hospital admissions, A&E, and ambulance response times has deteriorated significantly and Welsh targets have not been met for years.
In England A&E performance and ambulance response times have been deteriorating too, with English hospitals also struggling to meet targets. But performance is consistently higher than in Wales: in November just 51 per cent of Welsh ambulances responded to life threatening calls within eight minutes, compared to 70 per cent in England. A report published last week by the Welsh Audit Office on planned treatment found that Scotland and England are doing better against more stringent targets.
The picture on waiting times for people referred by their GPs for cancer treatment is a little better for Wales. While performance has dipped slightly in both countries, in absolute terms Wales remains marginally ahead of England, despite missing its (higher) target.
2. Wales hasn't experienced the recent growth in delayed discharges or emergency admissions seen in England
The data on delays in discharging people from hospital are hard to interpret. But they do suggest that Wales hasn't seen the recent spikes in people held up in hospital waiting for discharge that England has. Nor has Wales seen the growth in emergency admissions that seems to be putting such pressure on English hospitals.
This might be because spending on Welsh social services has been protected until now. But as our first Fact or Fiction blog suggests, cuts to social care in England aren't wholly responsible for problems in A&E. And in Wales, the average length of stay is much higher than in England, suggesting that patients are not being discharged into the community as effectively as we would expect given the relative investment in social care.
3. Different spending decisions have been taken
England has protected NHS spending since 2010, which has seen some small real terms growth over the last four years. In Wales, health spending was cut in real terms by 4.3 per cent between 2009/10 and 2012/13 , although there have now been further cash injections in 2014/15 and planned for 2015/16 partly to reverse this trend.
While Wales spends more per head on healthcare than England, when we adjust this for the age profile of the population, it spends significantly less per 'age-adjusted' person than comparable regions of the UK, such as the North East.
On the other hand, England has cut government grants to local authorities,resulting in a 16% reduction in funding for social care for the over 65s — a cause of some anxiety. In Wales, local authority spending has held up, although this is now planned to change. Wales has chosen to prioritise its spending differently within the health sector, adopting policies like free prescriptions and car parking.
Fact or Fiction?
Looking purely at performance against the totemic targets (A&E waits, ambulance response times, waits for planned treatment), it is a fact that the Welsh NHS performs more poorly than the English NHS.
But it is too simplistic to draw conclusions based on these narrow measures that the Welsh NHS is significantly worse than its English counterpart. These measures don't tell us much about the quality or safety of care received or the experiences of patients. And that is more important.
The Welsh Government has made different spending decisions and has placed greater emphasis on prevention, public health and social care. It has adopted a less ferocious approach to managing the system's performance against these totemic targets than in England. There is also unfinished business in looking at the shape and size of the hospitals in both countries, but there is an acknowledgement that there is a particular need for change in Wales.
Any attempt to understand the differences between the two countries must take all of this into account.
Arguing over past NHS performance in England and Wales can only take the debate so far. With public finances under strain across the UK, local authority spending on social care set to fall even further, and demand for health services on the rise, it is clear that services—whether in Wales or in England—will not cope if they do not at least keep pace with population change.
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