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Morgan: Cutting NHS bureaucracy

Speech to the National Assembly for Wales.

"I will begin by outlining why we have tabled the debate. The Minister for Health and Social Services was my inspiration. Having been so candid in her opinion as to the problem in Wales today around the commissioning of services within healthcare, I thought that the Minister needed an opportunity to outline what she plans to do for LHBs and commissioning generally within the health service in Wales over the next few years. We do not accept either of the amendments tabled this afternoon.

The Labour restructuring project that scrapped five health authorities only to replace them with 22 local health boards has been disastrous. It has demonstrated a level of incompetence in health service restructuring that has never been seen before.

It was ill-thought-out and it demonstrated all the worst traits of Labour in power—there is far too much bureaucracy, far too many committees and far too much confusion. It is only now, a few years following the introduction of LHBs, that we see how poor they have been in commissioning services, the trouble that they have run into in providing the services that people need, and the way in which they have lacked capacity, expertise and the resources to do the job that Jane Hutt thought that they would do when she was the health Minister.

I could have tremendous fun with this issue, but the consequences of Jane Hutt's decision at that time are very serious. We have 22 local health boards that lack capacity, at resource level and commissioning level.

Given their varying levels of success, it is clear that their size affects their performance, and it will get worse, especially as developments take place over the next few years—I can point to the introduction of pharmaceutical products that will be sanctioned by the National Institute for Health and Clinical Excellence and approved by the All Wales Medicines Strategy Group as an example.

In considering likely developments over the next few years, we know that local health boards will simply struggle to do the job that they are expected to do. We know that they are struggling to provide for certain aspects of the general practitioner contract; we know that they did not have sufficient resources to provide Herceptin for patients with breast cancer; and we know that they will struggle to manage the workload that they are expected to manage as new developments appear over the next few years.

We also know that the Minister for Health and Social Services is very keen to restructure NHS trusts. As the biggest providers, trusts are very much in the driving seat when it comes to secondary care. They currently outweigh local health boards.

Asking an LHB to stand up to a big NHS trust is a bit like asking a primary school pupil to take on a sixth-former. There are five local health boards in the former Gwent area that are all trying to negotiate with the Gwent Healthcare NHS Trust. It is impossible to accept that LHBs have any weight in negotiating effectively with NHS trusts.

I am not saying that NHS trusts do a bad job; overall, I think that we have some very capable and experienced people working in our hospital and secondary care sector. However, it is unreasonable to expect LHBs to be able to stand up to them. The situation will become more difficult for them and it will become more pronounced as soon as we see the merger between those NHS trusts in Wales. Those super trusts will have considerable weight in terms of the delivery of services and LHBs will simply lack the clout to commission the services that they need.

There has been no overall benefit to coterminousity with local government. I challenge the Government to publish any evidence that it has that suggests that coterminousity between the 22 local authorities and the 22 local health boards has produced a single tangible benefit to patients.

In terms of bedblocking, it has done nothing to alleviate the pressures on the acute sector, and it has done nothing to convince local government that it needs to set priorities to ensure that people are moved out of the acute sector and into the community. Where the unified assessment process is being rolled out in Wales, it has done nothing to alleviate the anguish and concern regarding the current long-winded process, and joint-working in terms of this process has not brought a single benefit to patients. Joint-working between local health boards and local government is a luxury; it is certainly not normal practice in Wales.

Those are my views, but the evidence is clear when you ask people around Wales about their views on the current commissioning structure in Wales. The 'NHS Wales Barometer 2006' survey stated very clearly that, while there was some support for the argument that local health boards are well-positioned to improve the health of their local population—although I would argue that, after a couple of years, there is no evidence that the health of local populations has improved—the view that the LHBs could improve health services was less widely held.

That really is a problem, because local health boards were established to commission services and to improve service delivery. That simply has not happened.

The evidence goes on to say that there was relatively little opposition to the notion of restructuring both types of organisation—trusts and LHBs—over the next few years. The Minister has been very candid in the way that she has talked about the problems. In an interview with Hafal, the mental health charity, the Minister said:

'There is a plethora of commissioning bodies and it's very difficult for people to understand what it all means in terms of the services they receive. I don't think this plethora allows us to have effective commissioning.'

The Minister goes on to state that,

'People are getting lost in the gaps between providers of services but, worse than that, some people are getting batted back and forth between various places and that's not acceptable'.

I welcome the Minister's opinion, and I just hope that her frontbench colleagues support her opinion. However, there is clearly confusion in the Government. In May 2002, Jane Hutt said that the new statutory LHBs would take on a new responsibility for commissioning, securing and delivering healthcare.

It all sounded like a very exciting, ambitious agenda. She claimed that they would deliver the best service for the people of Wales. Prior to May of this year, Brian Gibbons as the health Minister announced that some services would now have to be commissioned at a regional level to enable more effective negotiations with the trusts. Now, Edwina Hart has decided that the confusion needs to be tackled, and that it is something that should not be tolerated.

All three people are still members of the Assembly Government and members of the Cabinet. All three individuals have a very different view about what we should be doing with local health boards.

We are very clear on this. We do not think that we can sustain 22 mini health authorities in Wales. The Government should be examining, as quickly as possible, the benefits of introducing an all-Wales commissioning body, to give our nation the strategic direction it needs in the commissioning of these vital services.

If possible, I would like a definitive statement. I would like the Minister for Health and Social Services to answer this question this afternoon: do you see a future for 22 local health boards in Wales? I would also like to know why the Assembly Government has not bothered to undertake any independent assessment with regard to the effectiveness of the role of LHBs. We need to resolve this problem urgently, Minister.

You have already started to tackle the trusts; we now need to start tackling the problems created by your party when 22 local health boards were set up. If you do that, you will have our support, but I urge you to reject the amendments and support the motion that we have tabled."

"Dechreuaf drwy amlinellu pam yr ydym wedi cyflwyno'r ddadl. Y Gweinidog dros Iechyd a Gwasanaethau Cymdeithasol wnaeth fy ysbrydoli. A hithau wedi bod mor onest ei barn ynglyn â'r broblem yng Nghymru heddiw o ran comisiynu gwasanaethau ym maes gofal iechyd, tybiwn fod y Gweinidog angen cyfle i amlinellu'r hyn y mae'n bwriadu ei wneud i fyrddau iechyd lleol ac i gomisiynu yn gyffredinol o fewn y gwasanaeth iechyd yng Nghymru dros yr ychydig flynyddoedd nesaf. Nid ydym yn derbyn yr un o'r gwelliannau sydd wedi'u cyflwyno y prynhawn yma.

Bu prosiect ailstrwythuro Llafur, a gafodd wared ar bum awdurdod iechyd ddim ond er mwyn cyflwyno 22 bwrdd iechyd lleol yn eu lle, yn drychinebus. Mae wedi dangos lefel o ddiffyg gallu ym maes ailstrwythuro gwasanaethau iechyd na welwyd ei fath erioed o'r blaen.

Yr oedd wedi'i gynllunio'n wael ac yr oedd yn dangos holl nodweddion gwaethaf Llafur mewn grym—ceir llawer gormod o fiwrocratiaeth, llawer gormod o bwyllgorau a llawer gormod o ddryswch. Dim ond yn awr, ychydig flynyddoedd wedi i fyrddau iechyd lleol gael eu cyflwyno, yr ydym yn gweld pa mor wael y buont o ran comisiynu gwasanaethau, y trafferthion a gawsant wrth ddarparu'r gwasanaethau y mae ar bobl eu hangen, a'u diffyg capasiti, arbenigedd ac adnoddau i wneud y gwaith y credai Jane Hutt y byddent yn ei wneud pan oedd hi'n Weinidog iechyd.

Gallwn gael hwyl mawr â'r mater hwn, ond mae canlyniadau penderfyniad Jane Hutt ar yr adeg honno'n ddifrifol iawn. Mae gennym 22 bwrdd iechyd lleol sydd â diffyg capasiti, ar lefel adnoddau ac ar lefel comisiynu.

Ac ystyried graddau amrywiol eu llwyddiant, mae'n amlwg bod eu maint yn effeithio ar eu perfformiad, a bydd y sefyllfa'n gwaethygu, yn enwedig wrth i ddatblygiadau ddigwydd dros yr ychydig flynyddoedd nesaf—gallaf dynnu sylw at gyflwyno cynhyrchion fferyllol a fydd yn cael eu hawdurdodi gan y Sefydliad Cenedlaethol dros Iechyd a Rhagoriaeth Glinigol ac yn cael eu cymeradwyo gan Grwp Strategaeth Feddyginiaethau Cymru Gyfan fel enghraifft.

Wrth ystyried datblygiadau tebygol dros yr ychydig flynyddoedd nesaf, gwyddom y bydd byrddau iechyd lleol yn cael trafferth i wneud y gwaith y disgwylir iddynt ei wneud. Gwyddom eu bod yn cael trafferth i ddarparu ar gyfer rhai agweddau ar y contract meddygon teulu; gwyddom nad oedd ganddynt ddigon o adnoddau i ddarparu Herceptin i gleifion â chanser y fron; a gwyddom y byddant yn cael trafferth i reoli'r llwyth gwaith y disgwylir iddynt ei reoli wrth i ddatblygiadau newydd ymddangos dros yr ychydig flynyddoedd nesaf.

Gwyddom hefyd fod y Gweinidog dros Iechyd a Gwasanaethau Cymdeithasol yn awyddus iawn i ailstrwythuro ymddiriedolaethau GIG. Gan mai hwy yw'r darparwyr mwyaf, yr ymddiriedolaethau sy'n bendant yn arwain y blaen ym maes gofal eilaidd. Maent yn drech na'r byrddau iechyd lleol ar hyn o bryd.

Mae gofyn i fwrdd iechyd lleol herio ymddiriedolaeth GIG fawr rywbeth yn debyg i ofyn i ddisgybl ysgol gynradd herio aelod o'r chweched dosbarth. Ceir pum bwrdd iechyd lleol yn ardal Gwent gynt sydd oll yn ceisio cyd-drafod ag Ymddiriedolaeth GIG Gofal Iechyd Gwent. Mae'n amhosibl derbyn bod gan fyrddau iechyd lleol unrhyw rym i gyd-drafod yn effeithiol ag ymddiriedolaethau GIG.

Nid wyf yn honni bod ymddiriedolaethau GIG yn gwneud llanast o bethau; credaf fod gennym rai pobl hynod o alluog a phrofiadol yn gweithio yn ein sector ysbytai a gofal eilaidd. Fodd bynnag, mae'n afresymol disgwyl i fyrddau iechyd lleol allu eu herio. Bydd y sefyllfa'n datblygu'n fwyfwy anodd iddynt a bydd yn dod yn fwy amlwg cyn gynted ag y gwelwn uno'r ymddiriedolaethau GIG hynny yng Nghymru.

Bydd gan yr ymddiriedolaethau anferth hynny rym sylweddol o ran cyflenwi gwasanaethau ac, yn syml, ni fydd gan y byrddau iechyd lleol y grym i gomisiynu'r gwasanaethau y mae arnynt eu hangen.

Ni fu unrhyw fantais gyffredinol i gydffinio â llywodraeth leol. Heriaf y Llywodraeth i gyhoeddi unrhyw dystiolaeth sydd ganddi sy'n awgrymu bod y cydffinio rhwng y 22 awdurdod lleol a'r 22 bwrdd iechyd lleol wedi esgor ar unrhyw fantais wirioneddol i gleifion. O ran blocio gwelyau, ni wnaeth ddim i leddfu'r pwysau ar y sector acíwt, ac ni wnaeth ddim i ddarbwyllo llywodraeth leol bod angen iddi osod blaenoriaethau i sicrhau bod pobl yn cael eu symud allan o'r sector acíwt ac i mewn i'r gymuned.

Yn y mannau hynny lle mae'r broses asesu unedig yn cael ei chyflwyno yng Nghymru, nid yw wedi gwneud dim i leddfu'r gofid a'r pryder ynglyn â'r broses hirfaith bresennol, ac nid yw gweithio ar y cyd o safbwynt y broses hon wedi esgor ar unrhyw fantais i gleifion. Mae gweithio ar y cyd rhwng byrddau iechyd lleol a llywodraeth leol yn beth prin; yn sicr, nid yw'n digwydd yn arferol yng Nghymru.

Fy safbwyntiau i yw'r rheiny, ond mae'r dystiolaeth yn glir pan ofynnwch i bobl o amgylch Cymru am eu barn ynglyn â'r strwythur comisiynu presennol yng Nghymru. Datganodd arolwg 'NHS Wales Barometer 2006' yn glir iawn, er bod rhywfaint o gefnogaeth i'r ddadl bod byrddau iechyd lleol mewn sefyllfa dda i wella iechyd eu poblogaeth leol—er y byddwn yn dadlau, ar ôl ychydig flynyddoedd, nad oes dim tystiolaeth bod iechyd poblogaethau lleol wedi gwella—yr oedd y farn y gallai byrddau iechyd lleol wella gwasanaethau iechyd yn llawer llai cyffredin.

Mae hynny'n broblem wirioneddol, oherwydd fe sefydlwyd byrddau iechyd lleol i gomisiynu gwasanaethau ac i wella'r modd y caiff gwasanaethau eu cyflenwi. Yn syml, nid yw hynny wedi digwydd.

Â'r dystiolaeth ymlaen i ddweud mai ychydig, ar y cyfan, o wrthwynebiad a gafwyd i'r syniad o ailstrwythuro'r ddau fath o gorff—ymddiriedolaethau a byrddau iechyd lleol—dros yr ychydig flynyddoedd nesaf.

Mae'r Gweinidog wedi bod yn onest iawn yn y modd y bu'n siarad am y problemau. Mewn cyfweliad â Hafal, yr elusen iechyd meddwl, dywedodd y Gweinidog:

Ceir gormodedd o gyrff comisiynu ac mae'n anodd iawn i bobl ddeall beth y mae hyn oll yn ei olygu o ran y gwasanaethau y maent yn eu cael. Ni chredaf fod y gormodedd hwn yn ein galluogi i gael comisiynu effeithiol.

Â'r Gweinidog yn ei blaen i ddweud,

Mae pobl yn mynd ar goll yn y bylchau rhwng darparwyr gwasanaethau ond, yn waeth na hynny, mae rhai pobl yn cael eu gwthio yn ôl ac ymlaen rhwng gwahanol leoedd ac nid yw hynny'n dderbyniol.

Croesawaf safbwynt y Gweinidog, a gobeithiaf y bydd ei chyd-Aelodau ar y fainc flaen yn cefnogi ei safbwynt. Fodd bynnag, mae'n amlwg fod dryswch yn y Llywodraeth. Ym mis Mai 2002, dywedodd Jane Hutt y byddai'r byrddau iechyd lleol statudol newydd yn cael cyfrifoldeb newydd dros gomisiynu, sicrhau a chyflenwi gofal iechyd. Yr oedd hyn oll yn swnio fel agenda gyffrous ac uchelgeisiol iawn. Honnodd y byddent yn cyflenwi'r gwasanaeth gorau i bobl Cymru.

Cyn mis Mai eleni, cyhoeddodd Brian Gibbons, fel Gweinidog iechyd, y byddai rhai gwasanaethau bellach yn gorfod cael eu comisiynu ar lefel ranbarthol er mwyn galluogi cyd-drafod yn fwy effeithiol â'r ymddiriedolaethau. Yn awr, mae Edwina Hart wedi penderfynu bod angen mynd i'r afael â'r dryswch, a'i fod yn rhywbeth na ddylid ei ddioddef.

Mae'r tri pherson hyn yn dal i fod yn aelodau o Lywodraeth y Cynulliad ac yn aelodau o'r Cabinet. Mae gan y tri unigolyn safbwyntiau gwahanol iawn am yr hyn y dylem fod yn ei wneud â byrddau iechyd lleol.

Mae ein safbwynt ni ar hyn yn eglur iawn. Ni chredwn y gallwn gynnal 22 awdurdod lleol bychan iawn yng Nghymru. Dylai'r Llywodraeth fod yn archwilio, cyn gynted â phosibl, fanteision cyflwyno corff comisiynu i Gymru gyfan, i roi'r cyfeiriad strategol y mae'r genedl ei angen wrth gomisiynu'r gwasanaethau hanfodol hyn. Os yw'n bosibl, hoffwn glywed datganiad pendant.

Hoffwn i'r Gweinidog dros Iechyd a Gwasanaethau Cymdeithasol ateb y cwestiwn hwn y prynhawn yma: a ydych yn gweld dyfodol i 22 bwrdd iechyd lleol yng Nghymru? Hoffwn gael gwybod hefyd pam nad yw Llywodraeth y Cynulliad wedi trafferthu cynnal unrhyw asesiad annibynnol o effeithiolrwydd swyddogaeth byrddau iechyd lleol. Mae angen inni ddatrys y broblem hon ar frys, Weinidog. Yr ydych eisoes wedi dechrau mynd i'r afael â'r ymddiriedolaethau; yn awr mae angen inni ddechrau mynd i'r afael â'r problemau a grëwyd gan eich plaid chi pan sefydlwyd 22 bwrdd iechyd lleol. Os gwnewch chi hynny, fe'ch cefnogwn, ond fe'ch anogaf i wrthod y gwelliannau a chefnogi'r cynnig a gyflwynwyd gennym."

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