Sunday, 10 June 2018


When is a democratic vote not democratic enough to accept ? - perhaps in the case of the EU Referendum? How dare the British electorate vote the "wrong way" in the face of sound advice from the majority of big business, establishment political parties, cuddly celebrities and most trades unions? The majority of voters clearly must have been mistaken or mislead or too stupid to understand the issue?

 Of course not, everyone who registers may have a vote but how they cast it is influenced by many things. This is too brief a post to mention everything I learned as a volunteer for Vote Leave but I hope gives some insight into the campaign where I live.

BREXIT  - A Result Not Expected? 

The overall UK end result was  52% leave 48% remain with some sharp local and national differences.

In Wales the overall result was 52.5% leave, 47.5% remain.

In defence of not accepting the result, some cite a case that people did not know what they were voting for. I think that probably works both ways. As someone who did quite a lot of canvassing and leafleting I would say that reasons volunteered for the choice of vote were quite varied and on occasion neither logical nor comprehensible on both sides.

The campaigns had pretty good UK media coverage, The Remain campaign was better resourced and establishment supported, and had in some areas good political party support..

The Leave campaign was less well resourced , and had far less support from the political establishment, although I was aware of shy leavers, in all the main political party members who didn't wish to speak openly what they thought, but probably voted leave against their own party's policy. UKIP were the only party to wholeheartedly support Brexit and  understandably were individually very committed..

It did seem to be a fair contest by UK standards. Usually the best organised, best publicised and biggest spending campaign wins elections. Across the UK in many areas, especially the more remote and rural , the only literature delivered to voters doors was likely  the government sponsored pro Remain  leaflet.Remain should have won and was expected to do so.

Why was Brexit triumphant?

These are the reasons I feel are important in what happened from my own experience. Personally, in my own bubble in Llanelli I was sure the constituency was voting Leave, I was hopeful the county would vote Leave and in the final days was informed by Vote Leave that  they felt we could well win Wales. How everyone else was doing  in the UK I knew as much as the average TV viewer. My impression was for most, if not all of the campaign, the remain camp were complacently confident and the Leave camp  was hopeful but not at all certain of victory.

The economic arguments were generally considered and most Leave voters, I believe, were willing to take a risk on  possibly precipitating an economic downturn  in the hope of a better economy in the long term. They certainly were not swayed enough by "project fear" to change their minds in large numbers, as hoped.

Perception of Benefits of EU funding

In Wales the Remain campaign was very much on the specific economic grounds, that generous "EU" funding was practically the mainstay of our economy and as a poor area, the nice EU would always be generous to us. Without their good offices, we were told, the begging bowl would remain empty for good.

I live in Carmarthenshire. In theory my area "benefits" from EU administered structural funds. money which the UK government would not apparently otherwise give to the needy poor regions. There is lots of agriculture so the Common Agricultural policy should be seen as a generous contribution to our well being. Several local "EU "funded projects are much appreciated. Some tourism also benefits from  EU administered funds. However, much is perceived to  be spent without much benefit to ordinary people and the local economy has by no means been significantly improved.

As this had hardly  been "game changing" to the local economy,  which continued to be poor and based on low wages, it did not influence many. Some, especially middle class pubic sector workers did tend to be worried  by the prospect of losing  EU grant money. 

 The area's most prominent and usually most active political parties were Labour and Plaid Cymru
who emphasised the financial benefits of the EU as the main reason to vote remain. The cruel UK government would surely forget to give Wales or our farmers any of this money. Many voices gave the impression that this was not UK money paid into the EU  returning to the UK but that it was some magical charitable gift from our noble,generous  friends across the water

.There was a single  embarrassing display of unity where clearly uncomfortable  prominent members of the 2 parties, Labour and Plaid, posed for a photo in Llanelli town to support the Remain cause. No further co-operation was noted.

The Leave campaign can also be criticised for not initially clearly showing where these gifts of grants and subsidies came from. It took the much criticised "Red Bus" to actually drive a narrative on how much  UK money did not come back from the E.U.  and that "EU funding" did not mean free money from the philanthropists of Europe, but UK money administered in the name of the EU..


In Llanelli this was not a big specific issue on the doorstep  although a few did express hostility to the idea of Eastern European immigration and  believed that some people did come here just for the benefits and get council houses ahead of locals. The number of EU migrants is small.  No one volunteered much negative personal experience to me other than one family complaining that some Eastern European gentlemen neighbours regularly got  drunk in the alley behind their home and sometimes messed up their bin bags on collection days.

 The issue was more that of border and immigration control and the fear that free movement of people would, at some future time, allow mass migration from the EU into the area. In a poor area where local people can have difficulty getting even  reasonable minimum wage jobs, I suspect no community where jobs are lacking wants a threat of competition for jobs from outsiders.

The "Take back Control" narrative was very popular and frequently echoed. Activists, while canvassing you don't take  much time to interrogate people's interpretation of the slogans. One tends to thank them for their support and move on, rather than ask them why they are supporting you?

Disgust with the EU's treatment of our Prime Minister

Even those who are not Conservative supporters were shocked when David Cameron , our then Prime Minister, was offered little by the EU to help quell dissent on the European Project.

For those of you who wish to be reminded of the sad "thin gruel" David Cameron returned with from Brussels the BBC website has an excellent list of what he wanted and what little he got.

It still makes chilling reading as one realises that it is not only a record of major political failure but also the contempt in which the UK was apparently held by the other EU members. While  marching on to the goal of a united states of Europe they were quite aware of British reluctance. Euro-scepticism has always been fuelled, on the right of the political spectrum, by the prospect of loss of British Sovereignty. This was seen as a huge "own goal" and gave the opportunity for Brexit.

 I have talked to a few European politicians since the referendum and they concede that Cameron's brush off treatment  was a gamble, but they had no expectation of anything other than a grudging acceptance of the generally unhelpful fudge . They realised that ever closer union will not, in time, have included all the current EU states but had been hopeful that the wealthy UK  would have stayed and funded them for longer than it looks like now. When the UK leaves, the Common Agricultural Policy will likely suffer in that many of the members, especially the newer, smaller accession countries rely on our donations to fund their CAP.

I found many Conservative supporters angry with both the EU for treating us with contempt and with David Cameron for being  so weak. The most common question asked from this source was "If Leave wins, will David Cameron Resign". I thought he would, and he did. That issue alone I think was adequate motivation to vote to leave the EU for them.

Plaid's support of EU as a friend to minority nationalities and languages

Plaid Cymru have always had a weird love affair with the EU, seeing it as a structure to help promote the small regions and nations and their cultures. It is true that the EU do formally list the European minority languages and nationalities and encourage representation, at an advisory level, for these groups. In theory they campaigned hard for Remain, in practice locally here they didn't, but I believe many of their voters did follow the party line.

Personally, I am not convinced that this "generous" EU policy is anything other than placating these groups.  I have witnessed, over the years, quite firm EU action to prevent unwanted regional autonomy and national  secession,  including an effective campaign against the Yes vote in the Scottish Referendum.

 The Scots were told that if they voted for independence they would be expelled from the EU and if they wished to rejoin they had to reapply, accept the Euro and it would take at least a decade. In the meantime they would have a hard land border with the EU in the form of England,  their economy would collapse and readmission would take over a decade. No seamless passage of goods for them!

Since the subsequent problems with Catalonia, Plaid Cymru has had quite a shock as the friendly, cuddly EU image they had imagined has been severely challenged by events. I was surprised that they did not have much of a campaign for Remain here.. In fact, when leafleting for Leave the only other similar activity. for almost all of the campaign, I noticed was promoting local fast food outlets. No canvassing by them noted, One Remain poster and some welsh language car stickers on a single car was all I saw travelling around Llanelli.

Some Plaid members have told me that in 2016 they already had some ambivalence to the issue and after the assembly election in May 2016  they were tired of campaigning and not convinced that there was a chance of a Leave vote anyway. Considering events, I believe the EU has since lost the shine it once had amongst Nationalist here and they may change their votes if there is a second referendum unless the Catalonia issue is resolved positively.

Radical Nationalists,in Wales generally took a position  like Jim Sillars in Scotland, and were of the "out and out" persuasion. The United States of Europe, the political result of "ever closer union" is obviously a mega-state which would heavily and forcefully resist any separatism.

Strategy: first exit EU, then exit UK

posters by Gethin ap Gruffydd

I agree with the logic of this, if you are a small country wanting independence, being part of a rigid European system which is concentrating power somewhere else is of no advantage whatsoever and a Threat to self determination, just as the Catalans have recently discovered.

Where were the Labour Party?

In Llanelli this was a bigger mystery than the absence of Plaid Cymru. They have more activists than
Plaid, are usually well organised and focused but the lack of a visible Labour Remain campaign on the streets until very late in the campaign was a mystery. A few Labour members were openly supportive of Leave and others, some quite prominent locally, covertly gave support under strict agreement of anonymity- asking for leaflets and posters to be delivered  to specific addresses/ streets for instance.

Labour, and Plaid,, had apparently not asked the question of whether or not people had come to an opinion on the referendum in May, when they were canvassing the area for the Welsh National Assembly Elections - allegedly to avoid confusion. I had asked the question at this time and noted the answers. Many people had already firmly decided, before the Brexit campaign had got fully underway.

This meant that Labour in Llanelli started real campaigning perhaps only when they realised that there was a danger of the local vote producing a Leave majority, I only saw them working in  the last 2 weeks of the campaign.. They were seemingly trying to play catch up while probably running blind. Large numbers of their supporters were already pledged to the Leave side and there was a lot less chance for them to make any difference so late in the day.

The local left wing radical socialists were generally saying they were supporting Leave , citing the "Capitalist Club"  reputation of the EU and pointing out that our UK workers rights were actually better than the EU minimum and had been achieved in the UK by unions' political campaigns, not  just EU regulation. They saw the Conservative government as a bigger threat to workers rights than leaving the EU.

The End Game

My only previous experience of a major contested referendum was of the 2014 Scottish Referendum.

From this I learned that when people have expressed a firm view they probably will keep it, so don't waste much time arguing with people who clearly don't support your view, and target the undecided in the final stages. My impression of Llanelli was there were not many truly undecided  people likely to vote.

Those who said they were voting for the first time, were not teenagers, but much older, some having registered to vote for the first time just for the referendum and they were generally voting Leave and for the first time in their lives felt their vote mattered.

The the last stage is to get out your vote.and not the opposition's. I believe Leave in Llanelli, despite having far from a comprehensive canvass record, had a much better idea of where their vote was than Remain.

At the Carmarthenshire Count,  the overall result was Leave 53.7% Remain  46.3%.

 There were no separate figures produced for the 3 parliamentary constituencies involved but the Llanelli polling station boxes did not disappoint and I suspect that "project fear" had some effect. on the final result. but too little to win the day.

Interestingly, for election nerds, the postal votes in Carmarthenshire did not reflect the final total vote,  as it often does. We scored them as 50/50 with a suspicion that they might actually be just slightly favouring Remain. It was a relief to see the polling station boxes opened!

The day before the referendum Nigel Farage made his final speech where he characterised the vote as the People versus the Establishment and said leave voters would crawl over broken glass to vote for Brexit. Hyperbole, but it does capture the mood of the campaign and that Leave voters were  probably far better motivated to make their point, and prepared to vote even though many thought they would probably lose, just to register their discontent.

As for Remain, it is difficult to make the status quo exciting and the approach of trying to scare people against change can backfire, In 2016 there was a majority of  UK voters yearning for change and willing to take the risk of  leaving the European Union. The Establishment thought they would win and didn't. Democracy delivered, and many MPs and AMs  and even the 1997 referendum on the Welsh Assembly have been won and lost by much smaller proportional margins without requiring a re-run.

 Many of  the losers accept the Brexit result but others are still very bitter and don't. I suspect this isn't just a loss of a vote but for them, but a challenge to their whole political outlook.

 I still meet people who assume that a nice middle aged, middle class , nationalist lady like myself must have supported Remain and who seem a bit shocked when I confess I didn't. 

After this experience I doubt any UK government will risk another  referendum on anything, anytime soon!

 Siân Caiach

Wednesday, 30 May 2018

Future Wales NHS (3) Plans and shams - Consultation Time


In Carmarthenshire and Pembrokeshire  a "consultation" is in full swing as to the futures direction of the Hywel Dda University Health Board,which covers the 3 counties of Dyfed.

In the words of the Hywel Dda Executive:

We have an ambition for our local NHS and a once-in-a-lifetime opportunity to work with you to make it better for everyone. We want to provide the highest quality care, with excellent outcomes that improve your health and well-being and provide you with a good experience wherever you live and receive your care. We want to help you maintain your health, well-being and independence, recognising that good health is much more than living longer; it is living healthier lives, from before birth to older age"

There are 3 proposals:  A, B, and C

In all cases Bronglais in Aberystwyth remains as it is now, a General Hospital. In all cases Withybush hospital, near Haverfordwest, is downgraded to a community hospital. In 2 scenarios West Wales General Hospital also becomes a community hospital but in option C is a "planned care" hospital which sounds better. None of these hospital descriptions are clearly defined in the consultation questionaire.

Currently West Wales General Hospital on the outskirts of Carmarthen is a district general hopsital and provides basic emergency care via an Accident and Emergency department and has the best range of services in the board area. Hywel Dda "University" Health Board intend to downgrade this hospital to a "Community" hospital in options A and B or to a "planned care hospital" in option C in the consultation.

 In all options the A & E and urgent care at WWGH is replaced it with a brand new  "urgent care"hospital on the Carmarthenshire/Pembrokeshire border described as "somewhere between Narberth and St Clears". The build will take 5-10 year.

East Carmathenshire and Llanelli itself will need to be serviced for most urgent/emergency treatment by the nearer Morriston Hospital as the travel distance will be too far to the new emergency unit. Abertawe Bro Morgannwg University Health Board will be able to bill Hywel Dda for the cost of treatment of Carmarthenshire based people, so the money "follows the patient".  

Also included in all options are 10 "community hubs" across the region. 

They include the current community hospitals of Amman Valley, Llandovery, South Pembrokeshire and Tenby. Also there are 5 units currently in the planning stage at Cardigan, Cross Hands, Tregaron, Aberaeron and Delta Lakes Wellness Village. Llanelli. Aberystwyth Health Hub is just labelled as "New". The community hospital exist already but the building of the rest of the hubs is likely to take several years.

A view of Delta lakes site where the Llanelli Hub has not yet been started

These community hubs will deliver preventative medicine, community based care for those with chronic illnesses and early help and treatment to prevent hospital admission. They will work hard to prevent anyone getting too ill and having to go to hospital. They may contain local GP surgeries and be able to perform diagnostic tests currently available in hospitals. 

The "choices" are whether or not the 3 existing southern hospitals, Prince Philip Hospital, Llanelli, West Wales General hospital, Carmarthen,and Withybush Hospital, Haverfordwest, are designated as "General Hospitals" or "Community Hospitals". At the moment PPH and Withybush are designated "General" , a vague term not to be confused with the term "District General Hospital" which refers to a hospital with a wide variety of specialities which can treat most medical conditions. A "General" hospital seems to be one with limited emergency medical care, diagnostic and clinic faciities and day treatments with a minor injuries unit, such as PPH is now.

In all 3 scenarios WWGH is downgraded and presumably its major emergency functions transferred to its successor new hospital. 

The timescale of building the new facilities (5-10 years) means that the desired result of attracting and retaining medical staff to the new look Health Board and the newly built units is a long way off. In the current NHS staff market, jam tomorrow is unlikely to attract new staff until the units are not only completed but shown to be working well. Reputation is the strongest factor for recruitment in new systems and how long this one will need to be up and running to gain that is not clear.  The plans may even encourage workers to move to other areas from those likely to be downgraded.

So it is very simple. Select the least worst option. (Similar to voting for your MP)

If you live in Llanelli or Carmarthen East this is probably proposal C (although some in the extreme north of the County have pointed out that Prince Charles hospital in Merthyr could be quicker for them to get to than Morriston  where the real serious emergency stuff will be provided to this area)
If you live in Carmarthen town area you will want to keep the downgrade at WWGH Carmarthen to a minimum and accept proposal C as your local hospital downgrade will be to "planned care" rather than a "community" hospital, 

If you live in Pembrokeshire  all the proposals are equally poor in that your hospital is downgraded into a community hospital in all options. Only worth filling in the "consultation" if you go for your own personal 4th box of "another alternative".
The proposals are to be marked 1.2 and 3, with no 4th vote option so it obviously a wasted vote to use the 4th box as no-one knows what you are voting for - unless everyone in Pembrokeshire writes in the same thing and only votes for that choice? 

Its not a true consultation, just a manipulated endorsement of plans already made. It is not sensible to make plans about the Welsh health service in isolation and surely all the Health Boards should be involved and co-operating?

In  June 1970 the new box girder Cleddau Bridge collapsed killing 4 men, injuring others working on the bridge, and narrowly missing most of the village beneath. It was rebuilt, and the delay in the injured getting help drove the desire for a proper emergency hospital in the area. The replacement bridge may well last far longer than the district general hospital the local community fought to get built and more recently to keep.  
The Cleddau Bridge

  Siân Caiach

If you would like to contribute:

consultation ends 12th July

Monday, 7 May 2018

Wales 'Future NHS (2) - grow our own staff or depend for ever on other countries?

Wales was officially part of England during the early years of the NHS  and this is reflected in the organisation of the Welsh NHS ,more a regional sub branch than an integrated health service for Wales. Devolution could have produced more control of doctor and nurse training - a system reflecting the geography and needs of the people.  Instead our government took over the administration of health services but not the training and recruitment of doctors and nurses for Wales.
The other UK small nations have been more proactive and better resourced, helped by their political importance and greater historical investment in some of their facilities. As in other things devolution for Wales also devolved the chronic under investment in the Welsh Health Service. No catch up funding.

Scotland {pop. 5.4m}has 5 medical schools. Northern Ireland {pop 1.8m} opens its second medical school next year in Londonderry. Magee College, University of Ulster, already has a well regarded school of nursing and this new medical school will have a postgraduate entry and an annual intake of 120 students. The Republic of Ireland, a nearby EU country with a population of  4.7million, has 6 medical schools, 5 undergraduate (one of which specalises in foriegn students) and one postgraduate.

According to the GMC we only have one medical school in Wales {pop 3.06m,} which presumably means that the small postgraduate medical school at Swansea is listed under "Cardiff" The figures they give is total medical student numbers in Wales 12016/17 are undergraduate 1,521 students and postgraduate 61. the undergraduate courses are generally 6 years long and the postgraduate ones 4 years long. This suggests an annual "production" of  doctors in Wales of around 330 . The GMC breakdown shows ethnicity amongst other things and figures from the National Assembly which funds Welsh Students assembly suggest that the number of Welsh domiciled students entering the local medical schools is around 20% of the total. I've asked for figures of the number of Welsh Students studying in the rest of Britain but they have not been provided.

A legacy of the UK's imperial past is the widespread use of foreign doctors. In the past students were attracted here from the colonies as were young doctors in training.  In the early years of the NHS the idea was that they stayed here a few years then returned with  their knowledge to their own countries but the UK became ever more dependent on these foreign doctors. In more recent times doctors from the EEC have come, attracted in part by the higher salaries doctors enjoy here compared with continental Europe .

In recent years the conversion of nurse training to a university degree qualification and the inadequacy of local nurse training numbers has led to foreign recruitment of nurse on a large scale,. Countries such as the Philipines  encourage their nationals to train as nurses, in large part to work abroad and send money home to their families, boosting the economy of their country. Taking the gift of nurses from the developing world may fill the gap but leaves us open to future shortages if these countries improve their own economies and  health services, so needing their own nurses and being able to provide a good wage, or if political instability or conflict reduces the supply.

I have asked the Welsh Government for the numbers of doctors and nurses we in Wales need annually, No answer. I have been informed though, that only 20% of Cardiff medical students are officially Welsh domiciled. I could not find out how many welsh students are at medical school in the rest of the UK where the Welsh Government and the Welsh NHS will be subsidising them through grants and bursaries.

The UK has for decades relied on foreign staff and acts as if the supply will always be there, Training doctors and nurses is expensive here and restricted to applicants with high academic qualifications. In order to improve the UK supply you may need not only more places on courses but also more doctors and nurses involved in teaching and expansion of the university departments. These UK degree courses are already oversubscribed with lots of intelligent young people turned away every year.  The higher number of women doctors and the predominance of female nurses also means that "in house" creche facilities and  transport from childcare facilities to school and back are needed. Doctors and nurses from the developing world are more likely to leave their families at home.

Wales needs to decide whether to adopt self sufficiency in staffing the NHS or continue to rely on the generosity of the developing world. Some countries have always planned on self sufficiency.

                                                Icelandic medical students in training.

In Iceland, {pop. 380,000} the policy has always been to train their own doctors and nurses. They produce 48 doctors a year from their only medical school in Reykjavik.  Their infant mortality is the lowest in the world, their longevity  figures are impressive (highest life expectancy for men in the world, women's in the top 10} and they train doctors using the Australian model through the medium of Icelandic. There is no private practice although there is a fee system for GP visits.

Other countries have different systems. The irony of the shortage in Wales is that  some of the areas where staff are hardest to retain are the last strongholds of the welsh language. Although welsh speaking nurses are in evidence, welsh speaking doctors are not so much and the Welsh government policies are not helping . The " Gifted and Talented" program in Welsh Schools encourages the academically outstanding to make the most of themselves, go to  Russell Group universities and especially Oxford and Cambridge. The planned new acute hospital between Narberth and St Clears will bring a large influx of staff who are unlikely to be well speaking and because of its geographical isolation will be looking for homes in the area, or possibly not coming at all. The choice of a job is not just about filling a vacancy but about what is best for your partner and family. Cities are ideal as there is more chance of getting a job for your partner, more choice in childcare and education for your children and, especially if you are in training and will need to move on, more chance to find suitable accommodation. 

Most ambitious students may well end up going to "well known"medical schools of which there is a good choice in England if you make the grades. The financial support is the same whether or no you decide to study in /Wales,  in contrast to Scotland where only if you stay in your country to study medicine or nursing (or any other degree except those not offered in Scotland}will your fees be paid.

Many countries with remote rural areas struggle to get doctors to settle there and it may lead to adoption of more high tech diagnostics in the GP type units, efficient extraction of the very sick and injured to specialist hospitals, as happens in the highlands and islands of Scotland, and sometimes long journeys to get specialist operations like hip and knee replacements, as in Sweden, where the expert surgery is done away from home and the rehabilitation provided by the local hub.

What we need in Wales is not isolated organisation of GP and hospital services dictated by local authority boundaries but leadership from our government to shape a future for healthcare in Wales. 

Siân Caiach

Student numbers :

Thursday, 3 May 2018

Wales' Future NHS - (1) How can the NHS give the best service in Wales?

Wales, unlike Scotland and Northern Ireland, does not have the geographical isolation from England and internal transport connections that assists the other 2 smaller nations in the UK to organise their NHS on a clear geographical basis with a degree of independence. Wales is dependent in some areas on using the English NHS and this anomaly has never been addressed, or even seen as a problem at all. Health is a devolved issue so in supposedly the hands of the Welsh Government.

Welsh Government has kept the NHS within local authority boundaries and reorganisation has provided larger Health Boards but not necessarily better care. In fact, internal asset stripping and pet projects have often seemed to make things worse rather than better.

Lack of internal transport infrastructure means that the North and South of Wales cannot easily integrate NHS services or share resources. For instance there is only one specialist Children's hospital in Wales, in Cardiff, our Capital city.  Transport from the north of Wales to the South is difficult , relatively slow and often expensive and so Sick children in the North of the Country go to Liverpool. People in parts of  Mid Wales also use hospitals in England much easier for them to access than those in Wales.

As I've mentioned, health boards serve geographical models based on conforming to local government boundaries. I live near Llanelli. Our A&E was downgraded some time ago to a minor injury/illness unit. Last year I had a housework accident where I fell off a chair and cut my head open while clearing cobwebs. I didn't have concussion but needed a lift as the cut required pressure on it to stop the bleeding. I went to the local minor injuries unit at our local hospital 5 miles away where a nice GP put a couple of stitches in. A good job. If I had a more serious injury I should go to Carmarthen but in reality would go to the nearer A&E at Morriston, in the neighbouring Health Board, Abertawe Bro Morgannwg..

After various reorganisations Llanelli's District General Hospital, Prince Philip Hospital, has been repeatedly downgraded. Of course, that is not the official description as the publicity for the "Front of House improvements would lead you to believe that this is a ground breaking new way of centralising services in a very positive manner.

The proper Accident and Emergency I should go to if I had suffered a more severe illness or injury is in Carmarthen, some 16 miles away down a road {A484} that does not lend itself to easy or speedy driving. Parking is very restricted and not free, access to some departments often problematical.

 Hywel Dda health board have downgraded Llanelli safe in the knowledge that many local residents will go the nearest A&E with medical emergencies if they can access transport. Abertawe Bro Morgannwg Health board them picks up the tab in Morriston and Hywel Dda saves money. Call an Ambulance in the Hywel Dda Area and you will be taken to your own area acute hospital, irrespective of how far away it is and the proximity of other hospitals "over the border".

Wales has a heavily populated city belt on its South Coast, a less dense population in the valleys to the north of these cities and a vast area populated much more sparsely. Roughly, the population of Wales is 3million people.  Approximately one third  live in the 3 southern cities, a third in the post industrial valleys relatively close to the cities and the rest in a variety of towns, villages and homesteads scattered over the rest of Wales.

One disadvantage of our representative democracy is that many health decisions are dictated by the pressure to be seen to "do something" to improve health care in the 4-5 year election cycle. That has led, over the 70 years of the NHS , to hospitals and facilities being provided and updated for communities based on perceived local needs and internal political and medical  and independent of what  neighbouring areas were doing or planning and although the creation of the National Assembly should have been an opportunity to take stock of what we had and administer  the separate Health Authorities within  a  regional and national context.

 Instead we seem to have mergers  which are administered by new local managements with the risk of acquisition of  funds,staff and departments by those units politically stronger , often because they had the largest hospital in the merged group and have used their majority on Executive boards which tend to reflect  this strength. In Carmarthenshire this has meant till now a major bias towards Carmarthen with more and more facilities crammed on to the site at the West Wales General Hospital there.

The 2 issues which restrict sensible decisions on our hospital services are the management structure and the lack of accountability.

Firstly,Health Board  Management, especially when isolated and also constrained by local authority boundaries, may make poor decisions For example,  Accident and emergency departments are the most expensive, needing 24 hr staffing with full support services, so there is big financial imperative to limit their number. However, without increasing capacity in the lucky surviving A&E unit(s) plus adding more ambulances and paramedics due to the distances now needing to be covered to deliver the patients to the care, the result is usually loss of quality in the service, with long waits and possibly dire consequences for individuals not seen and treated in good time. The only sum they add up is the one related to the "savings" of closing units with no apparent consequences for poorer patient care. The Health Board acts alone, consultations are done after the basic decisions are made at Board level and if a choice is given, it is a choice between options almost everyone will find unacceptable on one level or another.
Prince  Philip Hospital after A&E removal

Accountability is very poor, representation on the "lay"positions in boards meant to represent the public are often poorly representative of the local communities. Few local elected representatives are featured and the public meetings of Health Boards are well choreographed publicity performances which allow little or no meaningful contribution by the public.

 Many other small countries have rural areas with relatively low population density and other areas with high density. The general UK social trend may well be  urbanisation and in low population areas it is hard to provide the quality of  emergency care that most cities do. Putting "University" in the name of all our health boards will not fool junior doctors and young consultants into thinking that academic high quality medicine is equally spread all over Wales and attracting them to fill our jobs.

We do not have enough Academic Medicine in Wales, we don't train enough of our own children as doctors and nurses in Wales{80% of medical students in our medical schools come from outside Wales} and we do not have a plan to improve our services in a way which will address these issues. Such a plan can not be left to the isolated and geographically constrained Health Boards. It needs an all Wales solution. Not only the NHS provision must improve , but also the way our country works.

Siân Caiach,

Wednesday, 18 April 2018

TRANS WOMEN BELONG IN WOMEN'S PLACES - a personal view on Ladies' toilets and other facilities for women. The call to exclude some women because their chromosomes are male is addressing a non existent problem.

I am deeply saddened by the rhetoric of supporters of the “Women’s Place” movement who recently met in Cardiff. Trans women may upset some people because they were born as male infants, but gender, like sexuality is something directed by your brain rather than your physique or chromosomes.

Trans people have always been with us but until the last century were restricted to dressing and acting like the gender they preferred and there are many historical accounts of those who chose to do so, sometimes so successfully that their biological,  natal gender was never revealed or only discovered after their deaths.

Trans people, like gay people, are not mentally ill and the Transgender Pioneer Dr John Randell, a Welsh man, was the first doctor in the UK to provide an NHS service to the trans community. A psychiatrist himself, he realised the "problem"was resolved by helping his patients to live in the gender they knew they really were. 

 In the 60s and 70’s his treatments were restricted and cautious not only because they were new but also as Randell feared the hostility towards providing this treatment on the NHS, which some of his medical colleagues expressed at the time, would be fed by any patient who regretted having body changing surgery or hormone treatment. John died in 1982. At that  time there was no way for trans people officially change their gender but now it could soon be a simple process.

The majority of people now agree with equality for homosexual people and favour gay marriage and are comfortable with gay people having equality. I doubt that there is any serious opposition to trans people changing their gender more easily on their official documentation. 

However, the  “feminist” group called “Women’s Place” seems to want to restrict the activities of trans women by claiming that women need their own special places – these include, according to various speakers : female public toilets, female changing rooms in shops, the girl guides and Labour Party All Women Shortlists.

Trans women feel equally female as the natal (or “cisgender”) females who wish them to restrict their movements into these special places for women. The argument is that these natal males are men, and as such they will use these places not to get changed in privacy or check their make-up as one might expect a reasonable person to, but to upset or even assault women.

Former Plaid Cymru AM Helen Mary Jones discussed her opposition to the new proposals to allow trans people to freely officially change their gender on her Facebook page on 10th March 2018. The rights of women and girls are in her opinion threatened. She said:

At first glance one might say, 'why not? Can't a person be whoever they want to be?' And this was what I at first thought.
But I have reflected. This means that a male bodied person would then have the legal right to access all women's spaces - from changing rooms in shops and swimming pools to rape crisis centers, domestic abuse refuges, and women's prisons. Simply because they say they feel they are a woman and therefore they are one. The perceptions of the women and girls in those spaces may be very different. What happens then to the right to privacy of those women and girls? What happens to their right to feel safe, away from men, if they have been hurt and abused?
These changes have already begun to happen, without a change in the law. For example, people who define as transwomen are already held in women's prisons, without the need for any medical transition to have taken place. Topshop has already changed its changing room policy so that to access the women's changing rooms one simple to state that one is a woman. These changes may enhance the rights of some trans people, but in my view they undermine the rights of women and girls.

Trans women are women. Mentally, they have never been men. They are feminine in outlook and psychology. They do not belong in male toilets and changing rooms and they are sometimes at real risk from trans phobic men, who have, on occasion, violently assaulted and even killed trans women. Can you imagine what might happen if they were forced to serve sentences in male prisons?

 The comments about domestic abuse and rape crisis centres seems particularly callous to me, as these women are at equal risk of family and partner violence and sexual abuse and yet Helen seems to believe trans women who have been assaulted are a terrible danger and should be abandoned. Does she intend to stand on the steps of a rape crisis centre demanding all women seeking refuge undergo chromosome analysis to determine if they “deserve” sanctuary?

They are no more risk to other women than natal women, and for them these female only spaces are also safe and valued; they want to pass as women, they want to live as peacefully as any other woman would. To exclude them from women’s public amenities because they have male sex chromosomes is bizarre. It is surely cruel to force them to use male “spaces” and therefore “out” themselves every time they need to use the facilities.

 It is probably much more dangerous to trans women to be excluded than the imagined horror of a possibly “male bodied person” being allowed to register as a woman. Imagined horrors are the stock and trade of these arguments. The proposition is to force these women to “out” themselves as trans every time they use a bathroom or changing room because of hypothetical stories driven by the idea that the physical traits you are born with will drive one to become a sexual criminal.

The stories of what can happen to some of these women when they are “found out” in public and alone, are not hypothetical, the risks to their mental and physical health are very real. And if they chose not to take that risk, they will be forced to live their lives in the closet, which we now know has devastating effects to mental health. How can you live as yourself in public if you cannot even use a bathroom safely?

If a man truly wanted to assault a woman he doesn’t need to go through months of therapy, hormone treatments, surgery, name and legal gender changing to do so. In fact under Helen’s proposals he could simply claim to be a trans man, a group Helen seems to have forgotten, and who, after a period of hormone therapy generally are, I assure you, completely socially indistinguishable from natal men. She's also not clear about which toilets non-binary transgender individuals should use. 
It seems unlikely that anybody would go through the often harrowing experience of coming out to their families, possibly being disowned by their loved ones, being disrespected in the media and on the streets, living in fear of being found out, applying for legal changes and undergoing long hormone treatments and serious surgery, just for the chance to leer at women in a bathroom.

Punishing trans women as a group for imagined crimes will not protect natal women any more than they are now, but it may throw trans women to the wolves. This proposition of segregation is hurtful even if in practice it is impossible to "police".

I am not comfortable doing this to my fellow women, trans or otherwise. Helen’s argument hinges on the idea that trans women are inherently, from birth, a threat, no matter what the personality and morals of each individual woman may be. That seems to me a very unfair and cruel judgement, and it is on this basis that in her own words she believes their rights should be curtailed. I simply disagree.

 I see other women still suffering indignities and humiliation simply for who they are. As a feminist I believe in offering solidarity to all women who need it. Surely trans women are our sisters, who equally share our marginalised position in society and deserve solidarity from feminists, not hostility? 

 Siân Caiach

Tuesday, 10 April 2018

Future Wales - Population Shift - Older and wiser?

We are living longer. In Wales not quite as long as our neighbours in England but now longer. on average, than our parents or grandparents. Statistics show the trend clearly {ref my last blog Future Wales-How Long Shall We live?} Add to this a low birthrate and the result is a growing  proportion of the elderly. By 2030 most people in Wales , it is projected, will be over 50 years old and in many communities outside of our cities, the majority of adults may well be even older.

What are the likely consequences of this population shift?

The Health Service is most energised by the demographic predictions from the current data. The number of people aged over 75 years is expected to double in the next 10 years.  At a recent conference leading GP Dr Clare Gerada  asserted that over 65's will, in the near future, be the largest population group in the UK.

Currently more and more of the medical care of the elderly is being provided by general practitioners. As this age group visits a GP for a consultation 12-14 times on average the GPs are concerned whether they can cope. There is little sign of a sufficient  increase of GPs and old age specialist doctors in the pipeline to cover this expanding need but there has been a shift to offer more services in the community.  Many common,chronic conditions are already monitored by nurses and other allied medical staff, rather than doctors. Despite long waits, occasional failures and regional inequality, the NHS is, though imperfect. still the best overall health service in the World. 

The increase in lifespan is, for most people, likely to be an experience of better health in middle and later life, so the actual amount of and length of disability and ill health in individual lives may  not increase in direct proportion to  our longer lifespans. 

It is the increase in the numbers of  elderly people in our populations which has to be planned for. Increasing pension age and so keeping the fit elderly working, makes them economically active for longer. but also occupying jobs which would have been vacated in favour of younger workers in the past

As in many things, Wales has less primary health care provision per head of population. According to  BMA figures the number of GP's per head in Wales is low.

GP numbers in the UK :

England 7,613

Scotland 958
Northern Ireland 349
Wales    454

How will the elderly vote and what for?

World Economic Forum Report 2015

An old saying goes, “If you’re not a liberal when you’re young, then you don’t have a heart – but if you haven’t become a conservative when you’re old, then you don’t have a brain.”

In the UK home ownership is said to shift your views to the right and certainly older voters are thought to be less radical. 

 By 2030 the majority of voters in most European Countries will be over 50.

This is part of the conclusion of the World Economic Forum report in 2015. After noting that the elderly are currently politically more likely to support pensions, healthcare and even crime fighting over provision of jobs and housing there is uncertainty as to which way this growing group will act politically.. 

"However, our results also suggest that we should be cautious when projecting age patterns, since they are far from deterministic. In other words, some young liberals may become old conservatives, but it also depends on the economic circumstances and events through which they live".


There is little doubt that there is a significant  growing  expansion of the elderly populations of the developed world. Whatever their  personal politics, in democracies the issues which effect and influence our older citizens are likely to become more and more important as their numbers grow.

Democracy will ensure that the elderly have a bigger voice in the future here in Wales. Already older people vote more often than younger ones, but their growing numbers should significantly affect the political outlook. A 60 year old in wales today can expect, on average, to live a further 25 years. Life expectancy is still increasing, although the rate is slowing, so it could be even more.

In later life will people still follow the tribal politics of their youth or will they mobilise to form powerful groups to represent their own interests? 
Probably a bit of both, but to win power, no party can ignore them. In fact, as the majority of voters will be elderly, every political organisation will be tailoring their message to the mature voter. 

The elderly used to be a relatively easy for governments to ignore. A nod to social conservatism or community policing was all that was needed.

 Closing care homes, reducing social care support , giving the elderly free bus passes while reducing bus services, reorganising health services for the convenience of Health Boards, not patients, planning new home builds for the maximum profit of the developers. not the needs of residents, the elderly have seen these things played out all over Wales. They may decide to use their electoral power to knock some sense into the shallow politicians whose lies have usually gone unchallenged. Many criticise politicians as untrustworthy, self interested and having poor memory of their electoral promises. Now those with the most experience of successful and failed political delivery have the most power to chose their elected representatives. 

Importantly, the older citizen is not only more likely to vote but also more likely to be geographically settled and have more concern for their homes, community and environment. Many financially and practically support younger family members. They will have developed an overview of their local areas and economies based on their personal observations and experiences. 

I doubt the older voters will continue to tolerate the politics of spin, the endless manifesto promises which were never going to be delivered and the same old "jam tomorrow" story of a better, fairer society which has failed to materialise over their long lives. It would be good to see more honesty and candour in politics, with an electorate who, in large part, really have heard it all before! 

Siân Caiach 

Monday, 2 April 2018

Future Wales: Reading the Tombstones - How long shall we live?

As in Education, Wales was devolved a health system which was not quite up to the average standard of facilities throughout the UK. To this add a "sicker" population. We also took over a depressed economy and many areas with inadequate housing and infrastructure. Poorer people tend to have less healthy lifestyles, less adequate housing, and less money to pay for the "extras" available to enhance health, from private services to helpful aids and home modifications. 

Since devolution we do live longer, but there is still a significant gap between Wales and England. However, the overall figures show even within Wales there is great variation. Life expectancy is something easy to quantify as births and deaths are registered.  Why life expectancy is improving is less clear.  Wales is following the trend, but not catching up. Wales may not feel like a rich country but compared with all the world's nations it is one, as it has generally good nutrition and healthcare. However, we should look to improving the standards at least up to the UK average.

Most deaths occur in the elderly and the big killers in 2016 were cancer, 28.5% circulatory illness [heart attack, stroke etc] 25.5% and Alzheimer/other dementia 15.6%. Over 75's are showing a small decrease in mortality.

Prince Phillip Hospital, Llanelli. 


Last year's [2017] data from IDS Scotland indicates a 1 year lag in the average life expectancy of Welsh men – who live to an average 78.4 years from birth- compared to their English equivalents, with Welsh women trailing behind by 0.8 years in living to an average age of 82.3.

In the field of  gross life expectancy the gap between England and Wales is obvious, with the sexes showing similar widening between English and Welsh men and women. The life expectancy increases in both populations but more in England than Wales.

Figure 1: Life expectancy for babies at birth by sex and country - ONS

England and Wales, 1991-1993 to 2012-2014
Male - England
Female - England
Male - Wales
Female - Wales
 Male - England: 74.18
 Female - England: 79.44
 Male - Wales: 73.42
 Female - Wales: 78.99
Source: Office for National Statistics
  1. Figures are based on deaths registered and mid-year population estimates, aggregated over 3 consecutive years.
  2. Figures for each country exclude deaths of non-residents.
  3. Newborn life expectancy has steadily increased in England and Wales since 1991-93. Life expectancy is higher in England then in Wales, while the gap between both countries has widened over the last 2 decades.
  4. The gap between male and female life expectancy at birth has also narrowed in both countries

Looking at the UK as a whole there is notable variation where, as a rule, poorer areas have poorer health.

Figure 3: Life expectancy (LE) at birth for males and females, by local area, UK, 2013 to 2015

  1. Local areas include lower tier local authorities (LTLAs) in England, unitary authorities in Wales, council areas in Scotland and local government districts in Northern Ireland.
  2. Isles of Scilly and City of London have been excluded from the map because of insufficient population counts

Poor health does not necessarily mean hospitals or community health resources are lacking. Nutrition, housing, geographical access, education and lifestyle issues are all factors and these figures above are indications only of how long people currently live. In all the UK countries there are sharp differences between the best and worst areas.


Life expectancy at age 65 differs by up to 5.6 years within U.K. countries

The opposite can be seen for females where the majority of highest and lowest life expectancies are different for each country. The only figure that was the same at birth and at age 65 was the lowest life expectancy in Northern Ireland, which was in Belfast.

In Wales we can be proud that people are living longer and larger portions of our lives are spent in reasonable health. This is common amongst developed countries throughout the world and thought to be due to a combination of healthier living and improved routine successful  treatment of many medical conditions and prevention of others through vaccination and education.

 In Wales the question is always "why the gap?".  We know the gap was there before devolution, and this gap remains despite general  progress in health and longevity.

How long we live is not only a function of formal healthcare but a range of nutritional, social and environmental factors which affect our health. The current movements to reorganise formal hospital based healthcare in Wales seem to be more related to the needs and difficulties of the health care providers than easy access to provision of  healthcare and adequate social care, which is arguably the more pressing concern of the population. 

Although most of us now can look forward to living longer, why are we not be living as long as our neighbours? 

  Siân Caiach