December 7, 2015
In the 1976 film All the President’s Men, the informant, Deep Throat, advised the investigative journalists, Woodward and Bernstein, to “follow the money” if they wished to get to get to the bottom of what was going on. And the same advice is likely to apply if we are to evaluate national and local government policy priorities in addressing inequalities.
The vast bulk of public spending in Wales is undertaken by local health boards and local authorities. Probably correctly, the Welsh Government has decided that “big is best” in terms of the size of the these bodies to delivery these services.
Whatever the advantages in bigger delivery bodies they can can create problems in terms of transparency and public accountability as power is concentrated further from communities and citizens. And as our public bodies become bigger and more centralised “following the money” becomes more and more difficult.
A substantial amount of Welsh Government funding is allocated to our health boards and local authorities through needs based formulae. But once the money makes its way to these bodies it is very difficult to monitor if it is being spent in line with the allocation principles. And as these recipient bodies get bigger this task becomes even more difficult.
Local authorities in Wales do not like hypothecation of Welsh Government funds. They wish to be free to make local decisions in line with local needs. But the methodology of resource allocation at a local level is often very opaque and it is very difficult to hold our councils to account in terms of their spending priorities.
In this era of austerity there is no doubt that our most disadvantaged citizens and communities are bearing the heaviest burden. The Welsh Government is working hard to mitigate this though a range of policies but it is crucial that this intention is mirrored where it really matters — at the front-line grass-roots level.
At the end of the day it is outcomes that matter most and it is excellent that programmes such as the Foundation Phase and Flying Start are subject to regular independent evaluation. But in many cases evidence of outcomes can take some time to emerge. In these situations intermediate or proxy measures have to be used and resource allocation ( qualitatively and quantitatively) is often an important guide.
Our most vulnerable citizens and communities are more dependent on public services. They are therefore the most vulnerable when vicious austerity programmes are being implemented. It is vital that effective means are put in place to make sure that our reduced levels of public investment goes to where the need is greatest. Our public bodies must have clear and transparent funding streams in place and that both local and national scrutiny take place to ensure that best outcomes are delivered.
Welsh Health boards cover populations from 132k in Powys to 678k in Betsi Cadwallader. Within health boards 4% of Powys’ population is in the poorest 20% compared to 39% in Cwm Taf and 27% in ABMU. But do we know that within these health boards that resources are allocated in line with this level of need at a local level?
In the recently published policy on primary care workforce, A Planned Primary Care Workforce for Wales, the Welsh Government has highlighted the importance of the emerging 64 “primary care clusters” as a basis for health care planning. These clusters have a population size between 25k and 100k. They are therefore a more sensitive unit size for health care planning on the one hand but also for measuring the level of health care investment and outcomes. Some work has already started on this and the Workforce policy is committed to building on this.
As this information becomes more available it is important that Health Boards “follow the money” and resources to ensure that their allocation is in line with needs and is producing the required outcomes.