Can you hear the joints creaking?

Image copyright bbc
Image caption The Welsh NHS is facing significant challenges over the coming years

On a day like today, Ali Baba comes to mind. How come?

Back in the days when I used to sit and suffer long journeys in the car with Mam and Dad, a educational quiz was an inevitable part of every journey. One day we were driving past Ebbw Vale. Who was the inspirational Welsh politician who hailed from here?

Silence in the back of the car.

Come on, the founder of the NHS? Silence.

A B?

Does that help? I, allegedly, ventured "Ali Baba" much to my older brother's delight.

What would Mr Baba, or even Mr Bevan, make of events today?

The English health service is dominating the headlines once again as the troubled Health and Social Care Bill returns to the Commons. It's been watered down, but not nearly enough for its opponents, many of whom are pointing enviously across the border at the relative stability of the Welsh health service.

If the Bill is passed in its current form, then the two systems will be so different as to be unrecognisable from each another. There are claims that private providers will effectively "take over" the English system under the new arrangements there, while in Wales, it will remain an entirely public health service, true to Aneurin Bevan's vision.

Well, maybe.

Today comes news that the Welsh NHS is considering using the private sector in order to bring down spiralling waits for orthopaedic surgery. The number waiting longer than the target time for for foot, ankle, and spinal surgery has hit 2,000, and according to managers, there's simply not the capacity within the NHS here to meet that key target of no one waiting more than 36 weeks for treatment.

Cardiff and Vale UHB say, along with other boards in South Wales, that discussions are underway with the local independent sector about available capacity, as well as looking to NHS hospitals in Newcastle and London in order to try and tackle the backlog.

It does sound uncannily like the Second Offer scheme from the early 2000s, which used private providers to get on top of waiting lists which, as the Welsh Government would no doubt point out, were way, way longer than they are today.

But at the same time, the Conservatives are equally keen to point out that today's news represents, on the face of it, a pretty huge u-turn from the government.

The One Wales commitment promised to eliminate the use of the private sector in the health service by 2011.

The Labour manifesto for the 2011 elections reinforced that pledge:

"We have delivered on our pledge to reform NHS Trusts to improve accountability, eliminate the use of private sector hospitals in NHS Wales and will continue to rule out the use of PFI in health services."

Asked for their reaction to the news that the NHS in Wales is now planning to buy in private treatment for patients, the government's reaction is very interesting:

"It is prudent for health boards to explore all possible avenues to ensure our targets are met by March."

Prudent? In a nutshell, say the government's opponents, it means - we are ideologically opposed to any use of the private sector by the NHS - except when we can't hit our waiting list targets.

The Tories would argue that makes a mockery of the pledge itself.

Once the rubicon's been crossed, they say, isn't it also equally prudent to do what we would in office and look at what other areas of the NHS the private sector could deliver more efficiently, therefore - potentially - lowering waiting lists across the board?

In reality, treating patients in Wales is far from a purely public enterprise anyway. Take secure and specialist mental health services, for example, which are almost completely reliant on private companies supporting public provision.

Dentists are effectively private practitioners under contract to the health service and paid per patient and treatment. Whither the no private pledge here?

Whenever the former Health Minister Edwina Hart was questioned about the promise to eliminate private provision during the last Assembly term, her logic was clear. Every pound spent in the private sector was a pound not spent building capacity in the public sector.

It made revenue spending seem like investment spending - which in a way it is. The Welsh pound should stay in Wales and work for Wales now and into the future, goes the argument.

The problem comes when you get a crunch, as has happened now in orthopaedics, where there is rapidly growing demand (30 per cent up over the last five years), and shrinking or standstill budgets in the health service, without the capacity to meet that demand.

Cardiff and Vale are now in that position, as are other LHBs, where they are scrambling to recruit consultants, the theatre staff and anaesthetists needed to clear the backlog, but have already identified that available funding will not be sufficient to meet the cost of recurrent or backlog demand.

The political row about today's news will no doubt spill over to when the Assembly returns from recess later this month. But those in the know are looking further ahead about what this says about the shape of the Welsh NHS in future.

They warn that, firm pledge or aspiration, u-turn or pragmatic adaptation to circumstances, this isn't a 'blip', where private sector capacity is needed to deal with a time-limited problem. Referral rates have increased across the board, and will continue to rise, so the issue won't be resolved come next March.

If you can't increase NHS core capacity with now limited investment (which you can't), then we're going to see more and more of the kind of dilemmas illustrated today. The government has two choices in that case - more use of the private sector, or backtrack on target waits.

If ministers decide the former is the least worst option, then perhaps the two health services, in England and Wales, might not end up looking quite so different after all.