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,