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,

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