I am writing this blog because we must stimulate a public, professional and managerial debate on the future of the NHS and junior doctor training in Wales – the foundations on which the NHS stands are being weakened even as I write.
I apologise in advance, for what is necessarily a long blog, as I touch on the inter-related issues of service provision, medical training, geography, cost, and – above all – urgency. Please bear with me!
The problem is that NHS Wales’ current dependence on junior doctors (primarily here for training, but used as the foundation for service delivery) is unsustainable. This is about recruitment, retention and variation in the standards of training in Wales. A previous report into training (Calman) envisaged patients being seen less often by trainees and more often by specialists and consultants, but this has not materialised in many Health Board areas, particularly in the acute and emergency specialties.
I worry that so few people have an over-arching appreciation of just how many different factors need to be aligned to dig the NHS in Wales out of its current predicament or how soon this needs to be done.
It is clear to me that the NHS in Wales must take immediate action to decouple the NHS from training in some hospitals. Failing that, both emergency and acute services in the NHS face imminent collapse from August 2014, because of an apparent failure of the service to plan far enough ahead for anticipated reductions in trainee numbers in key specialties.
The time is upon us for action – neither delay nor prevarication can be the response. There seems to have been a lack of prospective action by Health Boards over the last 3 years, despite being warned several times of the reductions in trainees.
It is possible that the newly published Greenaway Report (on the future shape of medical training) will help with training in Emergency Medicine, Paediatrics and Psychiatry in the medium and longer term, but this will take time to implement. The time for that to translate into outcomes just does not exist for the NHS in Wales.
The challenges in north Wales demonstrate the dilemma faced by rurality on the one hand whilst having cross border services geographically near by for those in the East, but three acute hospital sites on Welsh soil. Here, the challenge will be to have junior doctors on sites that can deliver training specific to their identified training needs, with a faculty of qualified trainers – most likely on two of the three acute sites. Different levels of trainees could be found on one tier of a rota at one hospital and others at another. This is not an all or nothing solution – services can (and must) be maintained on 3 sites with consultant and SAS Doctors, some of whom may wish to work towards Certificates of Eligibility for Specialist Registration. The value of this work needs to be clearly recognised. Yet the main topic of conversation seems to be of who will and will not be able to keep their bit of service open. This is unhelpful because it does not put the needs of patients first.
We cannot allow the changes in training and services to widen health inequalities, yet the needs of our patients do not seem to be at the forefront of many of the current discussions and future decisions being tabled. We seem to be moulding the patients to fit the NHS rather than building an NHS based on the needs of the population of Wales. Put bluntly, it is completely unnecessary, in my view, to make large numbers of patients have to travel 60-80 miles for relatively straightforward conditions or services (such as having a baby, for example).
There are new opportunities for academics and researchers to bring a different focus on each site and within different departments. North Wales has strong links with several universities, but the ‘U’ (University) in UHB remains unexploited for the benefit of the people of north Wales.
The timescale for the Deanery reconfiguration plans are ahead of those in the service and relocating or concentrating services on alternative sites takes both time and resources (financial and staff) to set up. Current gaps are often bridged by expensive locum staff, for example, so there will be a need to train non-medical practitioners, but we would suggest valuing and building on the excellent service given by Staff and Associate Specialist doctors throughout Wales.
The recent sums of money announced by Welsh Government to support transition are welcome, but seem designed only to prop up an existing service creaking at the seams, rather than address the needs of the massive reconfiguration phase staring us in the face. Now more than ever, the public needs to debate with politicians, both locally and nationally, to obtain clarity about what the future holds.
We cannot ignore the need for high quality postgraduate medical training in the solution. BMA Cymru Wales understands and supports the need to enhance and protect postgraduate training in Wales. The Wales Deanery has seen its funding cut and many training posts go un-filled in less popular services such as Emergency Medicine and Psychiatry, especially outside Cardiff and Swansea. This exposes rural parts of Wales to the prospect of the collapse of several services unless something is done urgently to join up the strategy across both healthcare and higher education sectors – for the benefit of the whole of the Welsh nation.
The matching of trainees to qualified trainers is more appropriate than broad-brush 1:11 training rotas that cannot possible provide enough clinical cases in the average hospital; which form the backbone of the NHS in Wales. It is perfectly possible, given the will, for the NHS to protect a smaller number of trainees such that rotas can be 1:8 in line with those in other UK Deaneries. The problem arises when trainees are used to fill gaps in service rotas, such that their training suffers – hence building the oft-touted 1:11 rotas becomes one challenge too far. An alternative would be for each Health Board to make the commitment for non-training doctors to bridge such gaps.
As a profession, we cannot continue to ignore what is going on .The alternative is to see the slash and burn of many elective, and some emergency, services and even more prolonged waiting lists, while the service catches up with the junior doctor staffing crisis that it has had warning of for several years. As now, the solution to this may end up being patchy, reactive, and ad hoc. Creating hugely expensive waiting list initiatives or transferring patients either to England or the private sector isn’t the answer. Each can be equally wasteful of Welsh NHS money. That is not to say, of course, that some specialised services couldn’t be provided with closer links with partners across our border, where this has clear benefits for Welsh residents.
There is absolutely no reason why the NHS in Wales should be re-shaped by a “collapse by default”, so 2014 will be a pivotal year – we will either be lamenting the removal of substantial portions of the NHS for many patients, or we will be celebrating a unique NHS for our nation that could be the envy of the world.
Let’s be clear – it doesn’t have to be like this. Only by collaboration and co-operation will the NHS in Wales plan and train it’s way out of this impending disaster.
Yes, there are commentators who believe that the devolved nations can avoid copying the fundamental dismantling of the NHS in England. Our solution to a population living longer and having more complex medical and social needs should have “Made in Wales” written through it.
BMA Cymru Wales remains committed to professional and intellectual engagement during the transition from our current unsustainable position to the new NHS in Wales.
I’m reminded of one of my favourite film lines, where Lord Scrumptious said to Caractacus Potts in the children’s film Chitty Chitty Bang Bang “Had your chance, muffed it”.
As we enter 2014, let us hope that the same cannot be said to those creating the future of the NHS in Wales.