Liberal beliefs need to be modified pragmatically to create a sustainable health service – especially in Wales

This site has been running for 3 years, and the majority of readers are professionals in the Health Services and supporting areas. You can follow by either registering ” on site” or by asking me to “link in” or become friends through facebook. For twitter feed you do not need to link and I have no idea of how many followers of NHSreality there are. Please spread the word with the link to all your contacts… the former NHS has gone, and the Regional Health Services are dying. There is now no NHS according to WHO: but we were all of us children of the original NHS.. Politicians are in denial and letting everyone down with their dishonesty..

The new philosophy of honesty and the inconvenient truth of covert rationing is explained,


in the beginning we pointed out the impossibility of quality and cost objectives both being met.

Recently another GP, John Evans from Solva has joined me in postings. He and I have different positions on the EU but otherwise we concur on the UK health services.

The major theme is that as a mutual all health services are more powerful if they are larger. They can offer more specialist services, more choice, and better outcomes. We feel that there is no longer, in practical ways that apply to citizens/patients, a National Health Service.

We believe obfuscation and denial, by politicians and the media, has led to a situation where the professionals no longer believe that their health service is founded on a rock, either ideologically or financially.

The result has been increasing “covert rationing” as technology and information advances faster that the state’s ability to pay.

The outcome of this is an increasing health divide. Those who can choose to exercise choice and go privately. Those who cannot suffer longer waiting times, lack of choice, worse outcomes and in the end this will lead to shorter lives.

Our suggestions are several and have (some of them) been adopted by BMA Wales. Meetings have poor turnouts due to a disengaged profession but those who have done have been persuaded. The suggestions all address the longer term. We have no solutions to GP and Nurse shortages in the shorter term other than importing them, as we have done in the past. If we do this standards will fall and opportunities for our own to train and find work will be reduced in the same cycle of undercapacity as we entered in the 1960s. To protect a longer term solution imported staff should be on 10 year visas with renewable options at the discretion of local authorities.


  1. Exit interviews should be done on all Health Service Staff, especially nursing sisters, consultants and board members, by an independent HR body. These should be summarised and fed back to Deaneries, Trust Boards and the Ministers in a depersonalised way at 6 monthly intervals. Retiring staff should have the option to put their exit interview in the public domain, provided it is not libellous.
  2. Rationing should be made overt. Trust boards should be free to ration low cost high volume services in their area. Regions should make the rationing decisions at Regional level for the low volume high cost treatments. Obviously, we can have more of the latter if we have less of the former.
  3. Medical Training should be “post-graduate” and not undergraduate. (Gender bias dealt with) and the Deaneries should be forced to send their students out into the periphery, where they will be based on DGHs. They need only attend Cardiff for assessments, and most teaching and tutorials can be “on line”. In this way doctors and nurses will become part of a community at a younger age, and more likely to stay.
  4. Whistleblowers need to be the first people in the honours list. The educational portfolios should have a “bullying” and a “poor culture” button which alerts the educational supervisor and the Deanery concurrently. The trainee should be taught how to protect himself by only entering such reports once he has been signed up.
  5. Elected representatives need their constituencies to be coincident with “health Areas” so that perverse decisions are less likely and exposed.. PR of any form will help less perverse incentives and outcomes such as the one to destroy the chances of a new build hospital at Whitland/Narberth some 8 years ago. Health boards need to be equally representative, and debates about ideology conflicting with finance need to be overt.
  6. In the end people will never be completely happy with a health service, but they will appreciate the inconvenient truth: we cannot have everything for everyone for ever. Pragmatic and overt rationing whereby citizens know what is not available to them is better.
  7. Fairness may demand different levels of rationing for those on different incomes.
  8. Co-payments for example could be geared to income tax codes, through an identity card. This would be revolutionary, but such a card could be used at times of war (the new war may be constant and terrorist related)

to monitor movements at all transport points, used for bank account entry etc. I appreciate this is illiberal, but it is a debate we need before the big terrorist event rather than after. Liberal need to think, in all our policies, where liberty ends. If the benefit to society justifies a relatively small loss of liberty then I support it. For example, ID cards at transport points could be discarded if things look up.

  1. One health authority for 3m people in Wales is sufficient. It would win the votes of most of the health professionals as they would regain choice. Why did we vote against Plaid?
  2. All health services should have the true cost printed on them, and the cost to the patient alongside. If “free” or a co-payment it matters little. Prescription charges could be reintroduced on a sliding scale if we linked to an ID tax card. Charges might be pragmatic for A&E(higher for drunks), and for GP visits, once again with sliding scales.
  3. Foreign Nationals without an E111 would be charged immediately by bank card.

I look forward to Greek style  debates on some of these issues. If we do not put our Welsh Health Service on a secure financial footing we are going to perpetuate the opposite of what Aneurin Bevan intended, and increase inequalities. It has already happened in Dentistry and Physiotherapy, (and Legal Aid), and shortly it will happen – private GPs will begin.

A new philosophy, what I believe: allow Trust Board members to use the language of rationing in media press releases

Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS

A reminder in poetry: “I am a child of the NHS”

A poem a day will keep your loss of empathy at bay, doctor

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…




This entry was posted in A Personal View, Rationing on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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