This is NHSreality (my own) response to the questions asked by the RCGP in Wales:
1. What matters most to you about health and social care services, and what should we concentrate on to make things better?
An honest language in health and social care rationing. We need to make it clear to citizens what is not available. This might be different for people of different means, but it needs to be overt. (We also need exit interviews conducted by an outside and independent Human Resources body, reporting both to the WG and to the Media in a depersonalised way.)
We need more doctors and nurses, physios and psychologists, all trained in the UK.
2. What do you see as working well?
Very little. Every service is under strain. What continues to work well is the denial of politicians and administrators, the gagging of staff, and the inability of the press and media to sustain a debate on a complex subject.
3. Can you think of any new ideas and good practice you have seen, that could be copied more widely?
I was in the habit of offering “open access” to psychiatric patients before I retired, on a Friday afternoon. I believe all practices would reduce their suicide attempt rate if this was accepted as normal practice. In hospitals I found that Friday afternoons were inadequately staffed (Flexitime?) and so if I was a CEO I would ask that all departmental meetings were ion a Friday afternoon, and have random phone checks on staff to see if they were present.
4. What problems are there in the current systems, and how do they show through in the services people get?
Everyone educated knows that the health systems of the Uk are unsustainable. What they do not know is the different rights of patients, outcomes, mortality and complication rates. These will become more evident over time as the WHO reports on 4 rather than one health system. Devolution has failed for Wales. Free prescriptions discourages autonomy. These problems show through in a disengaged staff, gagging and bullying, lack of exit interviews, particularly for consultants, top nurses and trust board members, but in general for all staff.
5. What do you understand by integration of health and social care and what do you think a fully integrated service looks like in practice?
There are risks in integration. These are made worse if rationing is not overt. Whilst the average citizen feels that he is covered for “everything for everyone for ever”, we will not get progress, or reality. I think that if we continue down the way we are, civil unrest is likely as systems fail, and important treatments are unavailable. Elderly, terminal, palliative, and mentally ill people are politically soft targets compared to those who will vote for many years.
6. What do you think stops improvement from happening and how could this be overcome?
Dishonesty and lies. Top officials unable to lead by articulating the truth. Disengaged staff who realise the whole of their health safety net is founded on sand, and holed.
This can only be overcome by new leadership, an honesty which is seen as a summary of the “hard truths” of a society where the technology is advancing faster than our ability to pay for it. This needs p[political permission and a long term approach to subjects such as manpower provision. The long term means longer than one or even two terms of office. Giving the people of Wales the opportunity to vote on reversal of devolution, returning to England and Wales, and having more money for health and education might help.
7. What more can people do to look after their own health and well-being?
Bring back prescription charges. Introduce ID cards with tax status on them, and a scale of fees related to income. This means waiting lists will have to be mush better/shorter and therefore such a system can only be introduced once there is an “excess” or overcapacity in trained UK doctors. (preferably graduates)
8. What improvements can be made to information and advice to help patients make decisions with professionals about care?
The rules of the game need to change.. Look at NZ and Scandinavia.. for sustainability.
A limited list of drugs. if patients prefer off the list they pay. Many more therapists as an option instead of (not as an adjunct( to drugs. More public health consultants. One IT notes system in Wales, starting with General Practice, and then expanding into A&E, etc. It will spread like a cancer.
9. Please tell us about any ideas you may have that you think could deliver real improvements to services.
Focus on Friday afternoons. Have a Full Time service until 17.00 at least, and until 22.00 hrs for Psychiatry. Allow GPs to escape from QOF. Performance related pay is all very well for a short period of time (2-3 years) but after that it demotivates.
10. What do you think should be covered by national rules and what should be left for local managers and professionals to decide?
Local rationing of services has to come, and should apply to high volume low cost items. National rationing should be about (as few as possible) high cost and low volume services. In this way there is local “choice”, but as little post code rationing differences of important and fearful conditions as possible. Co-payments according to means could work once waiting lists are short and there is an oversupply of doctos. If patients are on the lowest possible income and unemployed they should still pay something for everything, but get it back in their next Social Security payment. the cost of all services should be on the obverse or at the bottom of the paper. Eg Out patients, Scans etc.
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