Monthly Archives: April 2018

A Private GP or a paramedic? Paramedics to replace north Wales’ GP home visits

Do you want a Private GP or a Paramedic? Are you aware of the differences in their training and the emphasis on differential diagnosis with a doctor? Would you pay extra to have a GP visit? This is an experiment that may not work! Since Trusts are not insured, but covered by the state compensation fund, (and in Wales the reserved amount is greater than one year’s budget) this could be short termism at it’s worst, as either the beds are still filled, or the litigation bill rises. The post code lottery has dug itself in to N Wales.

BBC News reports 30th April 2018: Paramedics to replace north Wales’ GP home visits

The difference in training time, costs, and then in risk in the two professions is reflected in undercapacity in diagnostic doctors. How did manpower planning get it so wrong? What planning is there for either litigation because of missed diagnoses, or for extra work in the local hospitals as the paramedics fail to reduce attendance? This is an experiment forced upon a government by the rationing of places and the poor manpower planning over decades and successive administrations. Graduate entry to medical school would help – in 10 year’s time.

We have 10 years of undercapacity of doctors in primary care, and in hospitals, particularly A&E, ahead of us. What better advertisement for private GPs to start in N Wales, and what a shame that Aneurin Bevan’s dream of an equal health mutual should be threatened this way.

Blaming the : Doctor shortage ‘fault of immigration rules’ does not fool observers of the 4 health services over a lifetime. Since 9 out of 11 applicants have been rejected, for decades, this is the real reason there is a shortage of doctors.

BBC news:

Traditional GP home visits could soon be performed by rapid response paramedics in a bid to reduce hospital admissions in north Wales.

A team of advanced practice paramedics would be available 24 hours a day 365 days a year.

It is one idea proposed by Betsi Cadwaladr health board (BCUHB) in a bid to transform primary care services.

The Welsh Ambulance Service said paramedics would complement – not replace – some GP practices.

It is hoped it will help stop people ending up in A&E.

A report by BCUHB assistant area director for primary care Wyn Thomas said the scheme would “address the immediate health needs of patients that, if not seen promptly, will end up being an unscheduled care hospital admission”.

The proposal, which aims to free up GPs for daily appointments and reduce A&E admissions, is just one idea to sustain primary care services to be put before the board at its meeting on Wednesday.

Another idea is to set up a “social prescribing service” to improve health and well being and “enable patients to be pro-active in managing their own conditions and well-being”.

Primary care services in north Wales have been under intense pressure in recent years, with one leading medic warning last year that a “crisis” in GP recruitment was “escalating”.

Since 2015, Betsi Cadwaladr University Health Board (BCUHB) has taken over the running of a number of GP practices across north Wales after they terminated their NHS contracts.

Now the board also plans to bring in a “flying squad” of professionals – doctors, nurses and practice managers – to help GP practices struggling with workloads and considering handing back their keys.

From 2015, the Welsh Government gave additional funding to health boards to improve the planning and delivery of primary care services and the BCUHB has already introduced changes.

These include having pharmacists, physiotherapists and other special services embedded in GP practices.

A Welsh Ambulance Service spokesman said it was working with the health board on the initiative to use paramedics for home visits, saying it was “currently in its early stages and contingent on funding”.

“If approved, a group of advanced paramedic practitioners will help to support primary care providers in some areas of north Wales where practices require assistance,” he added.

“We are committed to widening our clinical offer and will continue to work with BCUHB and other partners on system solutions that ultimately support patients.”

“According to the computer, you should be feeling better by now.”


Number of GPs in Wales hits lowest level in a decade

As the number retiring exceeds the number being appointed, the crisi deepens in General Practice. Never has such irresponsible manpower planning led to such a deficit in service. The RCGP rightly says says the situation is ‘unsustainable’. (Mark Smith in Western Mail and Mailonline 28th April 2018) It is ironic that we are talking in West Wales about a new Hospital, because the present 4 do a less than satisfactory job, and investing in Hospitals which already, along with administration take 93% of the health budget. General practice takes 7%. In the 1960s any minister of health when asked what he would like from the then NHS would have said General Practice. And yet, through rationing, denial and poor manpower planning we have virtually destroyed the health services most valuable asset. It is primary care sorting that makes the health services efficient (or not). With too few GPs to man out of hours, with overworked and overstressed doctors, there are too many patients missing out on seeing a GP. NHS111 is a laugh as it creates more work and not less. There is a skill with managing health risks, living with uncertainty appropriately, and giving confidence to patients. This is what is not going, as more patients will see paramedics first. The result will be safety first: over-investigation, over-referral and inefficiency.

The number of GPs working in Wales is at its lowest level in a decade and if the trend continues the service will become unsustainable.

That is according to new data from the Royal College of GPs which claims the workforce needs a major boost to prevent the service from reaching “tipping point”.

In 2017-18, there were 1,926 GPs employed in Wales, excluding locums, retainers and registrars.

That was 100 less than the peak in 2013-14 of 2,026 – and is the lowest since 1,882 in 2006-7.

Between 2016 and 2017 alone, the number fell from 2,009 to 1,926, a drop of 83 GPs or 4.1%.

In response, the Welsh Government said a more “complete measure” of GP numbers would include locums, retainers and registrars.

RCGP Wales claims the fall in the number of GPs comes at a time when demand for general practice continues to rise as a result of a growing population.


organisation says general practice services are now coming under major strain and this is having an impact on GPs’ ability to deliver the quality of care that patients need and deserve.

Dr Rebecca Payne, RCGP chairwoman for Wales, said: “The news that workforce numbers have fallen is very disappointing for GPs and for patients.

“Workforce shortages are already being felt across Wales, there are fewer GPs to cope with rising demand and patients are having to wait longer to see their GP.

“The situation is not sustainable. General practice can be a rewarding and fulfilling profession but the workforce is increasingly stretched for some GPs the pressure is becoming too much.

“It is imperative that the Welsh Government takes urgent action to boost the GP workforce and expand the number of other healthcare professionals working in general practice.”


w Health Secretary Angela Burns said that GPs had been warning of a recruitment crisis for years.

She said: “The Welsh Labour Government’s failure to heed warnings from organisations like the BMA has led to a serious crisis in GP recruitment and retention.

“Not only are they working under considerable pressure, they have also been burdened with the increasing cost of medical insurance. GPs have been warning of a crisis for years, and the issue of reforming their contracts continues to cast a long shadow over the profession.

“These new figures further emphasise the need for systemic, long-term planning of the Welsh NHS, including action to improve recruitment and retention initiatives for frontline staff.

“The Health Secretary continues to champion the ‘Train. Work. Live’ campaign, but it’s fast becoming clear that his department is not only failing to recruit more GPs – it’s failing to support those already working here in Wales.”

Plaid Cymru’s Rhun ap Iorwerth says the latest data is further evidence of Welsh Labour’s “incompetence” over doctor training and recruitment.

He claims the figures were a reminder of the need for a far more concerted effort to train doctors, including new home-grown doctors.

“Yet again we have a reminder that Labour’s failure to take doctor recruitment seriously is creating a crisis that if not addressed will jeopardise health service delivery in many parts of Wales,” he said. “These GP shortages have been predicted for years, with the numbers approaching retirement being highlighted every year, and the stress levels that cause burnout constantly highlighted. This year’s decline could just be the start of a wider fall – it’s already showing we have fewer GPs than 10 years ago.

“The Welsh Government, on their website, are claiming that many of those who have left have become locums – as if that means we shouldn’t worry about this fall in GPs. The complacency expressed about this is breathtaking. Locums are more expensive than permanent staff, and are likely to be working fewer hours.

“It’s also going to make it difficult for people to see their GP when they need to, which creates pressure on A&E and partly explains why we’ve seen the worst performance this winter.

“With Brexit, burnout and retirements putting our health workforce at risk, it’s quite clear we need a plan to train and recruit home grown doctors.

“Such a plan must include increasing training places

nd the development of Medical Training at Bangor, an initiative which Plaid Cymru is driving, which we secured money for through Budget negotiation, but to which the Labour government is being far too resistant.”


The fourth option for West Wales? Do we want “soft lies and gentle indifference”, until we realise the safety net is failing for us personally?

NHSreality has argued that we need to discuss “hard truths” and that the secret of providing health care is in “tough love”, where patients are encouraged to be self sufficient as much as possible. But removing the A&E from a region as large as Pembrokeshire is too tough, and a step too far. I have responded in writing today to the consultation process started by Hywel Dda Board, but with a 4th option which is outside their gift.

The fourth option can be downloaded here. The full text is below.

To: Steve Moore, CEO Hywel Dda University Health Trust Board (HDUTD), Corporate Offices, Ystwyth Building, Hafan Derwen, St Davids Park, Jobswell Road, Carmarthen, SA31 3BB   and Vaughan Gething, Welsh Government, Cardiff

Dear Mr Moore and Mr Gething,

The three suggestions currently put forward by the Hywel Dda board exclude an important 4th option. This is for Hywel Dda to combine with Abertowe Bro Morgannwg as one University Trust Board, and a new Hospital to be built in Pembrokeshire. This option is only within the gift of the WG in Cardiff.

The resulting population would be larger and give improved choice to patients.

At a time of severe under capacity, the junior doctor recruitment issue could be addressed by rotating posts within the new trust. Larger teams of consultants would take their turn in peripheral clinics and operating suites.

The new build should be in Pembrokeshire and has to include treatments which address the large numbers of elderly people in the future. Radiotherapy, cardiovascular services (including stent), and all the other acute services and technologies that encourage doctors to apply for jobs.

Carmarthen and Llanelli already have speedy access to Swansea. Roads westward will need to be improved and Carmarthenshire may then be tempted to use the new facility.

The threat to Pembrokeshire from removing the DGH is bigger than it is for anywhere else in the area, apart from Aberystwyth, which has a guaranteed facility. There could be a large emigration of people, and a real possibility of civil unrest.

Dr Roger W Burns


Copy CC (by e-mail):

Ian Lewis for Walesnline 30th April in Carmarthen:

The rows, petitions and the spectre of failure surrounding how to build a new NHS for west Wales

It’s not going to be plain sailing as a massive consultation on the future of west Wales healthcare gets underway

Paul Davies WAM in WG

Chris James Chair BMA Pembrokeshire and Withybush MEC

Western Telegraph, Western Mail, Milford Mercury

Christine Evans, Chairman, St Thomas’ Surgery PPG

Hywel Dda CHC

Laurence Williams LMC

Pembrokeshire & Carmarthenshire Radio

Owain Clarke for BBC News 19th April: New hospital and Withybush changes in Hywel Dda shake-up plan

Swansea should combine with Hywel Dda, This option is not in the Trusts gift, but is political. And the opportunity afforded by restructuring may be lost if choice and specialist access is not improved…

Update 4th May

NHS should look at ‘home-grown’ talent amid staff crisis levels and …

Western Mail letters: Wednesday, January 24, 2018

Three West Wales hospitals ‘could be closed’ as health board drafts …

Chiefs ‘desperate for health board to get this right’ over West Wales …

Pembrokeshire GP Roger Burns urges ‘fourth option’ (Western Telegraph)

‘No plans to close Withybush A&E before new hospital built’

ITV News: Hospital shake-up plans for west Wales

The Mail 2014: After the Mail’s devastating expose of the Welsh NHS we asked our …




A cross-party solution to NHS pressures?

Laura Keunssberg reports for the BBC News 24th April 2018: A cross-party solution to NHS pressures?

Just before Easter, Theresa May announced she had finally accepted the case for a longer-term, and bigger financial commitment to the NHS.

But how much to pay, and how to find the money is not yet decided.

The Health Secretary, Jeremy Hunt, has appealed to his colleagues for ideas, promising in a letter to all Tory MPs that solutions for the NHS and proposals on social care will be settled by the summer.

But a cross-party group of MPs including former ministers, is again urging the government to convert National Insurance into a specific tax for the NHS.

That proposal is part of a wider set of principles upon which they would base a commission to look at the health service’s long-term pressures, that is being published today.

Most intriguingly, members of the group tell me that Jeremy Hunt is open to their idea.

He has made it plain he accepts there may have to be increases in tax, but hasn’t made a commitment or a case for a particular option.

Potential plan

The government has moved frustratingly slowly for its critics on the fraught and controversial issue of how we should pay for heath care.

Demographics and demand mean the issue is more vital than ever.

The proposals being put forward by MPs as a potential plan are interesting in themselves.

But what’s also intriguing is the fact that MPs of different stripes, officially, have been able to agree them.

I simply can’t remember a different occasion when I have sat across from three MPs from different political tribes and they have not just grudgingly agreed to accept one or other of their rivals’ points, but have deliberately worked together to construct solutions for one of the country’s pressing problems.

Backbench revolution?

There has been a frenzy on occasion recently over whether a new centre party might explode onto the scene.

With frustrations about and suspicion of the front benches of both of our big parties, the idea is raised from time to time, although the genuine evidence of that is scant.

But by their admission, the three MPs I interviewed about their NHS plans are acting together not just because they don’t have much faith in their leaderships to act, but they fear it might be politically impossible for them to do so.

They see this as a gap into which backbenchers might be able to step, and potentially not just on the NHS, but on other issues like housing too.

Don’t write the headlines about a new party, or a new centre, whatever that means.

This is also not a start of some backbench revolution.

We are far from reaching a point where non-ministers can call all the shots.

But it is a growing feature of this minority Parliament that MPs whose places are in the Commons’ cheap seats are making their voices, and Parliament’s shout louder.

Swansea should combine with Hywel Dda, This option is not in the Trusts gift, but is political. And the opportunity afforded by restructuring may be lost if choice and specialist access is not improved…

It is hard to recruit to West Wales. The “little England beyond Wales” is culturally very different from Welsh speaking Carmarthenshire. I used to think Whitland would be near enough, but no longer.

Doctors choose centres of excellence in cities rather than rural areas to work in.

There is an under capacity in diagnostic physicians, and this will remain the case for 10 years.

Reconfiguring West Wales services gives an opportunity to raise standards, reduce infections, accelerate discharge and improve choice.

The medical model is changing, and teams of specialists raise standards fastest.

There has not been the investment in infrastructure that there should have been to speed transport.

Choice for patients needs to be encouraged by the system. A larger Trust ( preferably all of Wales – why not?) will give greater choice.

If a rural area such as Pembrokeshire wishes to recruit consultants and GPs easily, it needs to recognise the drivers for change in the medical profession. New doctors want to have access to new technologies, tests, and treatments. The medical model now involves large teams of specialists raising their standards together. Access to such centres is meant to be “equal” but in effect, especially in Wales, it is dependent on post code. Choice has been restricted to “within your own trust”, and outside referral restricted unless there is no service within your trust. Consultants and their juniors like to have access to specialist investigations, a complete set of treatment options, and research and teaching opportunities.

So why did I move to Pembrokeshire. I enjoy an independent mind-set, and the challenge of working in remote areas. But I saw the possibilities were better where there was a DGH (District General Hospital), a postgraduate centre and teaching opportunities. All these will go if my local hospital closes, or moves outside of the “little England beyond Wales”. I feel cultural affiliation, and when I seek medical care the first language should be one I understand. (English). Consultants arriving in the area were offered subsidised accommodation in a hospital house whilst they looked for a home. New physicians arriving felt they were cared for …

Within GP, the clinical variety and opportunities have reduced, and there is much less room for manoeuvre in todays group practice experience. The shape of the job has changed, and the people in it have changed too. Now it is 80% female reflecting the underperformance of males at age 18 when applying for medical school. It may change even more, because with too few diagnosticians, digital consulting, without an examination may expand, with resultant litigation risk. ( Murray Ellender GPs must embrace digital future – The Times 23rd April 2018 )

The threat to move our hospital outside of our county, and into another tribal area, will not be taken lying down. So we need a solution that allows consultants all the things they want, and our, mainly female, GPs to get what they want. With a 10 year deficit and shortage of diagnostic doctor skills, we have to centralise in some way or other. ( Patients want all services as close as possible, and many would choose local access instead of lower death rates. They will also demand it is all free, for everyone, everywhere, for ever. )

If we take out the hospital we take away part of the culture. House prices will fall further as professionals leave, and choose to live near tertiary care centres. The already dilapidated and sometimes empty heart of the county town will get even more squalid and forgotten. Yes, we can replace one culture with another, more cynical one. People are already disillusioned in the shires, where the vote went against staying in the EU, even though the people there had more to lose. Taking away their hospital without persuading them that it is for the greater good could lead to civil unrest…. and they will also have a Welsh language school they never asked for.

In the end we have to make the new solution attractive to medical applicants, and that means combining Hywel Dda with Swansea so that hospital jobs are rotated, the educational and research opportunities are there for all, and the important services; stents, stroke and radiotherapy are all provided on site. Without Swansea the new hospital needs more money to have the facilities needed to help recruitment and even then it may not be enough.

Dirty surgery such as gut emergencies should be treated in on of the old DGH theatre suites, and the rest of old DGHs become community care recovery centres. The funding must also be changed, so that all the country, patient and professionals, realises that financially, it is founded on a rock rather than sand. This will win hearts and minds.. but it is tough love.

My personal belief is in means related co-payments, scaled and managed centrally. I have some concern about how to deal with citizens who have cash flow poor, but are asset rich, but this can be debated once we agree to ration and use co-payments.

The three options are all reasonable, given the under capacity and recruitment problems described, and NHSreality goes for a new build in Pembrokeshire, along with new roads. If this were done, and/or the trust combined with Swansea, there would be a great improvement in services for West Wales patients. The finances are a different matter, and I expect continued denial all round.

IT – the solution and a problem… Every patient deserves an examination. GPs must not be robots..

Who wants to be a Hywel Dda board member? “Hywel Dda health board looks at hospital closure options”. The obvious solution is to promise a new build at Whitland, and a dualling of roads west.

Hywel Dda under pressure as doctor says ‘Glangwili will not cope’ once Withybush has been downgraded..

A poisoned chalice. Advertisment for Chairman of Hywel Dda…

Hywel Dda Health Board chief executive Trevor Purt to leave his post

Hywel Ddda on the way to the roasting oven of political dissent and civil unrest?

Image result for radiotherapy cartoon


NHS care funding a ‘postcode lottery’, says watchdog

The health watchdog, no less, says “NHS care funding a ‘postcode lottery’, (BBC News 20th April) and this should not surprise readers of NHSreality. Health care, especially in Wales and the rural areas is a lottery, as well as social care. My own mother, now 93 is demented and in a nursing home near Norwich (because we managed to get her in before she was so lost she could not adapt), but if she was a new patient she would be in an Elderly Mentally Infirm home, of which there are not enough. A retired teacher, and taxpayer, she has had no help from the health budget, but she does get attendance allowance. The population explosion in elderly nonagenarians and centenarians is coming, and we have no way forward planned for the expense. It worries those of us who are retired, and vote, that none of the political parties has a solution. Merging health and social care budgets simply compounds and obfuscates the problems.

Care patients are being hit with large bills because of a postcode lottery for NHS funding, a consumer group says.

Which? said people can be “25 times more likely to get their costs covered depending on where they live”.

It found South Reading Clinical Commissioning Group (CCG) paid social care costs for 8.78 patients per 50,000 people while Salford funded 220.38.

The Berkshire CCG said Reading has a very low elderly population – 12% against the national average of 17.7%.

The consumer group analysed NHS funding data for October to December 2017.

It found vulnerable people in England with the most expensive medical needs were not treated in the same way regardless of where they live.

The NHS continuing healthcare scheme is administered by local CCGs. It gives medics a national framework to assess patients, including older people with conditions such as dementia and motor neurone disease.

Top five funding CCGs [per 50k of population]

  • Salford – 220.38
  • Thurrock – 146.49
  • Wolverhampton – 141.19
  • Sutton – 131.96
  • Sunderland – 120.29

Bottom five funding CCGs [per 50k of population]

  • Luton – 20.49
  • Newbury & District – 19.33
  • Wokingham – 18.78
  • North and West Reading – 18.45
  • South Reading – 8.78

Which? also found there were inconsistencies with people living in the same region.

People in the Wolverhampton CCG are more than five times more likely to have their care funded (141.2 patients per 50,000) than their neighbours in Sandwell and West Birmingham (26.3 per 50,000).

Which? also found that nearly all areas are failing to meet the national framework guidance that in most cases people should not wait more than 28 days for a decision about whether they are eligible for funding.

It says it also found examples of families having the funding withdrawn suddenly. One woman was saddled with a £96,000-a-year bill after the needs of her mother – who has severe dementia – were reviewed.

A Department of Health and Social Care spokesman said: “We expect NHS England to ensure those with the highest and most complex health and care needs, who are eligible for this type of funding, have easy access wherever they live in the country so people can get the care they need – and deserve.”

Orkambi rationed for Cystic Fibrosis

It is expensive to develop new drugs. Britain and the UK has a 12 year patent rule, after which the drugs can be made competitively in a “generic” form by any company that can master the production. Development is expensive and a long term risk for companies and investors. Many products have been refused funding by the health services of the UK, until their patent is about to expire, or has expired. Other countries have similar rules. This all means that the payback for investment must be covered in 12 years…….

If governments want to share in the pricing decision, then they need to share in the risk of the research. And of course this will include many failures. 12 years seems a reasonable time frame for payback, until you or your next of kin is the potential beneficiary, and the treatment is effectively rationed. There are many new drugs to come, especially genetically engineered ones, but risky investment will cease if the payback time is reduced. It is a great shame that patients with cystic fibrosis cannot be funded for a new drug. It is, however, reasonable rationing, or tough love. But those who need it in 12 years time can be hopeful that it will be affordable then.

Cystic fibrosis: Company urged to lower cost of life-changing drug – BBC News 21st April 2018

Health ministers have urged a pharmaceutical company to drop the price of a life-changing cystic fibrosis (CF) drug for NHS patients.

Vertex Pharmaceuticals’ Orkambi costs £100,000 a year per patient, and has been deemed too expensive for the NHS.

The company rejected an NHS England counter offer, saying it was not enough to fund research into future medicines…..