Doctor shortages in the valley town that inspired the NHS

Doctor shortages in the valley town that inspired the NHS BMJ 2018; 362 

The recruitment crisis in Aneurin Bevan’s hometown and the surrounding south Wales area exemplifies the challenge faced across the country and rest of the UK. Jenny Sims reports from Tredegar

The birthplace of the NHS is generally acknowledged as Trafford General Hospital, Manchester, officially opened by Aneurin Bevan as Park Hospital on 5 July 1948. But 70 years on, it is still Bevan’s home town of Tredegar, southeast Wales, that can be regarded as where the service was conceived.

Bevan, then health minister, openly boasted that he was basing his ideas for the NHS on the Tredegar Medical Society, which provided free healthcare in the town for iron, coal, and other industry workers, who paid a halfpenny a week into a “sick fund” to run it. “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to Tredegar-ise you,” said Bevan, according to a quote etched on a plaque in the town.

That meant providing free services for all at the point of delivery, based on clinical need not ability to pay. But today, Tredegar, like many towns throughout the UK, is struggling to meet those needs and provide those services.

Major sustainability concerns

The population of around 14 000 is served by two general practices, one of which, the Tredegar Health Centre, was handed back to Aneurin Bevan University Health Board on 1 April because its two GPs want to retire.

A report to the local council in October 2017 described Tredegar as an area with “high levels of deprivation, unhealthy lifestyles and associated ill health.” It said, “The current GP premises are outdated and not fit for purpose. They do not facilitate multi-professional working, [are] lacking in expansion space and are not conducive to deliver modern primary care.”1 It went on to warn there was major concern about GP sustainability.

Gwent local medical committee chair, Deborah Waters, whose practice in Pontypool, less than 15 miles from Tredegar, has had a GP vacancy since September, is blunt: “Primary care is in crisis because we can’t recruit enough GPs or retain them. It’s not just a problem for Tredegar and the other valley towns, but throughout Wales.”

A BMA “heat map” shows that 74 practices across Wales are in danger of closure because of recruitment challenges (fig 1).2 It’s a message Waters has given to two Welsh health secretaries over recent years. “This one [Vaughan Gething] seems to be listening,” says Waters.

Fig 1

BMA heat map of Welsh general practice using data collected between October 2015 and April 2017 (Other=practice has indicated its future is uncertain or has scored high on the sustainability risk matrix). Further details are available at https://www.bma.org.uk/~/asset/4/30168.ashx4

Raft of policies

Gething, who has been health secretary since 2016 and was made additionally responsible for social services in a cabinet reshuffle in November last year, has called for radical change in how both services are run to ensure the survival of the NHS in Wales. Recognition that this overhaul is necessary is evidenced by a raft of Welsh government policies and service reforms aimed at integrating health and social care, expanding medical education, and providing new funding for various services—all aimed at improving people’s health and wellbeing and easing doctor shortages.

These include the creation of Health Education and Improvement Wales, a single body to develop the Welsh healthcare workforce that comes into effect on 1 October, and a long term plan for health and social care, A Healthier Wales.3

They build on other policies launched when Gething was deputy health secretary. For example, the 2014 primary care plan,4 which promoted physical, mental, and social wellbeing rather than the absence of ill health, and The Well-being of Future Generations (Wales) Act 2015, which requires public bodies to take an integrated and collaborative approach to find shared solutions, looking to the long term needs of future generations.

To help implement these policies, the country has been split into locality networks, with some GPs working collaboratively in 64 clusters with other health and care professionals to support them plan and deliver health services. In Blaenau Gwent county a health and wellbeing centre (an integrated health and social care model) is planned in Tredegar, into which the Tredegar Health Centre will relocate.

Selling the lifestyle

Many recruitment campaigns aimed at attracting doctors to Wales focus on lifestyle and quality of life, as well as career opportunities. Two Welsh doctors who have returned, partly for the quality of life are David Baker, a consultant trauma and orthopaedic surgeon at Neville Hall Hospital, Gwent, and Rebecca Nicholls, who has just started a three year specialist training post in forensic psychiatry in Bridgend.

Baker, born in Tredegar, left at 18 for medical school in Leicester, did his registrar training in London, and worked “all over the place” in England. He says: “I wanted to come back to my roots and connections. People are friendly and welcoming, the countryside’s great, and there are lots of opportunities.” (His wife, a former school teacher, is also from Wales.)

One reason Nicholls chose psychiatry over general practice was for the longer consultation times with patients. Born in Ebbw Vale (Bevan’s parliamentary constituency, just over three miles from Tredegar), she admits one of her reasons for choosing to go to Bristol Medical School was: “I wanted to get out of Wales.” But five years after returning to train and work in Wales, she and her husband have decided to stay. “We have friends and families here, people are friendly—and houses are cheaper.”

For the future, there is consensus that the best chance of retaining doctors in Wales is for medical schools to train more students from Wales. To this end, efforts are being made to expand medical school intake and encourage applications from students from diverse and underprivileged backgrounds.5

Case study: Glan yr Afon GP practice, Tredegar, Blaenau Gwent

A four partner practice serving more than 6700 patients, Glan yr Afon is down to a partnership of two GPs, supported by locums and an out-of-hours service.

GP Krishan Syal celebrated his 70th birthday on 1 August, but he will not be retiring. Nor has he any hopes or plans of doing so any time soon because continuous and concerted efforts to recruit a new GP partner have failed.

Having lured his younger partner, Georgy Mathews, 41, from a salaried job in Newport six years ago, Syal says: “I’m staying on now because of him. I don’t want to let him down.”

Originally from the Punjab, Syal came to the UK for its better job prospects. Trained in general medicine, then anaesthetics, he married, had a family, and moved from a hospital job in Wolverhampton to a general practice in the Rhondda valley in 1981, and then to the Tredegar partnership with another GP (since retired) in 2006.

“It was a good move, and there was no shortage of GPs then,” he recalls. Over time the town has slid into economic decline. But Syal doesn’t look back through rose tinted glasses. “A GP’s life wasn’t easier. When I started I was on call 24 hours, seven days a week and bank holidays,” he says.

Mathews, after qualifying in southern India, also came to the UK to gain further qualifications and experience. “My aim then was to go back,” he says. But now he’s settled in Cardiff with his family and understands the reluctance and apprehension of younger GPs who do not want to commute or commit to the workload, management, and financial risks involved in taking on a partnership.

Mathews dreams of Glan yr Afon become a training practice, which would stand a better chance of attracting future partners, he believes.