Author Archives: John D

Regionalisation Bites Monmouthshire Patients.. GPs Bite Back

Monmouthshire patients ‘forced to use Welsh hospitals’

On 7 April 2013 the BBC reported that ‘Some patients claim they are being forced to use “rundown” Welsh hospitals rather than more convenient English hospitals with better facilities.’ and that ‘The Monmouthshire residents say new cross-border rules mean the Welsh government is “dictating” where they can receive hospital treatment.’

Forest of Dean GPs ‘angry’ over cross-border policy changes

On 17 April 2013 a further report said that ‘About 10% of doctors in the Forest of Dean are retiring early in protest over policy changes, a former GP has said. Dr Peter Fellows said there was a lot of anger over Welsh government changes to stop its GPs referring patients to hospitals in England. This affects patients at three Welsh-registered surgeries in the Forest.’

The  [ironically named] Aneurin Bevan Health Board said ‘patient choice was an English NHS policy and not the basis of the health system in Wales.’  But then added that ‘there were some exceptions to the rule.’

We say: The NHS is not just under threat from privatisation of services. We no longer have a National Health Service but an increasingly regionalised one where different rules apply depending on where you live in the UK. Not only that but the ‘rules’ can, it seems, have exceptions. So what is the statement of policy for the Welsh Regional Health Service, and when will patients need passports or ID cards to claim their access to health services? What attitude does the WAG have to “gaming” to obtain choice, as described on the “choice” page in this website?

Is anyone else frustrated by this?  Let us know or provide further examples by replying to this post.

Interview with Peter Milewski retired General Surgeon

Mr Peter Milewski is a retired General Surgeon with a particular interest in Gut Surgery at Withybush Hospital

10th April 2013.

See also – Interview with Paul Davies (WAM) for Pembrokeshire. Don’t be afraid to interview your MP or WAM or SAM or other professionally elected member – and send the Audio file to this site.

Interview with Julie Milewski, retired Nursing Sister

Julie Milewski is a retired Nursing Sister, formerly in charge of Theatres at Withybush Hospital, Pembrokeshire.

10th April 2013.

To come shortly – Interview with Paul Davies (WAM) for Pembrokeshire. Don’t be afraid to interview your MP or WAM or SAM or other professionally elected member – and send the Audio file to this site.

Interview with Kim O’Doherty, retired GP

Kim O’Doherty is a retired GP from Saundersfoot, Pembrokeshire.

10th April 2013.

To come shortly – Interview with Paul Davies (WAM) for Pembrokeshire. Don’t be afraid to interview your MP or WAM or SAM or other professionally elected member – and send the Audio file to this site.

Rationing a Global Perspective

What is health care rationing? ….The Kings Fund says to beware if it is not done by doctors… But they admit it has to happen (1999!!).. Rationing of services to patients is occurring but in a covert and post code manner different in different areas of the country. I would suggest that, if it is a National Health Service, that high end (expensive service) rationing should be universal and fair, but low end rationing could be local (and pragmatically but unfortunately unfair). Please let me have copy letters as examples of rationing – these will be listed at bottom of this page..

I welcome suggestions to new links and articles regarding overt rationing around the world. Please contact me if you can make a contribution. The Nuffield Trust and the Kings fund are clear that we should be thinking about it, and if it has to be, that rationing should be overt. One of its foremost thinkers is John Appleby. If you would like to download the Kings fund document (2012) it is here.

The House of Lords has a Committee to consider the impact of demograhic changes on Public Services. Its original background report  and “call for evidence” (also on You Tube) has been met, and the conclusion as reported in the BBC, is that we are woefully unprepared and that public services may disintegrate if we do not reconstruct and re-invent them.

There will be much debate about methodology once rationing is accepted. A suggested model comes from Holland.


Another country, which used to have an NHS like approach (Covert rationing by area and Post Code) has changed and for the last 20 years has controlled its costs much more effectively, whilst encouraging autonomy for high volume low cost items. This is New Zealand and this perspective by W. Edgar, director of the NZ National Health Committee makes the process overt. Discussion in journals such as Law Medicine and  Ethics has also been interesting.

Is it time to look abroad (The Times) for new models?

Holland has an insurance based system with obligatory state cover for those without means.

Germany has a tiered insurance system.

Australia as New Zealand has a mixed service with co-payments for entry.

Canada’s system is based on the NHS but has a method of fiscal transfers (Health Canada is not responsible for the funding of Canada’s health care system. The federal government provides funding to the provinces and territories for health care services through fiscal transfers.)

The USA is a complex picture of mainly private provision (for adults) and state provision newly agreed for children under Mr Obama. Improvements in child and perinatal mortality and morbidity are inevitable, and so opponents are going to do everything they can to sabotage before the same improvements we had in the UK are universal in the USA. Proof figures should come out in 2-3 years time… Meanwhile Wikipedia is the best site I have found for US heath care. Try the official US government portal, but remember you will not be covered unless you take out special insurance for a visit.

comparison between US and Canada is also available on Wikipedia.

The Irish Medical System has two leveover depending on means. The Irish dont try to pretend that everyone will have an equal service and so they ration healthcare effectively. Wikpiedia gives a non biased account.

Examples of rationing.

  • Infertility treatment access differs in different regions.
  • Obesity surgery indicators differ in different regions.
  • Prescription charges.

Cancer treatment. In most European countries a diagnosis of Cancer prostate would invoke an immediate referral for radiotherapy if that was part of the treatment of choice. Even in low grade prostate cancer, the reassurance that treatment is not delayed is helpful to the patient however here is an example of the information which is provided [complete with typo in last line], and when the patient asked the likely waiting time for radiotherapy the answer was “at least 6 months”.

A Personal View

Open Government mean that nothing is hidden unless it might do more harm .. Covert rationing is all around us. Is it harmful to let us know the reality?

I wrote the following article for our local paper but it has not been published – editors prerogative.

Not Everything We Want Is What We Need

Not everything we want is what we need. Sweets, biscuits, ice creams, inactivity, obesity and diabetes testify to this.

Do we really need so many planned operations to be “local”? The Longley report shows that specialist units reduce death and complication rates. I get the impression that Pembrokeshire citizens might vote for higher rates of both if their services remain local – can this be true?

Doctors will need to be peripatetic. The consultant will work in the specialist unit, but he will also be doing out-patients near you. Blood samples & Images can be sent to a centre, but the face to face discussion between specialists somehow needs to be preserved – Skype? The specialist teams will discuss options, complications, and will raise standards. There has always been a medical recruitment issue in West Wales: bigger units will attract more doctors.
120,000 persons are not enough to supply a modern DGH. Longley has proved this. Most doctors themselves, given the choice, will opt for a specialist uniti.
Local representatives will always petition for their “voters” before they accept the utilitarian view that the health board members ii are paid to deliver. It is right to re-organise, and it was wrong to reject the option (acceptable now?) of a new build 5 years ago. We have got too much of what we wanted then, and not what we need now.

i The fact that patients don’t have choice to go outside of Hywel Dda is worrying, and puts us at a disadvantage with English patients. They can choose, under their NHS, to go to Cardiff for an operation which we in Pembrokeshire cannot. Worse still, the information needed to make a choice is not available to GPs (and patients) in Wales, and GPs are less and less informed about services outside their own local trust.

ii Spare a thought for your Trust Board: constrained by the edicts of WAG. The really deep problem is our lack of a philosophical debate, but this needs a separate article and probably a different medium for adequate discussion. This is the responsibility of politicians – but they are ducking it. The tensions in our society, and in the profession, do not bode well for a happy 2013.

Dr. Roger Burns

The Healthier Life

The Healthier Life say on their website “We are the web’s leading natural and alternative health resource! Our pioneering experts report the latest breakthroughs in natural medicine often years before you’ll ever hear about them in the mainstream media.”