Category Archives: Professionals

Why not implement no-fault compensation? Because it needs a longer term perspective and a PR system to get it through.

Frances Gibb reports in The Times 23rd June 2017: Medical negligence payouts ‘unaffordable’

Reforms to curb the soaring costs of medical negligence, which could see taxpayers paying out £2.6 billion a year by 2022, must go ahead, a report has urged.
The NHS spent £1.5 billion on clinical negligence claims last year, enough to train more than 6,500 doctors, the Medical Protection Society said. The not-for-profit organisation , which supports 300,000 healthcare professionals worldwide, is calling for a package of legal reforms that would strike a balance between compensation that is reasonable but also affordable.
Its proposals include a cap on future care costs which would be paid on a tariff to be agreed by an expert working party. It also wants to use national average weekly earnings to calculate damages awarded, to avoid unfairness between high and low-income earners.

and the comments are good as well. In Wales the amount set aside for future litigation/compensation is more than one year’s budget. Why not implement no-fault compensation scheme? Because it needs a longer term perspective and a PR system to get it through. Apologies would then be like confetti..

Image result for confetti cartoonand that’s not to mention apologies from our masters re both contract and staffing levels:

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Scotland (and I hope Wales will follow) has announced legislation to protect doctors if and when they apologise. Doctors in Scotland get legal protection when apologising, explains MDU

Doctors in Scotland are being given legal protection when apologising to patients, the Medical Defence Union (MDU), explained today.

The Apologies (Scotland) Act 2016, the relevant part of which comes into force on 19 June 2017, makes it clear that an apology (outside of legal proceedings) is not an admission of liability. In the new Act, an apology is defined as:

‘…any statement made by or on behalf of a person which indicates that the person is sorry about, or regrets, an act, omission or outcome and includes any part of the statement which contains an undertaking to look at the circumstances giving rise to the act, omission or outcome with a view to preventing a recurrence.’

Mr Jerard Ross, MDU medico-legal adviser, said:

‘Saying sorry to a patient when something has gone wrong is the right thing to do and is an ethical duty for doctors. The Apologies (Scotland) Act provides further reassurance to doctors that apologising is not an admission of legal liability. In the MDU’s experience, a sincere and frank apology and explanation can help restore a patient’s confidence in their doctor following an error and help to rebuild trust. This is important for a patient’s future healthcare and can help to avoid a complaint or litigation.’

Doctors have a professional duty of candour, set out in the General Medical Council’s Good medical practice which states: ‘You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress you should put matters right (if that is possible), offer an apology, explaining fully and promptly what has happened and the likely short-term and long-term effects.’

A legal duty of candour was also introduced for health and social care providers in Scotland under The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 although it has yet to be brought into force by enabling legislation. It will mean that doctors and other health and social care staff in Scotland will have to inform patients and their families when a patient has, in the reasonable opinion of an uninvolved registered health professional, died or been unintentionally or unexpectedly mentally or physically harmed as a result of their care or treatment.

Although the Apologies Act does not apply to the legal duty of candour, the Health Act itself makes it clear that ‘an apology or other step taken in accordance with the Duty of Candour…does not of itself amount to admission of negligence or breach of a statutory duty’.

The GMC has published ethical guidance on the professional duty of candour which explains in more detail what constitutes an effective apology for healthcare professionals. This includes advice that apologies should not be formulaic and that the most appropriate team member, usually the lead clinician, should consider offering a personalised apology, rather than a general expression of regret.

In Wales the amount set aside for future litigation/compensation is more than one year’s budget.

David Williamson for Walesonline 30th Dec 2016 : More than £600m allocated to pay for clinical negligence and personal injury claims against the Welsh NHS in the future

In the last financial year £74.6m was paid out and £682m has been set aside for future payments

NHS faces ‘compensation time bomb’ as clinical negligence …  GP online25 Jul 2016

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BBC News28 Nov 2016


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Leimyoscarcoma treatment options unfair…. in west Wales where choice is anathema.

I do not mind if something/some service is denied to everyone in the UK paying into the same mutual. What I do not like to hear is when someone in my town and post code is denied a treatment which is available in London. The National Sarcoma centre is at the Marsden, and there is a National Sarcoma Service. Unfortunately, unbeknown to the citizens and taxpayers of Pembrokeshire, until they suffer from sarcoma, is that this service is not available to them. This is what NHSreality calls COVERT rationing because one is not aware of it in advance. Net result is that money is raised, and this one patient gets “private” care. What about all the others in Wales? Local exclusion would be all very well for high volume low cost treatments, (this is not allowed) but is patently unjust for low volume high cost treatments. (allowed under the current “rules of the game”) Will the trust respond by saying they feel this is reasonable rationing? No way. They will use the words exclusion, restriction or prioritisation to justify their position. As a trust in special measures ( bankrupt and getting worse) it is not surprising they wish to save money… and the treatment may be poor value for money but this shows how unfair the situation is for those in West Wales, and it is repeated across many specialities and treatments.

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BBC News reports today 23rd June 2017: Haverfordwest mum’s ‘roadblocks’ to SIRT cancer treatment

NHS Wales has been accused of “not being set up to deal with” certain types of cancer.

Anca Falconer, 36, from Pembrokeshire, was diagnosed with Leiomyosarcoma (LMS), a type of soft tissue sarcoma, just days after giving birth in 2010.

Her request for specialist treatment in England was refused.

The Welsh Health Specialised Services Committee said the success of Selective Internal Radiation Therapy (SIRT) “has not currently been established.”

Mrs Falconer, who lives in Haverfordwest, initially underwent extensive surgery and chemotherapy for her rare liver cancer, but it returned.

Her first request to the committee was rejected in 2013 on funding grounds, and her cancer consultant refused to submit another application, describing the efforts as being “futile”, and she was told she would have to find the money herself.

Fundraising efforts allowed her to receive the first round of SIRT, which involves injecting radioactive microbeads into the liver, at a cost of £10,000.

Mrs Falconer, who had been bedbound for about three months, said she felt transformed after the treatment.

“Within days I was able to stand up again. I can play with Mary and take her to school,” she said. “I had lost hope before.”

The second round of treatment costs £20,000 and is due by late August.

Mrs Falconer’s husband, Richard, 51, said NHS Wales was “not set up to deal with soft tissue sarcomas” with many of the specialist centres in England.

He added that he thought experts in Wales had “given up on his wife” four years ago and that she had received “nothing more than palliative care” and “roadblocks to all curative options that should have been on the table”.

Dr Sian Lewis, medical director for the Welsh Health Specialised Services Committee, said the “clinical effectiveness” of SIRT for the treatment of liver cancer “has not currently been established”.

She said it is only available to a limited number of patients in NHS England as part of a programme to assess its effectiveness.

The Welsh Government said NHS Wales will make a decision regarding the routine commissioning of SIRT when the results of the evaluation become available next year.

False hopes

Abertawe Bro Morgannwg University Health Board, which provided chemotherapy to Mrs Falconer, said if previous funding requests have been declined by the committee any subsequent submission has to contain “new clinical evidence”.

A statement from the health board said, while it could not comment on Mrs Falconer’s case, its “clinicians fully appreciate the distressing situation its patients are in”.

“It’s because of this they would never consider falsely getting a patient’s hopes up by resubmitting an already declined request when there is no new clinical evidence available.”

Hywel Dda University Health Board has also been asked to comment.

September 2016 – Mark Smith for Walesonline: Three Welsh health boards have been placed under additional Welsh Government scrutiny

Cardiff and Vale, ABMU and Hywel Dda are just one level short of ‘special measures’

Adrian O’Dowd in the BMJ 15th June 2017: Trusts boost ratings by engaging staff and including clinicians in management

Adrian Dowd in the BMJ 23rd June 2017 : The only way is up: the “special measures” trust that got back on its feet

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Mums, you have a 1:200 risk of stillbirth – what can you do about it?

Sorting out the figures from the office of National Statistics is not easy. Comparisons between the 4 different jurisdictions are not obvious. Different countries produce figures in different years and the speciality is changing rapidly. Concentration of specialist services has been shown to work, provided transport links are good. Even remote areas of Canada and Australia can have good figures given the right infrastructure. The latest (2013) BBC report from Wales indicates there is a lot to be done in our poorest region. (Stillbirth rate ‘unacceptably high’ in Wales say AMs) The rates for the different Welsh regions are summarised and available in real time, and show that Cardiff and Vale trust is worse than Hywel Dda. 15 babies a year die daily (The SANDS charity) in the UK. It is time to address this, and locally led midwifery units at a distance from specialist centres may not help. Deprivation and smoking go together…

So what can you do about it? Mums can stop smoking, stop alcohol, stop drugs, reduce weight if obese, eat a better diet, keep active and fit, go to antenatal classes, and meet other mums for support. Moving to a richer area would not affect an individual’s risk, but if moving meant the specialist services for a high risk pregnancy were closer this might be well worth considering… The governments job is to treat populations and the illiberal success of the anti-smoking lobby is a major gain. Going privately may increase your chances of intervention (perverse incentives) and figures for private outcomes are not available from the UK. Australian results suggest worse outcomes.. Its an option not only to make the baby on holiday, but to have it away from home..

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There is good news in the latest statistics, but the BBC announced yesterday that there was only one country worse in the EU and that was Malta. There is much to be done.. The Times leader on Stillbirths – by Janet Scott of SANDS.

Chris Smyth reports in the Times 21st June 2017: Better care during birth could have prevented hundreds of baby deaths

Three quarters of babies who die or are brain damaged during birth could have been saved with better care, a study has concluded.
Hundreds die each year because mistakes are repeated and hospitals must improve heart-rate monitoring and staff communication, the report by the Royal College of Obstetricians and Gynaecologists said…. almost one in 200 babies is born dead…

and on June 22nd: Stillbirth rates decline for the first time in a decade

Stillbirth rates have started to fall for the first time in a decade, according to figures that underline the importance of pressing hospitals to take action.

In 2015 about 250 babies survived who would have died two years earlier, figures that recorded an 8 per cent drop in stillbirth rates suggest. Experts said that the fall would have to speed up to meet a target to halve stillbirths by 2030.

There are also still big variations, with death rates a third higher in the worst-performing areas than in the best-performing.

The Royal College of Obstetricians and Gynaecologists (RCOG) said yesterday that three quarters of babies who died or were brain damaged at birth could have been saved had they received better care.

It was the latest in a series of reports and safety initiatives underscoring repeated errors in maternity units that have appeared since The Times highlighted complacency in the NHS over stillbirths in 2012. The latest figures suggest that such messages are starting to filter through, with stillbirth rates falling from 4.2 per 1,000 births in 2013 to 3.87 in 2015, according to the most authoritative academic study…

…Overall in the UK the number of stillbirths fell to 3,032 in 2015 from 3,252 the year before, but deaths before and soon after birth still vary around the country, from 5 to 6.5 per 1,000…. Disappointingly, the findings show only a small reduction in neonatal death rates.”

…Deaths within the first week of life were 1.74 per 1,000 in 2015, compared with 1.84 two years before….

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Infant Mortality and Stillbirth in the UK – Parliament UK (2014) .pdf

Infant death rate ‘lowest ever’ recorded – BBC News (best in the affluent areas, and some areas saw worse results).

It does  not help when a charity (Kicks Count) is reported in the South Wales Argus 20th June:  Baby heartbeat detectors should be banned, says pregnancy charity when they really mean for unqualified patients.

In Scotland the Herald on 15th June reported the main reason for improvement: Smoking rate in UK second lowest in Europe after 25 per cent fall …

The long term results of rationing midwives and doctors in training…

“Reducing the ratio (of maternity staff in Surrey) to balance the books is the worst of all decisions.”

Stillbirths in all different UK systems are still too high

50,000 short – not £millions but staff…. 

and now we need more despite Brexit: (Chris Smyth June 22nd – NHS in talks to recruit Indian nurses to deal with staff crisis).

Michael Safi in the Guardian 2014: Babies born in private hospitals ‘more likely’ to have health problems – The Study, which looked at 700,000 ‘low-risk’ births in NSW, suggests higher rates of medical intervention could be the cause

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The Times leader on Stillbirths – by Janet Scott of SANDS.




Its the “philosophy” sillies – and I am talking to you politicians.

Ron Lilley on and in his e-mail blog to 5000 people rightly points out some of the problems with regard to the disintegrating, formerly National, health services. He points out that a lack of leadership (read “honesty”) leaves us with no idea about how the health service will run next year, let alone in 25 years’ time. Reading his blog he alludes to, but does not mention rationing, making him equally culpable for dishonesty… The workforce is not enough, and is too female biased. Even the spin on Wales recruiting more GP trainees (By bribery) is not reality. We need twice as many in Wales alone to cover the next generation. This can never seem to be said…. and many doctors are working a 3-4 day week but doing well over 40 hours. The reporting is shallow..  How many MPs have Private Medical Insurance (PMI) and why? Its the “philosophy” sillies – and I am talking to you politicians. 

Reasonable rationing is derided, and when reversed because of politics this is celebrated. Laura Donelly in the Telegraph: ‘Monumental’ NHS U-turn

Deserts based rationing is unofficial and facilitated by “privatisation”, especially for the obese.

Despite a “primary care led” Health service, the staffing needs of A&E, so badly planned, trump this as we are in meltdown. In such a situation prevention should rightly be abandoned, and emergency treatment becomes essential. So GPs all need A&E training, (as well as Paeds, Psych, O&G etc….. this is not the case as Deaneries’ decisions are not taken by GPs but Consultants.

Roy Lilley opines: (

The call is for a national debate about the future of healthcare.  The debate, if there is to be one, is as much philosophical as it is practical.

Thus far we have struggled to survive by cutting, patching and repairing.  It is inconceivable we can survive another year of the same.

The way forward is beset with difficult choices as much about how we behave as it is about how the institutions that provide our care, behave.

Setting aside issues of the ‘money’, there are four questions; let’s call them the ‘retains’, that spring to mind.

1.  Will we retain our present willingness to share our risks?

The potential is for middle-class families, presented with options to clunky access to primary care, to elect to pay subscriptions for Apps such as Babylon or Go-Doc and start to undermine the solidarity of the NHS.

The NHS only works because it is ‘our’ NHS, we agree to syndicate the costs and risks of our illnesses, disease, accidents and maternity.

We may be lucky, pay our dues and only have rare occasions to call-in a dividend of care.  On the other hand, disaster may strike and put us on a long and painful road to recovery.

We may not share your pain but we do agree to share the cost.

Employers, frustrated at the thought of losing the skills of key staff to prolonged absence through illness, are already sparking a rejuvenation in the private insured care market, in the hope of circumventing waiting lists, now north of 300,000.

If support is fragmented the NHS fails.

2.  Will we retain power and influence at the centre or are we prepared to give it away in devolution and independence?

How the NHS is organised is important.  We have seen what happens when the NHS is broken up.  The disastrous Lansley reforms gave us a disaggregated, fragmented leadership model and a confusing array of over 200 commissioners; most of them inexperienced, too small to be effective and too costly to run, to be viable.

Devolution may be a seductive alternative to government from Westminister but sharing budgets means sharing risks.  However, we have also seen, from the better CCGs, fragmentation can bring decisions closer to populations.  In the worst, macho CCG management is already set on giving away the NHS, to third parties, to run for ten or even fifteen years.

Do we want to give the NHS away?  How much do we want to break it up?

3.   Will we retain the tendency to ‘accumulate’ healthcare data or will we make a determined effort to ‘use’ personal information for the wider public health.

Do we overcome the reservations we have about sharing data?  The Caldecott conclusions do not bring us closer to solutions for front-line staff trying to work across boundaries.

The extent to which we agree to our data being pooled is the extent to which public health bodies will be able to forecast and plan for a healthier nation.  Thus far, overriding concerns about privacy have slowed progress.

4.  Will we retain our resistance to interference in our lifestyles or will we surrender some choices in the interests of good health and wider societal gains, seeing it as a civic duty.

Perhaps governments have done all the easy stuff with public health; adult literacy, childhood immunisation and clean water.  The future lies in the extent to which governments are prepared to interfere in the lives of ordinary people.

Are we prepared to accept the law interfering in our lifestyle choices?  Banning foods, penalising anti-social life-styles that lead to costs for the NHS.  Refuse treatments to the obese and smokers is one thing but in the interests of equity, do we refuse treatment to a person with a self-inflicted injury sustained in a recreational game of squash.

The four ‘retains’… Public health, data, holding-on or letting-go, sharing our risks.  Perhaps the cornerstones of modern healthcare upon which we either agree and build for the future, or we run the risk of being spectators as, through lack of clarity, vision and determination, we watch it fall apart.

I judge there is an appetite for change if only we knew what it looked like?

How can you paint me a picture of the NHS in 2025 when you can’t sketch what it will look like next year.

Have a good weekend.


 Chris Smyth in the Times 16th June 2017: Young doctors go part-time to avoid long hours

A shortage of family doctors has been exacerbated by millennials’ reluctance to work long hours, the NHS training chief says.
More part-time young doctors means that the NHS now has the equivalent of 10 per cent fewer doctors, said Ian Cumming, chief executive of Health Education England, which supports the delivery of healthcare in England. Ministers have had to downgrade their estimate of the number of full-time equivalent doctors, he said……

Also on the same day: NHS secures deal with pharma for breast cancer drug Kadcyla

Kat Lay reports: GPs reluctant to refer fat men to clubs such as Slimming World

Laura Donelly: ‘Monumental’ NHS U-turn on breast cancer drug…

Neil Roberts for GPonline reports 14th June: Exclusive: Hospitals could need more than 200 GPs to staff NHS A&E plans

Owain Clarke for BBC news 13th June 2017 reports: GP recruitment: More junior doctors choosing Wales

Gender bias. The one sex change on the NHS that nobody has been talking about



State funded media asks the right question – at last

Hugh Pym reports for BBC news 7th June 2017: Is NHS rationing a possibility?

State funded media asks the right question – at last. Will they provide the right answer in our lifetime? The BMA is already on record as willing to debate the motion “Is NHS rationing a possibility?(Bournemouth in July) and in Wales has asked for an “honest language” in health. (and Exit interviews) More importantly, why have our intellectual elite, and the public health experts, media and politicians, failed to open the debate years ago, and continue even this week, before the  professions became disengaged and demoralised? Now that many have retired early, emigrated or changed career, it will take years to recover.

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Money, money, money – it’s a familiar background theme across the NHS in England, but the volume is increasing.

Campaign funding promises have been made but whoever forms the next government will find some challenging financial issues highlighted in their ministerial red boxes.

This week, reports of a tightening of the financial thumb screws have emerged. There is talk of rationing and, as one source told me, “unpalatable things” being contemplated by hospital managers and local health commissioners.

Under what’s been billed as a “capped expenditure process”, NHS England and the regulator NHS Improvement are telling some trusts to stick within spending limits even if that means tough decisions on the provision of non-urgent care.

The new pressure on hospitals and local health commissioning groups in England comes after some trusts overshot agreed spending targets during the last financial year.

Spending control

Since the start of this year, from the beginning of April, it has become clear that the biggest over-spenders have been unable to agree their so-called “control totals”. They have now been told to take firmer action to keep a grip on spending.

The Health Service Journal (HSJ) reported that NHS officials have contacted health managers in 14 areas of England with a series of proposals for controlling budgets. These include extending waiting times for routine procedures and treatments, downgrading certain services and limiting the number of operations carried out by the private sector for the NHS.

HSJ first revealed the tougher spending regime in April, quoting from a letter sent to those local health leaders who could not agree their budgets.

They were asked to decide “from which areas further expenditure reductions will be made”, including reviewing the range of medicines prescribed.

Interestingly, the letter and subsequent dialogue has been with both commissioners, who can limit what they are prepared to pay for, and trusts who might save money by curbing the volume of non-urgent care provided to patients.

There was a clue to this tougher approach in the update to the NHS Five Year Forward View plan, published at the end of March. The finger is pointed at those organisations which had historically substantially overspent their “fair shares of NHS funding”.

Put a lid on it

They are accused of “living off bail-outs” taken from other services. They are then told to confront “difficult choices” and if necessary “scale back spending on locally unaffordable services”.

An NHS England spokesperson said no final decisions had been made and when final choices were made locally they would need to be approved nationally. But there was no denying the fact that in some areas hospital managers and commissioners were being told to go further than before to keep a lid on spending.

The background to this is that NHS England is receiving a much smaller budget increase this year than in 2016/17 which, though originally billed as a generous “frontloaded” settlement, appeared to only just cover what the service needed. Patient demand will continue to outstrip the money available with the financial pressure even more intense this year.

Those who see the NHS as a bottomless pit always requiring more money to be poured in will call for more efficiency savings before another bailout is contemplated. Those who argue that the NHS has been underfunded for some years, with the share of national income devoted to health lagging behind other leading economies, will say the only answer is higher levels of government funding.

It’s a familiar debate and one which won’t go away after polling day.

Not enough money

The three main health think tanks, The King’sFund, Nuffield Trust and the Health Foundation, wrote a joint letter this week arguing that no political party was offering enough extra spending to cope with the demographic and demand pressures on the NHS.

They estimated that an extra £20 billion annually would be needed by 2022 over and above the most generous manifesto pledge.

The think tanks argue that failure to provide sufficient funding will result in longer waiting times for patients and a decline in levels of care.

Recent reports indicate NHS chiefs are already planning for that to happen.

Specific tax rises are short term, not enough and ignore the big issue.. Honesty.


Mandator NHS service plan for new doctors…..? Run, Doctors, Run! (While You Still Can)

The European Convention of Human Rights is going to be ditched when we leave the EU. Brexit could exclude much needed overseas talent, but also chain our own down. Getting experience abroad has been part of development for many doctors, most of whom return home. The undercapacity in medical staffing and manpower, and the more attractive “shape of a job” abroad do tempt many to stay. One answer is to remove performance management, improve morale by “showing care” (for staff) and training an excess for delivery in 10 years time. Juniors with ambitions to expand their horizons are incensed. Narrowing their experience will only help to reduce standards further. The time for feedback to the administration and the Hunt style “jack Boots” is gone, but below is article by Dr Evgenia Galinskaya, and I can only apologise for missing the deadline for consultation (June 2nd). Run, Doctors, Run! (While You Still Can)Image result for run away cartoon health

European Human Rights – The UK May Lose ECHR Human Rights‎

Neil Roberts reported in October 2016 in GPonline: Doctors face four-year mandatory NHS service as Jeremy Hunt expands medical training

David Millett reports for GPonline 13th March 2017: Doctors could face more than five years mandatory NHS service under DH plans

The Westleyan Insurance Society posted 30th March 2017: Doctors could face more than five years mandatory NHS sertvice under …

Pulse Magazine May 29th 2017: Run, Doctors, Run! (While You Still Can) by Dr Evengia Galinskaya


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The truth behind rurality: An increasing risk to individuals without access to a tertiary centre. Unethical rationing prevails.

The increased air pollution in the cities is countered by the lack of access to GP and specialist services in rural areas. The truth behind rurality is an increasing risk to individuals without access to a tertiary centre, Trusts have restricted choice.and this is particularly true in Wales where trusts such as Hywel Dda have restricted choice. Rationing by reducing choice options for certain post codes, but not for others, who pay the same tax, is unethical.

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May Bulman in the Independent reports 18th March 2017: Beautiful Countryside hides the ugly truth…

The BMA news reports in Rural Health on 25th March 2017: Truth is hidden behind “picture postcard” image.

Poor health in rural areas is masked by “idyllic image” of the English Countryside, said local government and public health leaders in a joint report. Official statistics do not paint an accurate picture of people’s health outside cities., they warned. The report said that a sixth of areas with the worst health and deprivation in England are in rural areas; residents of rural areas are more likely to be over 65 than those in urban areas (23.5 v 16.3%); and rural residents are less likely to live within 4km of a GP surgery (80 v 98%) and 8km of a hospital (55 v 97%).

Have targets improved performance in the English NHS? | The BMJ – not in rural areas.

David Oliver reports in the BMJ: David Oliver: Challenges for rural hospitals—the same but different (BMJ 2017;357:j1731

The UK is densely populated. Even Scotland, with only 62 people per square kilometre, pales in sparseness next to Canada or Australia, whose densities are 3.2 and 2.6, respectively.1

Even so, our rural areas face distinct challenges, and the problems facing urban health systems are exacerbated in the countryside: less car ownership, worse public transport, longer travel times to GP surgeries. Practices are smaller and have more difficulty attracting GPs. The hospital is often a long round trip from patients’ homes. Distance makes access to moderate level urgent and ambulatory care crucial, as is rehabilitation or end of life care at or close to home, as well as family and social networks.23

Community hospitals, where they exist, can be used as a hub. GPs, paramedics, allied professionals, and nurse practitioners with enhanced skills and roles are invaluable.4

Rural areas aren’t homogeneous. Alongside bucolic idylls, much rural deprivation exists: social isolation, single occupier households, and unfit housing stock are more prevalent. Rural and coastal communities have a high proportion of older residents, compounded by “urban drift” in younger people.

It’s harder to attract a workforce to low paid caring jobs. Community practitioners and teams take longer travelling to and between patients’ homes. Funding formulas don’t reflect these additional costs, further disadvantaging rural areas.

And reconfiguration of health services based on urban models risks leaving whole regions without a hospital. Some specialised services clearly benefit from centralisation, but a smaller rural hospital should be able to do a great deal, including level 2 urgent care. In sparsely populated countries such as Australia, hospitals much smaller than the UK’s can provide a wide range of services.5

The lower patient volume and smaller peer group can make posts less attractive to subspecialists who want to maintain specialty interest and skills. Parallel rotas for acute, internal, and geriatric medicine, for example, may be unviable.6

There’s a pressing need for confident expert generalists happy to deal with most of what comes their way and for peripatetic hospital clinicians providing clinical support beyond the hospital’s walls. It’s especially hard to attract consultants to these roles, so substantive posts and rotas go unfilled.

Doctors tend to settle in the region where they complete specialist training, often with a family base in the town.7 Medical school places are disproportionately concentrated in big cities, limiting trainees’ exposure to rural medicine.89 Doctor-patient ratios and applications for training posts are higher in the metropolis.

If we want to ensure fair access to care in rural populations, tailored to their unique circumstances, we need plans to tackle these issues. And we have to start by recognising that their needs are the same but different.

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Is choice an illusion in Wales? Not if patients pay to go privately.

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