Category Archives: Rationing

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians… “Wise doctors will retreat from the front line now?”

Jenni Russell reports in the Times 8th Feb 2018: Wise doctors will retreat from the front line now

Mistakes due to overwork are manslaughter. Not enough sickness and absenteeism? Nobody blames the management and politicians for their long term rationing, denial, and collusion of anonymity. Other countries and their leaders cannot understand us, including Mr Trump. (Stephen Glover in the Daily Mail)

Overwork and the risk of negligence cases make safer specialisms preferable to acute medicine

I was once responsible for a patient’s death. Or that’s how it could have been seen. It was years ago, in a gap year job, but the experience was so searing I can relive it with terrible clarity.

I was working as a nursing auxiliary on a hospital ward. At 9pm all the nurses were gathered in the sister’s office, two doors and 30 metres away, handing over to the night team. A physio was with an elderly asthma patient when she threw open the curtains around the bed and shouted: “Resus! Nurse, get the resus trolley!”

She meant me. I was the only person in a nurse’s uniform in sight or earshot. I ran. The heart resuscitation team was bleeped. I dragged the trolley, which was new on the ward that month, to the bed. I unwound the electric cable, seized the plug, looked around for a socket. And looked. And looked.

This was an old ward in a crumbling outbuilding and there was nothing logical about its power points. As the newest and most junior person on the team, no one had thought it necessary to show me where they were. While I hunted, with rising panic, ducking between beds, the old lady’s heart began to fail. The heart team arrived, a nurse grabbed the plug from me, the old lady died.

Was this my fault, or the system’s? If I had been faster that woman may have lived. Is someone who tries their best when they don’t have adequate backup the guilty party, or is the system around them also responsible, for not providing the support they need?

Any sane person would think the latter, but thanks to the punitive decisions of the GMC and the High Court in pursuing the striking-off of Dr Hadiza Bawa-Garba after an error which led to a child’s death, every doctor and nurse in the country now fears that they may lose their jobs, futures and reputations for a single serious mistake.

The doctor was under extreme pressure, covering for an absent registrar while overseeing six wards on four floors, on a relentlessly demanding twelve-hour shift. It was her first day back after maternity leave and she had had no induction training. The nursing rota was understaffed and the IT system was down for hours, meaning blood test results were critically delayed. Her consultant wasn’t present. All the evidence given testified to her being a committed, above-average doctor, and yet she has been thrown out of the profession.

The chilling lesson of the Bawa-Garba debacle is that context, character, remorsefulness and a good record will be no defence.

The unintended consequences of this hardline decision by the GMC are going to damage the NHS, not protect it. Doctors across the country are aghast, feeling, as an editorial in the BMJ said, that “there but for the grace of God go I”. Furious senior doctors are reporting themselves to the GMC for long-ago errors, to make that point. Newer doctors are now afraid to admit to theirs in case it backfires on them. And the devastating practical effects are now unfolding, unseen.

“I’m practising defensive medicine now,” one doctor told me. “We all are. I’m not taking risks. If someone turns up with a non-specific lump, I might before have used my judgment, said wait and see. Now I’m sending them for scans, second opinions, follow-ups, blood tests. Lots of that will be unnecessary, the NHS is already overloaded, and I’m adding to that. But I feel now I’ve got no protection, I’ve got to watch my own back.”

His fears are widely shared, an A&E consultant tells me. It’s going to cut the numbers willing to work in areas of acute medicine that are already routinely understaffed, like paediatrics or emergency medicine. If doctors know, as they do, that those are the jobs where they must take what are now career-threatening high-risk decisions, while covering rota gaps, fewer people will apply. “They’ll retreat to safer options — dermatology, genito-urinary clinics, specialisms like that.”

He warns that it’s going to mean a rise in staff going off sick in high-pressure disciplines, as people assess the new pressures of being conscientious. Instead of putting the patients first, many doctors will choose caution. “If you’re feeling a bit off, why would you risk putting yourself in the firing line? It’s going to be a lot safer to stay at home.”

There is particular fury at the GMC’s attempt to cover its back by issuing guidelines telling doctors that if they are in understaffed, unsafe environments they must create a paper trail flagging that up. As one enraged doctor pointed out to me, hospitals already know exactly when their rotas are missing staff. And as a fine column in the BMJ by the consultant in geriatrics David Oliver points out, now we are ordering overworked doctors to spend more of the time they don’t have in documenting that they haven’t got it. It serves literally no purpose, since if nothing goes badly wrong on their shifts nobody cares that they were overloaded, and if something does go wrong, that record won’t protect them.

The NHS is clearly alarmed by what has been set in train here, with many hospitals declaring they stand by their staff and the health secretary Jeremy Hunt setting up an inquiry into the implications of the Bawa-Garba case. But warm words mean nothing laid against the cold legal danger doctors are now in. They need safer staffing levels and an absolute assurance that when they make mistakes their institutions will share responsibility too. Until they get that, the health service is going to be weakened by this cruel and foolish pursuit.

Laura Donelly in the Telegraph 6th February reports: Hunt orders review of Medical Malpractice and Doctors Outcry  over manslaughter case:

Dr Hadiza Bawa-Garba was struck off the medical register after she was found guilty of mistakes in the care of a six-year-old boy who died of sepsis.

The case has been met with a backlash among medics, with thousands sending letters of support for the doctor, saying the decision ignored NHS failings and staff shortages which contributed to the death.

Dr Bawa-Garba was originally suspended from the medical register for 12 months last June by a tribunal, but has now been removed from the medical register following a High Court appeal by regulator the General Medical Council (GMC).

The GMC said the the original decision was “not sufficient to protect the public”.

Mr Hunt had already expressed unease about the situation, saying he was “totally perplexed” by the actions of the watchdog.

In particular, he raised concerns that doctors would no longer be open about errors, and be honest in their self-appraisals.

In a statement to the Commons, the Health and Social Care said clarity was needed about  drawing the line between gross negligence and ordinary errors.

Speaking in the House of Commons today, Mr Hunt said Sir Norman Williams, former president of the Royal College of Surgeons, will lead a national “rapid review” of the application of such laws.

He said Sir Norman will review how “we ensure there is clarity about where the line is drawn between gross negligence manslaughter and ordinary human error in medical practice so that doctors and other health professionals know where they stand with respect to criminal liability or professional misconduct”.

Mr Hunt said the review will also look at the role of reflective learning, to ensure doctors are able to open and transparent and learn from mistakes.

The review, which is due to report by April, will also consider lessons to be learned by the GMC and other regulators.

Charlie Massey, chief executive of the General Medical Council said: “We welcome the announcement today from the Secretary of State to conduct a rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England. The issues around GNM within healthcare have been present for a number of years, and we have been engaged in constructive discussions with medical leaders on this issue.”

He said the watcdog was committed to examining the issues, and to ensure fair treatment of doctors working in situations where the risk of death is a constant and in the context of systemic pressure.”

“Doctors are working in extremely challenging conditions, and we recognise that any doctor can make a mistake, particularly when working under pressure. We know that we cannot immediately resolve all of the profession’s concerns, but we are determined to do everything possible to bring positive improvements out of this issue,” he said.

The GMC is carrying  out its own review, and would endure the findings from the new review feed into it.

Dr Bawa-Garba was struck off over the death of Jack Adcock, aged 6, at Leicester Royal Infirmary in 2011.

The child, from Glen Parva, Leicestershire, was admitted to the hospital in February 2011, his sepsis went undiagnosed and led to him suffering a cardiac arrest. The courts heard Dr Bawa-Garba, a paediatrician, committed a “catalogue” of errors, including missing signs of his infection and mistakenly thinking Jack was under a do-not-resuscitate order.

But they also heard the doctor was working amid widespread staff shortages, with IT failures and delays in test results

At the time of the ruling, Jack’s mother, Nicola, said: “We are absolutely elated with the decision. It’s what we wanted.

“I know we’ll never get Jack back but we have got justice for our little boy.”

The Medical Protection Society, which represented Dr Bawa-Garba, said at the time: “A conviction should not automatically mean that a doctor who has fully remediated and demonstrated insight into their clinical failings is erased.”

An online appeal set up by concerned doctors has raised more than £320,000 to help pay the legal costs of Dr Bawa-Garba.

Agency nurse Isabel Amaro was also convicted of manslaughter on the grounds of gross negligence relating to the same incident and struck off by the Nursing and Midwifery Council.

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Oh dear. More money from Taxation will make no difference.. Digging the hole deeper?

NHSreality has spoken out against hypothecated taxation on several occasions.  This is at least a recognition of crisis, but the solution proposed will never work as the pace of technological advance and demographic change (more elderly) exceeds the ability of the state to pay for them. The solution proposed, without overt rationing, will be digging the hole deeper..

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BBC News reports 5th Feb 2016: NHS ‘should be funded by new tax’

A new ring-fenced tax to fund the NHS and social care has been proposed by a panel of health experts.

The panel, set up by the Liberal Democrats, says the NHS in England should be given an extra £4bn on top of inflation in the next financial year.

It has suggested replacing National Insurance with the new tax to close the funding gap.

A Department of Health and Social Care spokesperson said NHS funding “is at a record high”.

“[It] was prioritised in the Budget with an extra £2.8bn, on top of the additional £2bn already provided for social care over the next three years, and an additional £437m of funding for winter,” the spokesperson said.

The future of NHS money has been hotly debated as hospitals struggle to cope with the pressure on resources.

Last month, tens of thousands of non-urgent operations were delayed.

The 10-member panel included former NHS England chief executive Sir David Nicholson, Peter Carter, former chief executive of the Royal College of Nursing and Clare Gerada, former chairwoman of the Royal College of GPs.

It said on top of the £4bn extra needed for next year, an additional £2.5bn would be required for both 2019 and 2020.

Prof Gerada said that one of the issues is that working people over the age of 60 benefit from a significantly reduced National Insurance contribution, and people over 65 do not pay it at all.

She said National Insurance, which currently funds the NHS and social care, is inadequate as older people are living longer, and not contributing to the ring-fenced tax.

She said: “Old age is now between 85 and 95, so old age has significantly moved.

“Why shouldn’t I pay for my fair share of contributions if I’m working?”

As part of the recommendations, the panel also suggested reinstating a cap on the costs paid by individuals on social care.

In December, the government scrapped proposals to cap fees at £72,500.

It supported creating an office for budget responsibility for health and called for a series of incentives to get people to save more towards their adult social care.

The idea of a levy dedicated to funding the NHS was also suggested by former minister Nick Boles.

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There is a “need to put doctors in charge and force them to take account of patients’ views. Cancer survival rates are (just) one of the prime examples of NHS mediocrity.”

There is plenty of room for improvement. Whilst we have got good outcomes in Breast Cancer, the rare cancers                  and Prostate Cancer in men do worse.

Chris Smyth reports 3rd Feb 2018: NHS is crippled by top-down culture

Autocratic management is a leading cause of poor NHS care, according to the compiler of a European health service league table that ranks Britain 15th.

The UK trails Slovakia and Portugal while the best performers such as the Netherlands and Switzerland pull away, according to the Euro Health Consumer Index. Treatment is Britain is mediocre and there is an “absence of real excellence” in the NHS, the report concludes. Only Ireland does worse on accessibility measures such as availability of same-day GP appointments, access to specialists and waits for routine surgery.

The findings come after a global study this week found cancer survival in Britain still lagged well behind the best in the world.

Arne Björnberg, who compiles the Euro Health Consumer Index, said: “Cancer survival rates are one of the prime examples of NHS mediocrity.”

More money is needed to improve care, according to a study that finds a strong correlation between treatment results and how much countries spend on health.

However, Professor Björnberg said that the most urgent lesson the NHS could learn from other countries was about the corrosive effects of an “autocratic top-down management culture”. He said: “As a Scandinavian what strikes you when you visit the UK is British management is extremely autocratic. Managing 1.5 million using a top-down method doesn’t work very well. If you go and ask a secretary or a receptionist anything out of the routine in Scandinavia, the most negative response would be: ‘I’ll see what I can do’. But in the UK they will say: ‘I’ll have to talk to my manager’. Subordinate staff are not allowed to use their brains in the UK and managing a professional organisation like healthcare like that is not a good idea.”

The Netherlands has consistently topped the rankings, which some have attributed to a system of competing insurance companies. However, Professor Björnberg said that the main lesson to be learnt from the Dutch was not about market forces but the need to put doctors in charge and force them to take account of patients’ views.

“If you have intelligent people and make them talk to customers frequently, that is a good idea,” he said.

“You have 1.5 million intelligent and dedicated people working for [the NHS]. Liberate the medical profession and put politicians and amateurs at arm’s length.”

NHS bosses dismissed the findings, preferring an index compiled by the US-based Commonwealth Fund, which ranks Britain top of 11 global health systems. The NHS scores well on measures such as equal access, but ranks tenth at keeping people alive.

In Search of the Perfect Health System – a new book reviewed

 

Compared with 11 other countries UK ranked first – for it’s system and not for it’s outcomes

The Commonwealth Fund compares health systems. Unreality of MPs. ..

Performance relative to other countries. Commonwealth fund “mirror”.

Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

Our state-run healthcare model makes winter crises inevitable: the healthcare crisis seen from abroad, and publicised in the City.

Waiting times matter -especially in Wales – to see your GP, for investigation, and diagnosis as well as treatment.

Sky News 2nd Feb: Prostate cancer now killing more people than breast cancer – While breast cancer has benefited from a screening programme and significant research, prostate cancer has been lagging behind.

Its good news: “More people dying from rarer cancers” so less are dying from the more common ones..

 

When doctors know the system is failing, should they tell their patients? Yes. From East Anglia to Pembrokeshire….

Norfolk is facing a double hit. The Trust is victim of a PFI, and the CCG is underperforming in respect to cost cutting. Services are threatened…. Warnings were given over many years and Geraldine Scott of the EDP (Eastern Daily Press) reported: Commissioners in West \Norfolk could be stripped of their powers if £10million deficit is not solved. Add to this the cost of litigation as per previous posting, and Norfolk is bust.  \\\\\\\\\\\\\\\\\\\\\\\politicians have tried to put rationing decisions at arms length from themselves, but now gross failure means they will have to take responsibility. Message is, for the moment, don’t get ill in East Anglia.  David Oliver is a writing journalist doctor and his comments are perceptive. “Should NHS doctors work in unsafe conditions?” and “Let the NHS be honest with the public”, by which he means doctors are not telling their patients the truth…despite the statutory duty of candour.

Gareth Iacobucci reports in the BMJ: CCG criticises NHS England after being ordered to cut GP funding (BMJ 2018;360:k247 )

The head of a financially stricken clinical commissioning group (CCG) has launched an outspoken attack on NHS England after the group was ordered to cut GP funding to balance its books.

In a starkly written letter to local GPs sent on 12 January that was leaked to The BMJ, Paul Williams, chair of West Norfolk CCG, said that the group faced a “dire” financial situation, warning of “very unpleasant consequences” from decisions it was being forced to take.

Williams said that the CCG had been ordered by NHS England to cut local enhanced services payments to general practices, which fund work outside the core GP contract such as minor injury consultations, wound care, and phlebotomy. He wrote that “it is highly likely that there will be some reduction or possibly even cessation of LES [local enhanced services] payments.”

The CCG’s overspend is expected to reach £10m by the end of this year. Williams said that the situation had escalated because of “unreasonable assumptions” about what the CCG could achieve within its available budget.

As a result of the group’s financial position Williams said that the CCG board had been summoned to face “a star chamber of NHS executives” that had ordered it to cut services or face being taken over by NHS England.

He wrote, “At the end of the meeting, we were left in no doubt that unless we immediately start reducing expenditure then NHSE [NHS England] would not hesitate to disempower the government body and current executives and send in managers under legal directions to turn things around. They would have little regard for the long term consequences of their actions, their prime imperative would be to simply save money.

“I know this will be very disappointing for primary care and will no doubt produce some financial pressure in some practices, but unfortunately the CCG are being forced down this route by NHSE.”

Ian Hume, medical secretary of the Norfolk and Waveney local medical committee, said that any loss of income from LES payments would be damaging to local practices and would fly in the face of NHS England’s national commitment to invest in primary care.

Hume said, “It would give completely the wrong signal to general practice, which needs to be part of the solution. To cut enhanced services or primary care budgets is counterproductive.

“There seems to be an inconsistency between the approach from NHS England’s regional office and NHS England nationally. Cutting money in one place may have an increased cost to the system elsewhere. There is an incongruity about the whole approach.”

In a subsequent statement supplied to The BMJ, West Norfolk CCG said that the letter set out “the worst case scenario.” A spokesperson said that the group would not cut any payments to practices this financial year but added, “The CCG will review all [local enhanced services payments] for 2018-19. We shall want to look at their effectiveness, to make sure that every pound we spend delivers maximum quality and value for money. If any are changed, core GP services will not be affected.

“We shall continue this efficiency drive across all areas of the NHS to deliver maximum efficiency and maximum quality of care and reduce the deficit we face.”

Andrew Pike, director of commissioning operations for NHS England’s East region, said, “The current financial position of the CCG is of concern. The CCG has a duty to the taxpayer as well as to patients to ensure it delivers the agreed financial plan for 2017-18. The CCG has been requested to improve its financial position this year.”

The storm is coming: All Regional Health Services are unsustainable. The PAC are telling us the truth..

Telling harsh truths about the NHS is a bitter but necessary pill

The finance officers tell the truth: “NHS cannot make £22bn cut sought by government”..- there is no way forward under current philosophy

Candour and Transparency? – what a farce

 

Half of last year’s UK Health spend is earmarked for compensation claims. Pithed politicians have consistently ignored this problem… Now it’s payback time..

NHSreality has pointed out the political negligence in ignoring the need for “no fault compensation”. The first report recommending this was printed @ 1970 and although accepted by both parties, Lord Pearson’s report was never implemented. The perverse incentive for short term gains was too great. Long term gains would be felt now, and for the last 25 years if we had acted then. But negligence claims are not the only way our 4 health services can waste our tax take: NHS forced to pay £1500 for £2 pot of moisturiser.  We may need reform, but pithed politicians will find this beyond them. The total budget for England alone is £127bn. (Kings Fund) So £65bn is one half of one year’s spend! It has doubled in the last 7 years, rising at 11.5% over the last 5 years, We can assume Scotland, Wales and N Ireland have similar ratios. Now the bill is escalating, and due to our adversarial justice system, it will eventually overtake the send on health care on an annual basis. The position could be improved if the chancellor reverses his decision on the rate of compensation calculated by the Ogden formula. This results from rationing over many years, and now we will get the payback…

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Laura Donelly in the Telegraph 2nd January reports: Victims of medical negligence should receive less compensation or the NHS will face bankruptcy.

ictims of NHS blunders should receive smaller compensation payouts or the “staggering” costs of Britain’s negligence bills will bankrupt the health service, the Justice Secretary has been told.

Health service leaders have written to the Government, calling for cuts to payments for patients who suffer devastating injuries as a result of medical errors.

The controversial demand follows years of rising negligence payments, with current liability now at £65bn – a rise from £29 billion in 2014/15….

The BBC reports: Curb rising NHS negligence payouts, health leaders urge

Health leaders have written to Justice Secretary David Gauke urging him to reform the payout system for negligence claims against the NHS in England.

They say costs are spiralling, “unsustainable” and diverting vast amounts from frontline care.

The NHS Confederation, the British Medical Association and medical lawyers are among the signatories.

The Ministry of Justice has asked the advisory body the Civil Justice Council to look at ways to limit payments.

The annual cost of claims is said to have almost doubled since 2010.

According to the letter, the NHS in England spent £1.7bn on clinical negligence claims last year.

The letter says: “The rising cost of clinical negligence is unsustainable and means that vast amounts of resource which could be used more effectively have to be diverted elsewhere….

 

Thousands die needlessly as NHS fails to boost cancer survival rate, and dead patients don’t vote. How about a posthumous vote?

For those of us in the know, the emperor has had no clothes for some years now, since well before NHSreality began 5y ago. What is evident to the profession is not yet evident to the politicians…. Since dead patients don’t vote, there is no concern for them – yet. How about giving all citizens one posthumous vote…?

Chris Smyth reports in the Times 31st Jan 2018: Thousands die needlessly as NHS fails to boost cancer survival rate

Britain has failed to narrow a cancer survival gap behind the best in the world, according to a global study that suggests that thousands of lives are being lost to mediocre care.

Despite improvements in survival rates over the past 15 years, British patients still die of cancer earlier than those in other rich countries that are improving just as fast, according to data on 37 million patients in 71 countries.

As well as trailing the world leaders in Scandinavia, the US, Canada and Australia, for some cancers Britain is doing worse than Latin American countries such as Brazil and Costa Rica.

A shortage of doctors, technology and money still hold the NHS back while repeated reorganisations mean that the health service struggles to focus on sustained improvement, experts said.

When the international group of scientists first published comparative survival data a decade ago, ministers pledged to close the gap. Researchers estimated that about 10,000 patients a year died within five years of a diagnosis who would have lived if British survival rates had matched the best.

Updated figures show that in 2010-14 Britain had still not reached where other rich countries were in the early 2000s. For example, 60 per cent of patients survive five years after a bowel cancer diagnosis, up from 52 per cent in the 2000-04 period. Yet in Australia, where survival was 63.7 per cent 15 years ago, it has increased to 70.7 per cent.

Overall, Britain sits 17th in Europe for bowel cancer survival, unchanged from the early 2000s, and 30th in the world. For prostate cancer Britain is 16th in Europe and 26th in the world.

Michel Coleman from the London School of Hygiene and Tropical Medicine, lead author of the study, said: “The UK is still underperforming compared with other countries. There has been an increase but it’s still not enough to catch up. It’s fair to say the UK has been improving but the UK isn’t, as politicians have often suggested it should be, up among the best in Europe.”

Breast cancer was the only area where Britain had closed some of the gap. However, Britain still sits 14th in Europe with 85.6 per cent survival, up from 79.8 per cent in 2000-4.

Professor Coleman added: “The UK needs to consider improving funding for health services and the number of specialists to treat cancer patients because by any published metric the UK is not doing well. It’s not only doctors and health professionals but resources like radiotherapy machines are less available in this country.”

He pointed to Denmark, which has closed the gap on other Scandinavian countries with a national cancer plan.

Lynda Thomas, chief executive of Macmillan Cancer Support, said: “Better cancer survival rates are achievable, but this requires wholesale improvement, from earlier diagnosis to access to the best treatments.”

The Department of Health and Social Care said: “We know there is more to do, and NHS England is implementing the recommendations of the independent Cancer Taskforce to save a further 30,000 lives a year by 2020.”

Bullying is a sign of desperation. It is caused by circumstances.. These will get worse… Dead patients don’t vote…

Protest while you can – Dead patients don’t vote. Rationing in action…

Dead people don’t vote… End-of-life care ‘deeply concerning’

The NHS and reckless election promises. How about posthumous voting?

 

The West Wales options.

The West Wales options are now in the public domain, so readers of NHSreality can have access. The fact is that it is difficult, in an under-capacity market, to attract doctors to where there is no tertiary capacity, no research, and from where promotion is unlikely. When doctors do come and compete for jobs, is where there is a bribe, and a system that allows choices across Deaneries. This is present for GP training schemes, but is not yet facilitated for pre-registration F1 & F2 posts. The population demographic for Wales, and West Wales in particular, shows that Pembrokeshire has the highest population density, and that’s without holiday visitors in the  4 summer months…. Watch for the short term fixes, watch for nurses and other staff leaving, and the possibility of civil unrest. Whatever solution is proposed, the debate will be local, and a utilitarian solution will not come out of public meetings.

 

The official documents for the West Wales options are belwo.

6b. Feedback Form – Stakeholders (Template) vs2

3. Levels of Care and Menu of Services 08.01.18

2. Current ‘Long-list’ of Options 09.01.18

 

Good on you Mr Gavin Tait. Tell it as it is… and I bet you never got an exit interview.

Local politics and health: Hundreds from West Wales (Pembrokeshire) to protest at the Senedd against ‘downgrading’ of Withybush Hospital

The BMA Hustings – an uninformed line up of hopeful politicians. Withybush Hospital degenerates further.

Cancer doctor (Ann Barnes MBE) quits over understaffing at Withybush

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

West Cornwall Penzance), Cromer and now Withybush. All become minor injury clinics…

Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..