The decision to commit to a new hospital in West Wales has been inevitable – since the WG has no intention of combining Hywel Dda and Abertawe Bro Morgannwg (ABMU) and providing a sensible solution, a mistake is being made. Recruitment to West Wales has been poor at the best of times, and now that the rationing of medical school places over the last 30 years is coming home to roost, the Hywel Dda board have no other option. There are not enough professionals ready and willing to work in West Wales, and not enough money to fund them if there were. There is an ethical argument, from a population perspective, that rationing covertly )whereby nobody knows what is not available until they need it) is better than rationing covertly (whereby citizens know in advance what is not available in their post code). But from a liberal and individual perspective, this is unethical, as it discourages autonomy and choice. It seems some choices have to be planned for by saving money, and of course this option divides us into the haves and the have nots. Exactly what Aneurin Bevan tried to avoid. Medical professionals accept that the pace of advance of medical technology is faster than any states’ ability to pay, and that rationing is inevitable and endemic already. Politicians deny the need to ration, and until this becomes honest and overt, the hearts and minds of the caring professions will be disengaged from the politics.
It has been a “least harm for the greatest number” decision that Hywel Dda has been asked to make. It will please nobody. It will satisfy nobody. It may lead to more emergency deaths. As the population ages and the demographic suggests this will be for several decades, the problems of type 2 diabetes and dementia will become worse. The Welsh Health Service costs more per capita than the English because of poverty, and yet the WG takes more from the overall budget by top slicing. When dealing with a population as low as 3 million, this really matters and adversely affects the options in devolution. That is just one of the reasons devolution has failed.
Aberystwyth finds it even harder to attract staff, and the longer term prospects for their people are worse. Llanelli and Carmarthen citizens have speedy access to Swansea, and NHSreality, and most GPs in Pembrokeshire, feel that joining the two boards would be best. The decisions to build relatively new A&E and Renal units at Withybush in the last decade now seem very strange.
Is the fact that every county wants the new hospital the opposite of NIMBYism?
…Babies of both sexes in Scotland and Wales and baby boys in Northern Ireland are even projected to live shorter lives than their parents do after average longevity dropped slightly in parts of the UK.
Experts said that the government must investigate the reasons behind the stalling of life expectancy, which some have blamed on cuts to public services.
Between 2015 and 2017 the average life expectancy remained at 79.2 years for men and 82.9 for women, the Office for National Statistics said. There were falls in Scotland and Wales for both men and women, and among men in Northern Ireland, averaging 0.1 years.
If you believe these superficial reports you might like to think whether you want to go to your local DGH in all circumstances? Do you have much choice? Waiting hours in A&E is going to become routine. Don’t forget money, a good book, drink and food, and possibly a camping stove if you have to go.
This e-mail received today from RCGP Wales. GPs are asked to write to their WAMs. \But how did this happen, and why was so little done over decades? OOH and locum doctors in Pembrokeshire can earn prodigious sums and be put up in a hotel for working in Fishguard.
GP out of hours services are in crisis. The Wales Audit Office recently highlighted the decade of neglect of these services. Health boards are unable to fill hundreds of out of hours shifts, leaving some areas without cover in the evenings and at weekends.
This is unacceptable. We need to ensure that patients can receive high quality care when they need it
Patients’ needs don’t stop when GP practices close, but evidence shows that patients are finding it difficult to access care.
GPs are going above and beyond to try and make things work, but health boards are not providing the resource or support needed to deliver their own services, and patients are feeling the effects.
Arvind Madam, head of primary care for England, obviously lived in a city. Whilst it is good to raise standards in denser populations, and large teams can offer more, the problem in our rural and deprived areas is simply access. A friend tried to get an appointment in my old surgery this week, and was told there were none for 6 weeks. My old practice does not suffer from a recruitment problem, unlike many others in the area, but it is the holiday season…. several doctors are absent and access is difficult. I advised my friend to drop a written letter in and await a phone call. The letter with symptoms will have to be scanned and put into her notes, and the doctors will need to “safety net” ! She will get a response but she is articulate, literate, reasonable, and informed. What would the average patient do and feel? Mr Madam is like my patient, and his approach to a national shortage of diagnostic skills is understandable, but only partly truthful. In Pembrokeshire more and more practices are under special measures, and manned by expensive locums, some earning over £1700 per day, and accommodated in local hotels. The post code differential in quality and access is becoming clearer daily.
The end of small GP surgeries could be good for patients, NHS England’s head of primary care has suggested.
Arvind Madan said that the amalgamation of small, independent practices into bigger groups should be welcomed.
Dr Madan told the GP magazine Pulse: “There are too many small practices struggling to do everything patients now want for their families in a modern era of general practice.”
Earlier this year the magazine found that 1.3 million patients had been forced to move surgery over the past five years after their own had closed. Many GPs are struggling because of recruitment and funding problems. Dr Madan said that “a rationalisation of providers” would make the remainder more viable.
He said: “General practice here is built on a foundation of 7,400 small and medium-sized businesses. In all markets there is some degree of difficulty for a proportion [of them]. But I think we would all like modern, thriving general practice available to us and our families.”
He said that practices should take up the opportunity created to be part of new primary care networks covering 30,000 to 50,000 patients, which were made up of larger teams that included nurses, pharmacists and mental health workers.
“I think it is our job to help every practice on this journey. There is a degree to which the central national team can create the environment in which all practices can thrive,” he added.
“But there is also a degree of responsibility within practices, which I am sure they will accept, to take up the opportunity because I am not clear that passively waiting for the system to change around them is sufficient.”
His comments were criticised by GP union leaders. Mark Sanford-Wood, the British Medical Association’s GP committee deputy chairman, said: “Small practices are often delivering the best standards of care to patients, who are seeing the same doctor who is embedded within the community and has a detailed knowledge of individuals’ medical history.
“While the BMA believes there is a benefit in practices working together across an area, this needs to be done in a positive, mutually beneficial way, in which full support is provided to practices. For such systems to thrive, all parties, not least patients, must benefit.”
Michelle Drage, chief executive of Londonwide local medical committees (LMCs), said: “For general practice to do ‘everything you would want for your family’ it shouldn’t be placed in a market. Market success or failure should not be the measure by which we judge it.”
Rachel McMahon, chairwoman of the England Conference of LMCs, claimed that many practices simply did not have the resources available to change the way they worked. She said that all the efforts of the surgeries were going into “just keeping the doors open” and to suggest that they were able to drive a big transformation was being naive to the issues they faced.
“I am in the privileged position of being able to speak directly to patients at a variety of practices,” she said.
“My personal opinion is that the highest levels of patient satisfaction seem to be from patients who are registered with smaller practices, as they are able to experience a more personalised service.”
In the \economist July 21st Bartleby describes a new book by Jeffrey Pfeiffer, a professor of business at Stanford, “Attitudes in the American workplace”. The stress that kills American workers”, is a thoughtful assessment of un-to-date facts.. Do we have less stress than the US, and is this partially due to the safety nets of our 4 health services? Our health services have the highest rate of sickness and absenteeism of any organisation in the world!
HOW much golden leisure can you expect at the end of your working life? The OECD has calculated for how many years people in its member countries are now likely to be drawing their pensions, starting not from their official but their actual retirement age. It found that men could look forward to between 14 and 24 years in retirement and women between 21 and 28 (see chart 6). In many countries that was half as long again as in 1970, and in some of them twice as long. And the figures are probably an underestimate because they are based on life expectancy as it is now, not as it will be in future.
Retirement has been overdone. The original idea was that people should enjoy a bit of a rest after a life at work, but nobody imagined that the rest would stretch to almost a quarter-century. Some countries have already raised their official retirement age; others are debating whether it still makes sense to have a specific retirement age at all. One widely touted idea is to phase in retirement over a number of years. It does not seem like a good idea for people to be working at full tilt one day and twiddling their thumbs the next.
From an economic point of view, getting people to work for a few more years would solve many of the problems associated with ageing populations. By carrying on, those workers will not only save the public purse money by not drawing a pension but will also continue to pay taxes and social-security contributions, so those extra years are doubly valuable.
Moreover—though it seems an outlandish thought in the middle of a deep recession and rising unemployment—ageing populations are likely to cause labour shortages. In some countries and some sectors these are showing up already. In Germany, where the labour force is due to start shrinking from next year, a study by the Institute for the German Economy in Cologne identified a shortage of about 70,000 engineers in 2007, a rise of nearly half on the year before. The obvious place to look to fill such gaps is among well-qualified older people, and indeed the institute found that companies had stepped up their recruitment of engineers over 50.
Many countries already have laws to prevent discrimination on age grounds. America led the way with its Age Discrimination in Employment act in 1967, designed to make sure that the over-40s (greybeards of their day) were given the same job chances as younger people. Among other things, it prohibited reference to age in job advertisements. The act has since been amended a couple of times and now rules out mandatory retirement on age grounds for most jobs. That seems to have helped keep older workers in jobs.
The European Union in 2000 issued a directive that obliges member countries to ban discrimination in employment on a number of grounds, including age. France imposes a tax called the Delalande contribution (now being phased out) on employers who sack older workers. Although this can be quite hefty—up to a year’s pay—it does not appear to have saved many jobs. Rather, it has discouraged employers from hiring older workers.
Various countries have concocted an alphabet soup of initiatives and pilot projects to get older people into work and keep them there, with mixed results. Advocacy groups for older people such as America’s powerful AARP, and a growing number of similar organisations that are springing up in other rich countries, have helped to raise awareness of the issue. But survey after survey finds that where employers have a choice, they prefer to hire younger workers. Are they right?
On the face of it, there are plenty of reasons to plump for youth. In most countries, pay goes up as workers become more experienced and productive, and then declines again towards the end of their careers. But in some places—for example, France, Germany and Spain—pay just keeps rising. So even assuming that workers remain just as effective as they get older (see below), at some point they end up being too expensive for what they offer.
But employers are also doubtful that older workers can still hack it. Vegard Skirbekk of the International Institute for Applied Systems Analysis near Vienna has reviewed a large number of studies about the relationship between age and individual productivity and found a fairly broad consensus that productivity in many jobs declines substantially in mid-working life….
…Show me the colour of your carrot
But even if employers were happy to keep or recruit older workers, how enthusiastic would those workers be to carry on? That would depend on the circumstances. In the past few decades, when pensions in most rich countries were reasonably generous and early retirement was positively encouraged, only the most workaholic (or improvident) continued working. But now that money is getting tighter and early-retirement deals are off, the balance may well have shifted.
Most of America’s baby-boomers now say that retirement is not for them, partly because they fear they may not be able to afford it and partly because they actually like work. In Europe too there has been a change of heart from the retirement-minded 1980s and 1990s. In a recent FT/Harris poll 45-60% of respondents in the big European countries favoured working longer for a bigger pension (except in Germany, where only about a quarter wanted to carry on). But many older people would like a less onerous workload than they had at their peak, perhaps working part-time.
Japan, where it is customary to work well beyond the official retirement age, has found ways to allow people to step into less demanding roles. For example, at the head office in Tokyo of Hitachi, a giant global electronics company, over two-thirds of those who reach the company retirement age of 60 apply to be rehired. The company can usually find jobs for them, explains Takane Miwa from the company’s human-resources department, but often in a different division, sometimes part-time and always minus their former job title and seniority. The company pays the employee about 80% of his previous salary, which includes his public pension and a government subsidy, so it gets him at a bargain price.
Most other rich countries have not been good at making use of older people willing and able to work. The names of a few companies that have consistently recruited staff past retirement age—mostly retailers such as Britain’s B&Q and America’s Wal-Mart—pop up time and again, but the list never seems to get much longer. In the absence of a good choice of jobs, some newly retired people manufacture their own, turning themselves into self-employed consultants to do much the same thing as before, though perhaps at a less punishing pace.
It is worth bearing in mind that if many more older people were to stay on in the formal economy, some of the things they now do outside it and without monetary reward would fall by the wayside. Many newly retired folk sign up for voluntary work, and many more get drafted into family duties, looking after grandchildren or frail old parents. Such unpaid work does not show up in the GDP figures. If the people who do it held down regular jobs, much of those things would have to be paid for—or would not get done at all.