Future Hospital update from Wales
In Wales, where we have a large rural population, a growing public health crisis, and real terms cuts to the health budget, recent attempts to redesign NHS services have been met with a media storm, angry patient group protests and bitter political squabbling. Recently, the row has spilled over the border, and with a general election only months away, the Welsh NHS is, for the first time ever, a regular reference point during Westminster debates.
In the past year, stories of poor patient care and higher than expected mortality rates at some hospitals have led to claims of a ‘national scandal’ from prime minister David Cameron. The health secretary in England has suggested that the Welsh Government is ‘sleepwalking into a Welsh Mid Staffs tragedy’. The Welsh Government have called these accusations ‘utterly unfounded’, pointing to a recent Nuffield Trust report which suggests outcomes in the NHS in Wales are broadly in line with the rest of the UK, or have improved to a ‘similar level to England’.
Since devolution, the health service in Wales has followed a different path to England, abandoning the plurality of competitive providers, and rejecting the internal market. Instead, seven local health boards (see Fig 1) plan, secure and deliver primary, community and secondary care services for around three million people, with a focus on integrated care and collaborative working. In 2011, as budget cuts across the UK were announced, the Welsh Government asked all local health boards to publish new plans for ‘sustainable services for all communities’. In practice, this has meant the concentration of some specialist services in regional ‘centres of excellence’. After a long period of consultation, three sets of plans have now been published in north Wales, west Wales and south Wales.
In north Wales, the health board published its proposals for community services, neonatal intensive care, older people with mental health needs, and vascular services in January 2013. Some of these decisions were referred back to the health minister by the community health council, but a final agreement has since been reached, and the Welsh Government has confirmed that it will be working with other public bodies in north Wales to overcome local transport issues. However, the health board has not yet published its proposals for the future of acute medicine, despite the minister admitting in a recent media interview that A&E units in north Wales are now under review.
In west Wales, the process has been even more difficult. Some of the original proposals for emergency medicine, neonatal, maternity and paediatrics services published by the health board were rejected by the community health council, and in response, the minister established an independent scrutiny panel to consider the issues. At one hospital, the panel supported the replacement of a consultant-led A&E department with an emergency nurse practitioner unit, supported by GPs, a solution which is now being taken forward.
However, on some aspects of the proposals for neonatal services in west Wales, the panel was unable to reach a clear conclusion. It reported that without clear and definite plans for obstetric and midwifery services, it could not agree plans for neonatal services. The minister asked the health boards to carry out further work; he later announced that a final set of plans had been agreed, with a ‘phased introduction’ of centralised consultant-led neonatal services at one hospital in west Wales. He also announced an independent evaluation would be carried out a year later.
In south Wales, five health boards serving almost 2 million people came together with the Welsh Ambulance Service to work collaboratively on proposals for reconfiguration. In March 2014, despite widespread political and public opposition, it was agreed that the Royal Glamorgan Hospital would lose consultant-led A&E services and specialist care for mothers, newborn babies and children. However, plans are being drawn up to turn it into a ‘beacon site’ for a new model of acute medicine for people with chronic illnesses, and in April 2014, the health minister announced a substantial amount of funding for this work. The minister has also announced that care alliances will be set up, requiring clinicians from different hospitals and health boards to work together to provide patient care and share information, skills and expertise.
The difficulty, of course, is that so far, plans for reconfiguration across Wales have only looked at selected, specialist services. No health board has yet published detailed plans for the reconfiguration of medical specialties, and there has been no public consultation on the future of a safe acute service. The RCP has been involved in discussions with the South Wales Programme, and we have been talking with the health board in north Wales – but turning around the NHS has famously been described as turning around an oil tanker, and in Wales, things are no different.
As you might expect, the three opposition parties in Wales – Plaid Cymru, the Welsh Conservatives and the Welsh Liberal Democrats – have opposed these changes, as have several Welsh Labour backbenchers, many of whom are already thinking ahead to the next Welsh general election. Health is going to be the key battleground in 2016. Yet with the combination of an ageing population, spiralling numbers of patients with chronic conditions, unprecedented financial constraints and crucially, not enough doctors to cope with the looming crisis, surely change must happen, it will happen, and when it does, isn't it better to steer events, rather than letting them take over?
That is why Dr Alan Rees, RCP vice president for Wales, has established a Future Hospital Wales working group. This new group has been established to lead the Welsh contribution to the Future Hospital Programme by identifying key issues, gaps and opportunities for the Programme in Wales. We aim to take a whole Wales approach by working with local health boards, the Welsh Government, other professional bodies, patients, and RCP fellows and members to support the implementation of the Future Hospital recommendations in Wales.
Reporting directly to the UK-level Future Hospital Programme, the group is developing a programme of work looking at the delivery of acute medical services in Wales, engaging with hospitals and health boards across Wales, and consulting with a wide network of stakeholders. We believe that the launch of the Future Hospital Programme provides the RCP with a key opportunity to help plan for the safe, sustainable future of acute medicine in Wales – and once the plans are in place, the hard work of implementation will begin. Meanwhile, as the RCP in Wales takes this work forward, we will report our progress to fellows and members through the Future Hospital Journal.
- © 2014 Royal College of Physicians
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