Leading GP Dr Peter Saul believes the NHS is struggling and in need of a major overhaul, to meet the demands of modern day society. Here the Former Chair of Royal College of GPs Wales, Visiting Professor Wrexham University, Clinical Tutor Cardiff University, BBC Radio Wales ‘doctor’ and GP in Rhosllanerchrugog, gives his opinion what the problems are and how they can be fixed
It was hard sitting across my desk from my patient, an older man crippled by pain and knowing there’s nothing I can do to help apart from give him potentially harmful strong painkillers. He had already been over a year on the waiting list, and we had just been discussing how much it might cost to have his hip replaced privately. He shook his head “Those costs are out of my league. I’ll just have to soldier on and wait doctor”.
Bad enough for him, but the other problem was, as a carer for a seriously disabled wife, was he still going to be able to look after her, or was she heading for a care home soon? Sign up for the North Wales Live newsletter sent twice daily to your inbox.
The previous day I had had seen a lady recently out of hospital, but now with further complications. I needed to send her back, yet she begged me not to admit her via the over stretched Emergency Department where she knew she would endure hours of waiting. It took 20 minutes of gentle persuasion to explain I had no other option.
And those are two of the lucky ones that got to see me. Another patient had remarked that it is easier to get a Taylor Swift ticket than a GP appointment these days.
It shouldn’t be like this. As a GP who has worked for over 35 years in the role, I have never seen things so bad. Sure, Covid has made this worse, but this NHS ‘storm’ has been building for 15 years and I’m not sure that our health leaders in Wales have got a clue about sorting it out.
Let’s look at the facts. The UK spends 11.3% of our national wealth on health, this is more than most other ‘rich’ countries. Yet we have fewer doctors and nurses than our peers and, more to the point, worse outcomes for our patients.
Take cancer mortality, now 10% higher than other rich nations and stroke deaths at 30 days – 15% more. We have fewer scanners and other diagnostic equipment and more clapped- out buildings. Focus just on Wales and the figures look even worse.
Ambulances outside Ysbyty Glan Clwyd
(Image: Daily Post Wales)
Millions have been wasted, some on poor management such as high agency costs for staff because we haven’t had proper workforce planning, some because investment in facilities and diagnostic kit has not been part of the plan, some because money has been focused on hospitals without investment in primary care, community and social services.
Let’s look a bit more closely at primary care. GP services have heavily criticised since Covid and it is still too hard to get an appointment. As a GP I must put my hand up, yes, seeing us is harder, but you know what, we hate it too.
So, what is behind this issue? GPs are seeing more patients, a 4% increase since 2012, but there are fewer whole-time equivalent GPs around in Wales, a decrease of 25% according to the BMA. GP funding as a proportion of the NHS budget in Wales hasfallen while hospital finances have increased. It is amazing that while hospitals are now just about getting back to seeing similar numbers of patients as they did pre- pandemic, GP services are running at 120% of previous levels, seeing far more consultations.
With more staff and resources Primary Care could do even better. Welsh Government does not have a good track record. According to Senedd Research its plan to transform and modernise planned care is going nowhere fast.
Waiting lists aren’t improving, ambulance delays lurch from crisis to crisis and Emergency Departments struggle to remain safe. Things must change, and this needs to be about fundamentals not just money. So what’s on my ‘prescription pad for change’?
First, let’s break up the health boards. Too often they are dysfunctional and clamp a “dead hand” over service development and innovation. They are bloated and inefficient with layer upon layer of bureaucracy.
Take the Betsi Cadwaladr University Health Board (BCU) here in North Wales. It’s been in Special Measures for almost half of its existence! The so called ‘vertical integration’ where a health board commissions and then provides all the service has not worked.
Instead, we need to have services tailored locally for local needs, maybe run by slimmed down health bodies focused on the communities they serve. GPs here could also take a lead. First strengthen our numbers, invest in buildings, diagnostic kit and administrative support. Improve retention and recruitment through better pay packages. Let us be the people that our patients’ can call ‘my doctor’.
This means being there for them when they need us and also being the “care managers” ensuring that patients’ clinical needs are met. This is the heart of “relationship-based care” where patients and doctors can build trust and a collaborative relationship.
File image of a GP writing out a prescription
(Image: PA)
So, what would this look like? First better access for patients to see a GP, same day for urgent matters and same week for less serious consultations. Give every patient a named GP.
Practicalities might mean that they wouldn’t be around every day, but for an individual patient they would head up the local team providing care and be the “go to” person if there were problems.
GPs have a proven record of stepping up to meet demand when they are given the resources and incentives, so let’s do this but also hold them to account for delivery. A practice failing to meet access targets or turning away a poorly child at 6pm without good reason should take a financial hit at the very least!
We also need to get hospital specialists out into the community to run more clinics in health centres, surgeries and community hospitals. Community hospitals have been a Cinderella service in some parts of North Wales, let’s change that with major investments and more services on offer, give them back to local communities and GPs and stop treating them as outposts of ‘the big hospital’.
Let’s have primary and secondary care working together, sharing expertise for our patients. Let’s combine this with a big expansion in diagnostic equipment such as scanners
When patients needed specialist treatment their GP teams should be released from the health board “straitjacket” and empowered to refer to a variety of hospital providers, NHS and private, and not limited by geography. GPs like me would sit down with our patients to discuss hospital referrals, unlike now when they are just sent off into an administrative “black hole”.
Public Health Wales would be able to help guide this process. NHS elective surgery would be made more efficient by separating where routine operations are performed, such as cataracts, hip replacements and the like, from units where acute interventions were being performed.
These “elective care centres” would mean no more patients turning up for a booked treatment only to be told to go home as there was no bed because of an emergency admitted the night before.
Let’s also face some less popular measures. Centres of excellence for acute care are important, things like cardiac, stroke and trauma but these do best with big numbers and concentrated expertise.
This might mean a reduction of acute units across Wales but, with better transport and more expert care when patients arrive, there would be improved outcomes. This might also mean a switch to fewer but bigger, better Emergency Departments backed up by a network of minor injury centres.
Team NHS Wales involves lots of professionals, managers and support staff. I see and experience amazing dedication and all aspire to do even better. Let’s allow them out of the current organisational straitjacket. We need to rebuild a health service with patients at the heart.
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