What’s wrong with our hospitals in Wales?

Do you ever wonder what’s really happening to the NHS in Wales?  There’s lots of talk about hospital ‘down-grading’, shortage of money, patients treated without dignity… and equally, stories of marvellous care, lives saved and miraculous research.  But what does that add up to?  It’s hard to get a balanced view.  Who do you trust?

And yet people in every part of Wales will shortly be asked what they think about some pretty far-reaching proposals for change in the NHS.  How can concerned citizens hope to form a view on something so complex and so contentious?

It was precisely to inject some evidence into this debate that we were commissioned by the NHS in Wales to collect together and review the evidence on the quality of care in our acute hospitals, on the state of the workforce, and on access to hospital care.  And then to draw whatever conclusions the evidence would support on the best configuration of acute hospital services in Wales.

This is what we have now done.  The evidence has been gathered and laid out for people to make up their own minds.

We set out to get some straight answers to four questions that people often ask:

Q: On Safety and Quality: What’s wrong with our current pattern of hospital services?

A: There is an accumulating body of evidence which suggests that patients in Wales do not always get the best possible outcomes from their hospital care.  Outcomes can even vary according to the day of the week you are admitted.  In some key specialty areas – notably major trauma, general trauma and emergency care, stroke care, maternity and newborn care, and paediatrics – the way services are organised in Wales probably falls well short of what the evidence suggests is optimal.

Q: On the Workforce: We’ve got more staff than ever before, so what’s the problem?

A: There are now acute pressures on medical staffing in paediatrics, emergency medicine, core surgical training and psychiatry, and more generally in some of the more remote parts of Wales. A ‘perfect storm’ has developed, with more doctors in our hospitals, but actually less availability in comparison with the demand for their services.

Q: On Access: Is poorer access inevitable to ensure good safety and quality?

A: Centralising services is almost bound to increase some people’s travel times. However, there is a lot which can be done to mitigate the impact of the centralisation of some services. In particular, the risks associated with longer travel times could be substantially reduced, if pre-hospital emergency services were also re-configured.

Q: And putting the elements together: What’s the case for change?

A: There is now a strong case for re-configuring some hospital services, in Wales as elsewhere in the UK. This has a positive aspect – patient outcomes could be improved – and a negative aspect – some services will collapse because of shortages of key staff, if changes are not made proactively.  While these problems have been developing over time, the need for change is now urgent in some key specialties, as levels of medical staffing become acute. 

It is in the nature of this evidence sometimes to be frustratingly vague, inconclusive, contradictory, or simply non-existent, and not always to point to a single answer.  People therefore have to weigh the evidence for themselves, taking into account the interpretations placed upon it, and applying their own common sense. Health policy decisions are usually like this – in part about value judgements – and striking an acceptable compromise between different objectives is something else that readers must do for themselves.

People also need to sift the rhetoric from the reality.  A good example is about ‘centralising’ services.  Whenever you hear that phrase: beware!  It can hide a multitude of sins.  For example, if you have a stroke, you are best treated in a highly specialised stroke unit for the first two or three days of your care.  This might in the future be some way away from where you live, if you live outside the main centres of population.  After that, there’s often no benefit from staying in such a unit, and the rest of your rehabilitation can be provided just as well back in your local hospital.  Is that ‘centralisation’ of services?  It might be, for two or three days; but it’s not for the rest of your time in hospital.  Is it worth it, to get a better chance of surviving without long-term disability?

Finally, we need to recognise that sometimes, services are not as good as they should be, and that some services don’t do as well as others.  That shouldn’t be a surprise to anyone, and people working in the NHS have always known it.  But in the past the NHS has perhaps been too protective of us, allowing people to believe that they will always get the best possible care, regardless of where and when they are treated.  As more and more information comes into the public domain, NHS staff and the public will see that this is not always the case.  We should celebrate this greater transparency, because it provides the best possible incentive to make services better.

We now desperately need a serious public debate about these issues. Most of the NHS in Wales provides a good and robust service; but key bits are giving serious cause for concern.  Choices are now required on what to do about this.  To sit on our hands and ignore the evidence is to put at risk the quality of care for future patients.

Written by Professor Marcus Longley, Director

 Full copies of the Summary of evidence and of the supporting reviews can be downloaded from the website of the Welsh Institute for Health and Social Care, University of Glamorgan at http://wihsc.glam.ac.uk

This article is reproduced from an article appearing in the Western Mail on Monday 14th May 2012.

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