Is the NHS fraying at the edges?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j343 (Published 23 January 2017) Cite this as: BMJ 2017;356:j343
Abstract
The BMJ’s former editor Richard Smith reflects on what he has learnt from four decades of visits to the health system in Dumfries and Galloway
In 1980 I visited Dumfries and Galloway to see a health system that worked well at a time when many thought the NHS was facing its imminent demise. Thirty six years later I’ve been back for the fourth time with the same claims of impending collapse ringing in my ears, but this time I found an NHS that is fraying.
The Dumfries and Galloway region has a population of 151 000, which is expected to fall to 141 000 by 2037. The region already has the oldest population in Scotland, and the number of those aged 15-64 is expected to decline by 22% by 2037, while the number of people aged over 85 will increase by 160%. This is the demographic challenge common to the whole country.
The region has a low wage economy that is based mainly on agriculture, forestry, and tourism, but the biggest employer is the public sector. The median hourly wage in the region is £9.80, the lowest in Scotland; in Edinburgh it’s £13.66. Jeff Ace, chief executive of the health board in Dumfries and Galloway, told me that he has three main concerns: providing the right services for the ageing population, recruitment, and financial sustainability.
Building a system right for elderly people
In 2005 the Scottish government produced a report, called Building a Health Service Fit for the Future, predicated on the idea that the health service would increasingly be dealing with patients (most of them elderly) with long term conditions (see Table 1⇓). Dumfries and Galloway needs to make these changes.
How care for elderly people in Scotland needs to change
I saw most changes in this direction in Annan, the third biggest town in the region and one of the least remote. Neil Kelly, a GP and the clinical lead for Annandale and Eskdale, thinks that the present health system is unsustainable and is exploring ways to tackle this. These include “recreating self care,” reducing dependency, supporting lonely and isolated people in the community before they present in crisis, encouraging task sharing, strengthening communities, hastening health and social care integration, concentrating on what matters to patients rather than to professionals, encouraging people to have forward care plans, and promoting the use of information technology.
The region has a policy of integrating health and social care, but Kelly believes that integration and other reforms cannot be forced by central diktat but depend on change being made locally. People and relationships are what matter, and it’s important to recognise the wide variation among small towns.
Recruitment crisis
Recruitment came up in nearly every one of the 50 conversations I had over the four days I spent in the area. The problem is most acute in general practice but also affects other specialties. A few years ago many doctors competed for a place on the GP vocational training scheme, but now it’s only half filled. John Locke, a GP in Kirkcudbright, cites four reasons for the difficulty in recruiting GPs: young doctors don’t want to leave the central belt of Scotland or other cities; the national shortage of GPs, with many GPs working part time; many GPs choosing to work as locums; and fear of partnerships, with their complex business implications.
Some of the region’s towns, particularly in the remote west, have been trying to recruit GPs for years without any serious applications. GPs have responded by doing extra sessions, recruiting advanced nurse practitioners, and merging practices, but it’s a downward spiral: remaining GPs are put under greater pressure, making them more likely to retire early or do something else.
The Scottish government is now offering a £20 000 golden handshake to GPs who join practices in Scotland, hoping to attract GPs from England. But, as the GPs all told me, English GPs tend to earn more than the Scottish, negating the value of the handshake.
Stranraer, the second biggest town in the region and the most westerly, has the biggest problem. There were until relatively recently 14 GPs, but now there are nine and three advanced nurse practitioners, and all but two of the doctors are over 55. One of the three practices may close within weeks.
Recruitment of secondary care doctors is patchy, and the increasing specialisation of medicine presents problems. Even if subspecialists can be recruited they are likely to be working on their own, which is professionally unsatisfactory. And the subspecialists are either unwilling to take general medical admissions or are not fully comfortable with the conditions outside their specialty. This is unfortunate in that the majority of medical patients, most of them elderly, have multiple health problems. The reluctance of subspecialists to do a general take puts greater pressure on those that are, and one general physician told me bluntly, “I’m burnt out.”
The oncology service is provided from Edinburgh, which is perhaps the future for other mostly non-urgent services. An obvious risk for Dumfries and Galloway is that as services provided from cities come under pressure it’s the services outside the cities that will suffer the most. But if plans to merge Scotland’s 14 health boards into three come to fruition Scotland’s services may be organised differently.
The problem of recruitment of hospital trainees is less about numbers and more about experience. In some specialties, including medicine and anaesthetics, the trainees sent to Dumfries are junior, meaning that consultants have to do much more than would be necessary with more senior trainees. Several people told me that the most senior doctors on the medical wards at night might be only two or three years into their postgraduate training.
Nurse recruitment does not seem to be a problem, but I heard a lot about a shortage of care workers. And despite the elderly population, there is a shortage of beds in care and nursing homes. Around Kirkcudbright they are all full and it’s a case of “dead man’s shoes.” Most of the homes are care not nursing homes, and steadily rising standards are causing some to close.
Finance and some good news
Finance was Ace’s third main concern, and to put it simply the service is being kept afloat by spending the seed corn. Ace thinks that there needs to be an open discussion with the public about what can be afforded and what can’t.
I’ve concentrated on the problems of the region, but, as my accompanying blog describes (http://blogs.bmj.com/bmj), a new hospital is being built in Dumfries; information technology, which I described as a “black hole” in 1999, may now be the best in Scotland; emergency department targets are being met; and mental health services have made the transition from hospital based to community based services so successfully that there is no pressure on beds.
I fear that the remoteness and small population of Dumfries and Galloway have changed from being advantages in 1980, when medicine was less specialised and the NHS under less pressure, to being disadvantages in 2017. The nature of medical practice in the region is changing from a culture where everybody knew everybody and “mucked in” to help each other to one where providers are more fragmented. Locke, who has practised in Dumfries and Galloway for 30 years, once knew all of the consultants in Dumfries, but he recently realised that he knew only 22 of 81. Similarly he once knew all the GPs but now doesn’t. There were once many meetings between GPs and consultants, but now there are few.