BMA Cymru Wales manifesto for a healthier Wales
June 2006
Branches of practice
Secondary care, tertiary care and hospital and community consultants
Consultants are proud of the role they play in delivering a high quality, free at the point of access, National Health Service to patients across Wales. Consultants are keen to see the NHS improve and they constantly lead change, pioneering new techniques and services. Consultants are determined to see equity and freedom of access preserved, with care provided on the basis of clinical need. The BMA challenges the incoming government to engage with consultants to help them deliver the high quality service patients deserve.
BMA Cymru Wales believes that consultants should be involved in constructive dialogue at the early stages of policy formulation and reform initiatives. In the main, it is doctors who have to implement and reform of services, and their professional input at an early stage would help shape sustainable reforms.
The new Welsh Assembly Government should:
- increase capacity across the NHS to ensure that patients access the high quality treatment of their choice, quickly and close to their homes
- deploy increased resources, both money and staff, to 'front line' NHS services to increase capacity
- protect NHS core services against fragmentation and destabilisation
- treat patients according to their clinical need, setting standards that do not distort clinical priorities
- adopt health-economy-wide approaches to avoid long waiting times, particularly in A&E departments
- invest in consultants to enable them to lead improvements across the NHS
- in developing medical training, ensure that the impact on consultant time and deliverability are taken into account
- recognise and promote the important roles played by consultants across healthcare for the wider NHS.
General practice has been the cornerstone of the NHS since its inception in 1948 and is crucial in providing patients with continuity of high quality, personalised healthcare. With approximately 300 million consultations every year across the UK (nearly 90% of the work of the NHS) and a 91 per cent satisfaction rating (The future of general practice, RCGP 2004 p4), UK general practice is internationally renowned as the most cost effective form of healthcare delivery in the developed world. A number of countries with more expensive and fragmented health systems have begun to duplicate the UK system of general practice, with its emphasis on equity of access via registered patient lists with the GP providing the gateway to other parts of the health service. This ensures the coordination, continuity and comprehensiveness of healthcare, via a unique payment system linked to positive healthcare outcomes. In Wales in particular, the family doctor is highly regarded as the patient’s advocate.
However, BMA Cymru Wales is concerned about the lack of growth in the number of doctors training to be GPs. These GPs in training form the new life-blood of general practice and their numbers should be expanding significantly to match the increasing demands on family doctors with a primary care focused service. When one takes into account the changing work patterns of new GPs, with many of them wishing to work more flexibly, it is estimated that one needs to train 1.7 to 2.00 new GPs to replace each family doctor who retires.
Recruitment
GP recruitment is almost static in Wales at the moment and falling behind the other three nations. In order to remedy this BMA Cymru Wales would like to see an expansion in registrar numbers supported by a premises strategy that makes specific provision for training of registrars, medical students and F2 trainees. We would also like to see a commitment to offer F2 GP training to 70 to 80 per cent of all F2 trainees similar to the aspiration in the rest of the UK. Adequate incentives will be required to put in place the best possible training opportunities for these doctors at the beginning of their careers.
The new Welsh Assembly Government should:
- recognise the crucial role played by general practitioners and their teams in the NHS, with nine out of 10 NHS consultations (one million a day) being with a GP
- safeguard the internationally proven and much-needed personal service of the family doctor in a practice with a registered patient list, who also facilitates appropriate use of the rest of the NHS
- provide resources to enable GPs to give their patients adequate consultation times
- ensure there are sufficient resources for GPs to deliver the full range of services that patients expect and need. This should include improving health and health inequalities, for example, through the Quality and Outcomes Framework in the new GP contract
- give patients real choice through a system with sufficient capacity in which GPs can refer to a preferred consultant without restriction
- eliminate crude target setting that creates illogical pressures on appointment systems and distorts clinical priorities
- not risk jeopardising the continuity of high quality care delivered by mainstream general practice through fragmentation of services and a lack of strategic input to the planning and delivery of services
- not dilute or damage the UK's unique system of general practice through the inappropriate or excessive involvement of the private sector
- avoid politically attractive, but superficial and potentially flawed, policies that benefit neither patients nor the NHS in the longer term
- engage representatives of general practice in developing and implementing policy to increase the chances of such policy being workable, effective and supported by the profession
- engage GPs in commissioning patient services that are fair and equitable across the UK, adequately resourced, and involve GPs in devising new systems
- improve GP recruitment and retention, properly rewarding GP trainers and educators and putting a stop to funding cuts that have led to fewer opportunities to train as a GP
- adequately reward GPs for the support they give to community hospitals
- preserve GP pension benefits in the light of the reviews of the NHS pension scheme
- drive future change and make new investment cost-effective by ensuring resources go into general practice and not adding to an already over bureaucratic system.
Many countries are trying to move towards a UK-style system of general practice whereby well-qualified clinical generalists work in a primary care setting to help reduce the workload of an increasingly expensive secondary care system. At this time then, it seems almost unbelievable that the UK and Welsh governments should be suggesting changes that may very well threaten UK general practice.
These include: moves to bring the private sector into competition with the traditional family doctor, which could threaten the bedrock of NHS care; failure to fund adequately new initiatives and working arrangements; and uneven distribution of robust NHS management at local level leading to patchy implementation of improvements.
The present intention in England to extend the role of commercial private sector companies in primary care services in an effort to provide more choice to patients via Alternative Provider Medical Services (APMS) contracts carries significant risks, particularly if there is not a level playing field between providers. There is a danger that the UK's unique system of list-based general practice will be diluted and undermined by the fragmentation heralded by APMS.
BMA Cymru Wales firmly believes that politicians must give due consideration to general practice when debating and deciding on policies on the provision of healthcare, disease prevention and the NHS. Not to do so risks destablising the very bedrock of the NHS system.
The new Welsh Assembly Government must safeguard the internationally proven and much-needed personal service of the family doctor in a practice with a registered patient list, who also facilitates appropriate use of the rest of the NHS.
GPs, their patients and the public health
General practitioners play a vital role, not just in tackling illness, but also in preventing it. With smoking, alcohol consumption, diet and exercise being the most important controllable factors contributing to the development of major diseases, GPs can contribute to improving patients' lifestyles by promoting healthy living. However, the success of this role relies on three things:
- a good, trusting doctor-patient relationship, which in turn relies upon the traditional concept of general practitioners being the family doctor and gateway to the NHS. GPs are deeply concerned that the introduction and expansion of private providers in the primary care market place may lead to a fragmentation of the service that will devalue the GP's traditional, very personal role
- longer consultation times, which are dependent upon having enough GPs and on patients and others being encouraged to use the NHS responsibly
- adequate resources for the delivery of basic essential services in addition to appropriate resources for other areas of work undertaken in general practice.
By doing so, it puts chronic disease management, preventive medicine and high quality care right at the heart of NHS general practice. The new system recognises GPs' essential contribution to these vitally important health measures and promotes further improvements in GPs' standards. The QOF is a world first in addressing health inequalities by providing the best primary health care to all, regardless of geographical location and socio-economic status. It will be regularly reviewed to ensure that it keeps in step with the most up-to-date and best available clinical evidence. BMA Cymru Wales urges the incoming government to build on the enthusiastic response by the profession to the QOF by providing further resources for general practice, some of which should be available for expansion of evidence-based interventions which will deliver cost-effective benefits to the health of the nation.
Junior doctors
Junior doctors have an important role to play in many of the political parties’ stated aims to modernise the NHS. There are approximately 46,000 junior doctors working in the NHS throughout the UK and they play a significant part in the delivery of patient care.
The term ‘junior doctor’ covers a hospital doctor’s life between graduating from medical school to the time of achieving completion of specialist training. During this period the majority of time is engaged in the training grades within hospital practice.
The last 10 years have seen considerable reductions in their hours of work, but this has had a significant impact on working conditions, opportunities for training and work-life balance.
Life for a junior doctor continues to be extremely demanding and further improvements are needed to ensure junior doctors continue to have opportunities for training within the NHS in Wales.
The new Welsh Assembly Government should:
- invest in suitable, high standard facilities for junior doctors within hospitals, recognizing the new methods of working and the change to shift working
- enhance the work-life balance, the availability on out of hours catering
- promote and fully fund the opportunity for junior doctors to undertake their training in a less than full-time capacity
- invest in robust, available childcare facilities within the NHS to assist in shift working and flexible working practices
- invest and support a specialist medical careers service
- facilitate the smooth transition of the new training curriculum of Modernising Medical Careers and ensure the quality and availability of medical training is preserved. Both for those training under the existing scheme and equally for those training under the new scheme adequately fund the Welsh postgraduate deanery to maintain study leave to promote access to further necessary training.
Medical academics have three vital roles in healthcare; within the medical schools they design the medical courses, organise and assess students and run the teaching of our future doctors. Secondly they have a critical role in the health service providing specialised clinical services direct to patients and thirdly the medical academics lead research into the understanding of the biology underlying disease and in developing new treatments.
According to a recent BMA report, the recruitment of medical academics is at an all-time low. The number of medical academics in the UK has declined by 12 per cent overall since the year 2000, with a 33 per cent decline in the number of medical academics in training. Meanwhile, the number of medical students across the UK has increased in the past four years by about 50 per cent to nearly 7,000; soon there may not be enough medical academics to provide an adequate education to the UK's rising number of medical students.
The report offers little hope that this decline will be reversed in the near future, with only a quarter of young doctors surveyed saying they have even thought about academic careers.
The main deterrents to a future in teaching and research were identified as financial disincentives, lack of clear career structure, and the absence of advice or support. On the other hand, many felt that academic careers offered intellectual stimulation, greater flexibility of hours and greater autonomy than hospital jobs.
It is worrying that so few doctors see academic careers as a realistic or appealing option. With medical school intake on the increase, the need for qualified medical lecturers and professors to teach students, who will become future doctors in the NHS, is of high importance. Also, the NHS needs high calibre researchers to be able to develop the best possible treatments.
The pressure for research output is increasing as the universities prepare for the Research Assessment Exercise in 2008 with funds for teaching appearing to be used for research, research posts being advertised with minimal teaching and medical academic posts being filled by non-medical research staff.
The NHS is requiring greater clarity about the six sessions per week for clinical work by medical academics and the universities are not taking account of this clinical commitment when demanding more research.
The BMA has drawn up proposals to reform the medical training structure so that doctors are exposed to opportunities to experience teaching and research at an earlier stage of their careers. In addition to this, the report, says that more flexible working patterns would encourage doctors not to leave academic jobs, and recommends more academic activity in both the NHS and higher education.
Doctors working in academic medicine perform vital functions for the NHS and healthcare in general. They are employed by universities, charities and medical schools and in addition to teaching our future doctors, they are also involved in research and have a critical role in the health service providing specialised services direct to patients. Medical academic staff contribute at a local, national and international level and are leaders in health improvement.
However, there have been unprecedented increases in the number of medical undergraduates but this is taking place alongside a declining number of medical academic staff. This is a trend that needs to be reversed, as continued falls in the number of academics will adversely affect the NHS. They now account for 8 per cent of the NHS consultant workforce, a fall from 11 per cent 10 years ago.
Without the investment in medical academic staff here in Wales, there could be a detrimental effect on both the NHS and the education of tomorrow’s doctors. Fewer innovations and new techniques will be developed. Responsibility for teaching will be switched to an understaffed NHS and junior doctors and medical students will see certain specialties as unattractive because of an unacceptable workload, furthering their decline.
Wales has a deservedly high reputation for the quality of teaching and research undertaken in its medical schools. We are concerned that this could be jeopardised if steps are not taken to ensure that a career in academic medicine remains an attractive option for doctors in training. The new government must take immediate action to ensure that there are enough teachers in our medical schools; without them, it will be impossible to teach the doctors of the future and provide Wales with the medical workforce it needs.
Medical academic staff challenge all political parties in Wales to say how they will invest in medical academic staff to enable them to help in ensuring improvement across the NHS.
Medical students
The NHS needs medical students
Medical students represent a hugely significant proportion of the future medical workforce within the NHS in Wales. The years spent at medical school serve as a solid foundation upon which the knowledge, skills, attitudes and behaviour expected of doctors is built and where they are ‘prepared’ to meet the challenges of delivering effective, quality patient care.
The psychological, emotional, physical and financial stresses and strains during a medical degree can be considerable. The vast majority of medical students will eventually be employed by the NHS, making it critical that the incoming government invest further in these unique areas, both during their study years and beyond.
BMA Cymru Wales is pleased that top-up fees will not be introduced in Wales. While this is commendable, it must be noted that the significant financial burden on students comes from more than just tuition fees. There are considerable maintenance costs involved in doing a medical course and the government must consider/generate ways of reducing this burden. The prolific financial implications connected with studying medicine is discouraging to students from low socio-economic backgrounds making them less likely to enter higher education. Medicine is therefore, generally dominated by students from the higher social classes.
The government must address this imbalance and create further opportunities which give more young people the chance to become doctors. Widening this access is the responsibility of the government as well as the medical profession and we are pleased to note that the National Assembly took this issue seriously. However, much more needs to be done to encourage talented people from under-represented or non-traditional backgrounds to nurture their potential. Greater resources are undoubtedly needed to improve national widening access strategies.
We would also ask the new government to consider establishing local NHS bursaries for medical students whereby after graduating, they return home to work for a set period.
Medical students challenge all political parties to say how they will endeavour to do all of the above.
Public health medicine and community health
BMA Cymru Wales is a passionate supporter of public health initiatives. Over the last few years there has been consistent debate on a wide range of policy initiatives and we know what needs to be done. Now is the time for evidence-based action. This must happen now when public health is currently high on the political agenda.
Health is determined by a complex interaction of social, economic, environmental and personal factors. Health is marred by inequalities, for example, the type of housing and area people live in, household income and social expectations. Interventions likely to improve public health will require a combined package of social, economic, environmental and health policies.
Public health initiatives must be based on sound evidence, properly costed and funded and then be evaluated. When of proven benefit, they must be ongoing.
Wales continues to suffer from high levels of ill health when compared with other parts of the UK. However, there are signs of improvement with deaths from coronary heart disease declining and survival rates for many forms of cancer improving. Much of Wales's ill health is concentrated among people in the country's most deprived areas. Primary care, public health and community health professionals are playing a key role in helping to promote healthy lifestyles and prevent people falling ill.
Staff and associate specialists
These are doctors in the staff and associate specialist grade work at the senior career-grade level in hospital and community specialties. The group comprises staff grades, associate specialists, clinical assistants, hospital practitioners and other non-standard, non-training 'trust' grades. SAS doctors work in key service roles within the NHS Wales. Proportionally, there are more SAS doctors in Wales than in England and their numbers expand every year. It is therefore imperative that they are rewarded for the important work that they do.
Some of these doctors work in very specialised clinics providing continuing care to patients and their families. Using their in-depth knowledge they often develop specialised skills. Further details of some of their work may be found in Hidden Heroes available from the BMA or on their web site. Other members of the group are providing support for inpatient and outpatient service to reduce the work load of consultants and junior doctors, providing out of hours cover for house doctors or working shifts in various departments.
In Wales a Good Practice for SAS has recently been agreed between the WAG, Employers and BMA representatives. This needs to be implemented across Wales to ensure that the best standards of employment and support for these doctors who have some times poorly treated by the NHS are addressed. In order that standards are improved and that those involved are treated equitably and kept up to date for the benefit of the NHS. The career progression from staff and other grades to the associate specialist needs to be applied consistently across Wales in order to fulfil the potential and use their skills and expertise for the benefit of patients. It is also important that 20 per cent of their time is contracted for continual professional development.
The particular contributions made by the little recognised SAS group of doctors to the NHS in Wales are significant. Recognition of, and investment in, this group of doctors is much needed as they are an untapped resource in the NHS. Improvements to the working conditions of the 12,500 or so doctors in this group are essential to the modernisation of the NHS and will also help deliver improved patient care.
The current UK contract negotiations which are currently under way in London should be fully funded and delivered in Wales. The progress of staff grades to associate specialist needs to be applied consistently across Wales in order to fulfil the potential and use their skills and expertise for the benefit of patients.
Now that PMETB is up and running, there will be some doctors within the SAS grade who will require top-up training. Places should be reserved for these doctors. This initiative needs to be taken up by the Welsh Assembly Government to prevent these doctors from being disadvantaged and to allow them to complete their training in the required time. Some of this training could be undertaken as workplace based assessment within trusts, with the Welsh Assembly Government helping trusts to enable this to take place, benefitting the doctors, the patients and the trusts involved.
For further information about any of the topics raised in this manifesto, contact John Jenkins, Public Affairs Officer, BMA Cymru Wales
Telephone: 029 20 474646 or email: jjenkins@bma.org.uk