Specialising in Fewer Hospitals Will Make the NHS - and Us - Healthier; the South Wales Health Boards Last Week Published Ambitious Ideas for the Future of Obstetrics, Paediatric and Neonatal Care and Accident and Emergency. the Health Boards' Medical Directors Explain Why the NHS Needs to Concentrate This Consultant-Led Care on Fewer Hospitals

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| HERE'S an oftenheard saying in the NHS about making sure the patient gets the right care from the right person in the right place and at the right time. It's a catchy description of what we want to happen all of the time but it's most often used when we're talking about changing services.

The real truth of the matter is that not all patients are currently receiving the right care when they need it or, indeed, when they come to hospital for help. That's not to say that patients don't receive good care because, on the whole they do - and standards are continuing to improve.

But in some cases it can take some time for a patient to see the right clinician, especially if they are coming to hospital at night or at weekends, when we tend to have fewer senior doctors on duty.

There have been massive advances in medical care and technology over the last few decades, which mean we're now able to successfully treat diseases and injuries which would previously have been life-threatening. Tiny babies born very prematurely now have a better chance of living as a result of the incredibly complex care we're able to offer.

But this kind of hi-tech medicine can only be delivered by teams of doctors, nurses and therapists who have specialist skills. Patients get the best outcomes when they get to the right specialist team as quickly as possible.

Technological, medical and pharmaceutical improvements also mean the NHS is able to provide more sophisticated and responsive care in the community, outside our district general hospitals - for example, nurses are now able to administer daily intravenous antibiotics to patients in their own homes when previously these patients would have needed to be admitted to hospital.

The overwhelming majority of patients - some 90% or more - are treated in the community without ever needing to be admitted to hospital. The real revolution in healthcare is happening in our communities as more services are released from hospitals and provided on people's doorsteps.

But while all this has been happening, the way our hospital services are provided has largely remained still, stuck in a 1960s time warp when we believed it was possible - and the right thing to do - to provide as many services as possible on as many sites as possible.

This may have been viable half a century ago but it's no longer the case as a result of that increasing specialisation and because of changes in the way doctors work and are trained.

The European Working Time Directive has put very reasonable limits on the hours doctors are able to work - the days when over-tired junior doctors would clock up 100-plus hours of direct patient care a week are long gone. The net result of this is that we have junior doctors who are less fatigued, but we need twice as many as we once did to provide care.

Changes to the way doctors are trained after they qualify from medical school also have an impact on the way we provide services - as training has become more complex and intense, doctors-in-training need to see larger volumes of patients to ensure they have the necessary skills to specialise.

Doctors-in-training want to come to busy hospitals where they see these large numbers of patients but where they also work in larger teams of medical staff and feel supported - this historically hasn't always been the case in Wales and we need to make changes to attract doctors-in-training.

All this has had a significant impact on some of our key specialist services - most notably obstetrics, paediatrics, neonatal care and accident and emergency.

These are the services where we have been experiencing the greatest difficulties recruiting the doctors, including consultants. …