Will the Doctor See You Now? Week In Week Out


Will the Doctor See You Now?

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In some places, it's getting harder to see the doctor.

:00:07.:00:15.

The wife had to press redial 240 times.

:00:16.:00:19.

GPs say there are too many patients, and too few of them.

:00:20.:00:26.

We meet doctors retiring early because they say the job

:00:27.:00:28.

Fewer doctors, increasing demands, and something has got to give.

:00:29.:00:39.

There aren't enough new doctors to replace

:00:40.:00:40.

those who are leaving, and the pressure is

:00:41.:00:42.

There are GPs out there that are burning out

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and that's why I worry for my future if I continue

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So what does this mean for us, the patients?

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We're with a former NHS insider to ask what can be done.

:00:58.:01:00.

The general public are on the street saying, no, we want our old services

:01:01.:01:08.

even if it is killing people, and that's a real challenge.

:01:09.:01:14.

This was 8am last month in Tenby and a queue has

:01:15.:01:17.

These patients say it's the best way to get

:01:18.:01:24.

They need to spend more money on west Wales.

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We are more vulnerable and the system has been like it since I

:01:32.:01:38.

moved down here 15 years ago. At this surgery, like many others, they

:01:39.:01:41.

say there are not enough doctors to meet demand.

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And things got so bad for this surgery in Milford Haven last month,

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The practice will be under extreme strain, please only request

:01:48.:02:09.

appointments if they are genuine. -- emergency appointments.

:02:10.:02:11.

And patients at this health centre in Pembroke Dock have been

:02:12.:02:13.

complaining about getting an appointment there.

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The way they do their appointment system is really...it

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They open the lines at 8am and you can be 25 past eight,

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quarter to nine hanging on waiting to see if you can

:02:22.:02:23.

100 times in 20 minutes, trying to ring on a mobile especially.

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The wife was trying to get an appointment for herself.

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It's frustrating when you can't get an appointment to see your GP

:02:34.:02:46.

It's one of the things that gets patients most worked up

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We've been filming in surgeries to see why the system is struggling

:02:52.:02:57.

to cope and why GPs don't want to work in some

:02:58.:03:06.

areas, and what it means for you, the patient.

:03:07.:03:10.

One of the practices that's come in for criticism in Pembrokeshire

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invited us in to see the pressure they're under.

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They, like the others, say they don't have enough doctors.

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I would say we are about one and a half whole equivalents,

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We did advertise for about 18 months through all the journals,

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We've noticed as well the number of doctors coming

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And what we used to find was if they trained here they often

:03:42.:03:46.

stayed here so that source has dried up.

:03:47.:03:48.

We've tried to advertise outside Wales but that's failed and we've

:03:49.:03:51.

also lost doctors from the surgery who have emigrated out of the UK.

:03:52.:03:59.

Dr Thanujah is a registrar, one of the health centre's newest recruits.

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She told us about a typical working day there.

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On an average day I come into work, I do a bit of admin, I start my

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morning surgery and I have roughly about 12 patients to see in the

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morning and each one is allocated ten minutes. On average down here I

:04:26.:04:30.

will have four home visits to do each day. I will come back into the

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surgery, look at any paperwork, blood results that need action in,

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then my surgery starts again. Once afternoon surgery has finished,

:04:41.:04:44.

there might be more paperwork that needs doing before I go home.

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We find the demands from patient exceed what we are able to supply

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We have improved that lately because we have got more nurse

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practitioners and advanced clinical practitioners working for us

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and so are able to offer more appointments with those

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In response to complaints, the surgery's also changed

:05:07.:05:09.

the appointment system to try to improve access,

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but without enough doctors they are struggling.

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And they're leaving, including their most recent recruit,

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I feel that they have a better worklife balance out there. They

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also have better services, and patients out there in private care

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can book a 20 minute appointment. I think that gives the GP enough time

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to address the needs of the patient safely and adequately. There are GPs

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out there that are burning out and that's a shame. That's what I worry

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for my future if I continue to work in this health service.

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It's 8am and I'm at the Gardden Road surgery

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The same doctors have been looking after the same patients here for up

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It's a traditional family general practice.

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Just see how we are getting on. No ankles swelling?

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A General Practice is an independent business and doctors are partners

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There used to be five partners but by next April there'll

:06:30.:06:33.

And you have been there ever since? Yes, full-time.

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Yes, and we are very lucky to have had that, with mentors to show the

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way. Dr Coward says it's the pressure

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that's driving out older doctors. He is about to come down

:07:02.:07:04.

to two days a week. He's failing to recruit younger full

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time partners because they're put So you have got that perfect storm -

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fewer doctors, increasing demands Patients like Eleanor Valentine

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don't want to lose doctors who've I've been with this

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practice since I was born. Don't know where I'd

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be without them. But Dr Coward has had enough

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and is planning to semi retire. I'm going part time in September

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and Dr McCaddon is going in March. Today he is having to spell out

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the changes to other patients. With so few people coming

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through the system we will have five retired

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doctors coming in. I didn't know about this until a few

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days ago. I am quite happy now that I know this practice is going to

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continue. The number of GPs in Wales

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has gone up by 8% over But headcount alone doesn't

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tell the whole story. And doctors leaders in Wales say

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with more GPs wanting to work part time, and with patient demands

:08:51.:09:02.

growing, far more GPs Replacing those leaving,

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whether young or old, is a problem, because the trainees

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aren't coming through. I think there has to become fewer

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places... Malcolm Lewis trains

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the next generation of GPs. They haven't attracted

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enough students from medical school for years

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so a shortfall's been building. And future projections

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of the workforce paint Given we have only something

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like 2,500 headcount GPs in Wales, to have a potential shortfall of GPs

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maybe 700 by maybe 2024 is that's According to the Kings Fund,

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a health think tank, only one in ten GP trainees surveyed

:09:50.:09:58.

in England plans to work The Wales Deanery say

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it's much the same here. I think we are maybe the generation

:10:02.:10:16.

that sees ourselves as may be more mobile, not staying in one location

:10:17.:10:21.

for our whole career. Entering a partnership makes it difficult to be

:10:22.:10:25.

so mobile and move from one location after five, ten years.

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There's also a geographical divide opening up.

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Of these five trainees, only one could imagine herself

:10:29.:10:31.

practicing any distance away from a big city.

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plans would maybe to move further west. More long-term plans.

:10:36.:10:46.

Facilities in and around Cardiff and along the M4 corridor art may be

:10:47.:10:51.

better in some senses than rural locations. Other things that put

:10:52.:10:56.

people off working in rural rural areas is the workload, they are sure

:10:57.:11:00.

of partners and having to cover extra workload, you feel if you went

:11:01.:11:04.

there there would be other work to do.

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It's these views that lead some to say we'll see

:11:06.:11:07.

This doesn't mean surgeries will close, necessarily,

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We already have a situation in parts of Wales where GPs feel unable

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to continue in their practice and it's called handing

:11:16.:11:22.

back their keys or handing back the contracts to the health board

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and unless we are able to increase number of GPs.

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It may be that other parts of Wales will suffer that fate.

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Across north Wales, six GP partnerships have already given

:11:35.:11:36.

up their practices and they've been taken by health boards.

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Recruitment and retention problems are threatening a model of care

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that's served welsh towns and villages for decades.

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A survey two months ago by the royal College of GPs reported that more

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than one in five said they planned to reduce their working hours

:11:55.:11:57.

As a senior partner used to say who retired several years ago,

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you should aim to have natural causes on your death certificate.

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People tend to self medicate and things like that, go down the

:12:15.:12:21.

alcohol root and so on. People are getting burned out very quickly, and

:12:22.:12:30.

I cannot see anybody of my age working, carrying on doing six days

:12:31.:12:33.

a week. I want to drop down to two days.

:12:34.:12:34.

The same survey found eight out of ten doctors in Wales were worried

:12:35.:12:38.

they would miss something serious due to current workload.

:12:39.:12:44.

The amount of time which is spent in a consultation, although it usually

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runs to more than ten minutes, phone calls, interruptions, excessive

:12:54.:12:59.

house calls that we've always tried to contain, it's inevitably going to

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lead to some rather snap, snappy decisions than one would like. There

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is a safety issue. We do our best, but we do think, what have I missed

:13:15.:13:20.

today, what could I have done better? It's a fear.

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Betsi Cadwaladr Health Board told us they take the issue of patient

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safety very seriously and their role is to help take pressure

:13:27.:13:29.

But responsibility for safety of the individual lies with the GP.

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I wanted to ask our new Health Secretary Vaughan Gething how

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he responded to fears from doctors' leaders about enlisting more GPs.

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What's your take on what seems to be going on with GP recruitment? We

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know we have a real challenge on GP recruitment. Various different

:13:57.:14:01.

context in different parts of the country in a different scale in

:14:02.:14:04.

different parts of the country. We wouldn't be doing if we didn't think

:14:05.:14:09.

there was problem. That is why we have a primary care plan, it's worth

:14:10.:14:14.

putting more money in. When looking at diversifying the workforce, so

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GPs get to do more of what they can do and there are other professionals

:14:19.:14:21.

to do different things. I'm confident we can find a way through.

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Where GP surgeries have handed back their notices, we've always found a

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way to maintain the service for the public. Recruiting and retailing

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enough GPs especially in rural areas is a problem.

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Jonathan Richards was one of South Wales's most prominent GPs.

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We've often filmed him over his 30 years working in Merthyr.

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He deliberately chose the town because of its high levels

:14:52.:14:54.

The challenge we face at the moment is other things are changing society

:14:55.:15:04.

is changing, and expectation is changing, roles and responsibilities

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are changing and that's making the job of a family doctor

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substantially more difficult and more challenging.

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I have to confess, I was pleased to retire.

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A professor of primary care, he was also a clinical director

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As a former NHS insider, he believes we have to do things differently.

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I was finding day to day work, as a clinical GP, more and more

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challenging - harder and harder work.

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Do you mean traditional GPs surgeries can't function in the same

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In Prestatyn with partnerships throwing in the towel,

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the local health board has had to step in to provide the service

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I think this is something the nurse practitioner can deal

:15:57.:16:03.

if you bring in a urine sample with you as well.

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It's called Healthy Prestatyn, and it's a new kind of surgery.

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I'd like to book you in for an initial assessment.

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Does she have enough tablets to last till then?

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GPs, including Chris Stockport, work here not as partners in a business,

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but as salaried staff of the health board.

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I see lots of doctors in my day-to-day job,

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and in speaking to young doctors many are telling me and colleagues

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one reason they don't consider GP practice as a career

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is because they don't want to be involved in the running of business.

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They want to be employed under similar terms and conditions

:16:45.:16:47.

It's also pushing a different approach to healthcare.

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Nurse practitioners like Katie Dawson are increasingly

:16:56.:16:57.

common in surgeries, but Healthy Prestatyn is relying

:16:58.:16:59.

As a nurse practitioner, if you are can see the day-to-day presentations

:17:00.:17:15.

of minor illnesses, then it frees the GP to see the more

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complex cases that come But does she get any resistance

:17:19.:17:21.

from people who only Sometimes people insist

:17:22.:17:24.

they want to see a doctor and I don't force that,

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but sometimes - once they realise that you have skills to deal

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with them efficiently - I'm calling from the doctor 's

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surgery... physio therapists, all dealing

:17:35.:17:46.

with things the doctor And also that you're

:17:47.:17:50.

wanting to return to work? There's an occupational therapist

:17:51.:17:57.

who tries to boost people's independence, so they don't have

:17:58.:18:00.

to visit the GP at all. If people are staying active

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for longer and being able to self-manage,

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reaching their own goals, then yes, you are more in control and that's

:18:10.:18:11.

what they like. I have worked with patients who like

:18:12.:18:15.

having that sense of control. It's about self-management

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and not coming knocking I'm seeing patients that

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are being managed by other professionals that would previously

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have been on my list for the day. Not only managing them well, but,

:18:29.:18:30.

if I am perfectly honest, managing them better,

:18:31.:18:33.

because they are bringing other The doctors here say a third

:18:34.:18:35.

of their workload has been taken away, releasing more time

:18:36.:18:44.

for appointments and for the people It is making a huge difference,

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it means that patients I see are more complex,

:18:48.:19:04.

but I can use my skills I've been It's the first time this model

:19:05.:19:07.

of primary care has been tried on this scale,

:19:08.:19:12.

looking after so many patients. The Health Board says this new model

:19:13.:19:15.

can compete on cost with So is this the shape

:19:16.:19:17.

of things to come? Very possibly, says health economist

:19:18.:19:21.

Ceri Phillips. We cannot do the things we've always

:19:22.:19:25.

done. The system is on the verge

:19:26.:19:28.

of breaking. In some areas perhaps it's already

:19:29.:19:38.

broken - we cannot fix We have to look at what works

:19:39.:19:41.

in other communities. We have to look at other models

:19:42.:19:49.

of care and use of technology, we have to make sure that

:19:50.:19:53.

professionals do what only do Before retiring last year,

:19:54.:19:56.

Professor Richards was helping shape how his local health board,

:19:57.:20:03.

Cwm Taf, provided primary He says trying to make

:20:04.:20:05.

changes in the NHS creates I achieved quite a lot of small

:20:06.:20:09.

changes, but in terms of the broader things - that has

:20:10.:20:17.

proved much more challenging. People wanted to continue doing

:20:18.:20:20.

the things they we are familiar doing, and there were not

:20:21.:20:28.

all of the levers that I'd liked to have in place to say

:20:29.:20:36.

we can't keep driving the oil tanker in this direction,

:20:37.:20:39.

the oil tanker needs to be And and that does really does

:20:40.:20:41.

require a real small political drive, to say we simply cannot

:20:42.:20:45.

continue doing the same things He was particularly concerned

:20:46.:20:48.

about how smaller GP partnerships in places

:20:49.:20:58.

like the Cynon Valley would survive. He was helping them to work more

:20:59.:21:02.

closely together in clusters, He took us to see one

:21:03.:21:05.

of the surgeries involved. Sometimes we have to treat patients

:21:06.:21:13.

in corridors because This is sometimes used

:21:14.:21:19.

as a consulting room As you can see, very

:21:20.:21:23.

little space in here. This surgery in Mountain Ash has

:21:24.:21:28.

outgrown its building ? the practice is hoping to get money

:21:29.:21:32.

from Welsh Goverment We allowed the students and

:21:33.:21:42.

registrars to have a room to study downstairs but it is totally

:21:43.:21:43.

unacceptable, isn't it? Two full time partners

:21:44.:21:49.

and a salaried doctor and nurse look There's also a visiting pharmacist

:21:50.:21:52.

and nurse practitioner. If you mentioned anyone to Cardiff,

:21:53.:21:59.

I work in Mountain Ash, they say, couldn't you get a job anywhere else

:22:00.:22:03.

question at this is where we want to be, an exciting place to work and

:22:04.:22:08.

this is where the future should be. The answer for recruitment

:22:09.:22:11.

protection is to have a good working life, in a good place, with good

:22:12.:22:15.

people. But that doesn't come easily, does it? In the valleys we

:22:16.:22:21.

have a high number of patients who have a lot of chronic diseases, more

:22:22.:22:26.

than elsewhere. A high number of unemployed people and a high number

:22:27.:22:27.

of elderly patients. You see people and they're

:22:28.:22:36.

on 12-16 medications, It's not just are tablets, it's

:22:37.:22:38.

checking all conditions are managed. One of the things that's meant

:22:39.:22:41.

to help meet these demands These doctors say they are happy to

:22:42.:22:45.

come together with other surgeries. It builds up better

:22:46.:22:52.

relationships with other The Welsh Government has just has

:22:53.:22:58.

put a further ?6 million into supporting Wales' GP clusters,

:22:59.:23:06.

but as independent businesses, general practices can't be

:23:07.:23:09.

forced to join clusters, and around Wales there are reports

:23:10.:23:12.

of some being keener than others The Welsh Government wants to take

:23:13.:23:15.

pressure off hospitals by getting GPS to do more

:23:16.:23:26.

here in the community, but they are worried that will only

:23:27.:23:29.

add to their workload. And without extra money

:23:30.:23:35.

and resources, they won't be able The Royal College of GPs not enough

:23:36.:23:37.

money is going to general practitioners, whereas the number

:23:38.:23:43.

of full time hospital consultants in Wales has

:23:44.:23:45.

gone up by more than 40% over The Welsh Government is putting

:23:46.:23:50.

an extra ?40 million into primary But the proportion of the NHS total

:23:51.:23:54.

going into primary care, compared with hospitals, has gone

:23:55.:23:59.

down over the years, and GPs think But when Professor Richards

:24:00.:24:02.

was at the health board suggesting resources should be

:24:03.:24:13.

switched to primary care, he says he faced opposition

:24:14.:24:17.

from some consultants. Yes, people think -

:24:18.:24:19.

if I agree to this change, Might they decide instead of four

:24:20.:24:29.

consultants in the team, we only need two? It does come down to that

:24:30.:24:30.

level. And he says we all need

:24:31.:24:33.

to change our attitude. In Wales, the public hate

:24:34.:24:37.

changes to hospitals. Look at some ideas to change

:24:38.:24:39.

hospital services and the general public are almost on the streets

:24:40.:24:42.

saying "No, we want our old services" even if its

:24:43.:24:45.

killing people, and this Cwm Taf Health Board told us that

:24:46.:24:47.

"Working in an integrated system is partly about how the skills

:24:48.:24:55.

of GPs, hospital doctors and wider This means everyone working

:24:56.:24:59.

differently and collaboratively The board accepts that change can be

:25:00.:25:04.

difficult, but it's extremely proud of how their staff

:25:05.:25:17.

are embracing new ways of working. Driving change is challenge

:25:18.:25:20.

for the new Health Secretary Doctor Jonathan Richards told

:25:21.:25:22.

us there are too many internal barriers to change,

:25:23.:25:26.

and when he suggested the things to help the primary sector

:25:27.:25:28.

at the expense of the hospital, We've got to have a clear

:25:29.:25:31.

expectation from our point of view of how people will

:25:32.:25:35.

work with each other. There's no point pretending

:25:36.:25:37.

there aren't some rubbing together, or some rubbing apart from people

:25:38.:25:39.

from different parts of the service. And I do think we need

:25:40.:25:42.

to be more demanding, and having a much greater

:25:43.:25:49.

expectation then what works will then work will be carried

:25:50.:25:51.

out more consistently, and that is one of our biggest

:25:52.:25:53.

challenges in the service - how do we make sure that what works,

:25:54.:25:56.

when there's evidence that it works, is then delivered in a much more

:25:57.:26:00.

consistent basis right In the meantime, this system,

:26:01.:26:02.

to some extent, struggles on, held together by the dedication

:26:03.:26:08.

of doctors like these. Jonathan admires them,

:26:09.:26:11.

but also thinks the situation in the Valleys is unsustainable,

:26:12.:26:13.

until everyone agrees on change. If you take the needs of the people

:26:14.:26:25.

in the community here, they'd be best served by a larger

:26:26.:26:28.

team of people with economies of scale to bring in more staff

:26:29.:26:31.

working from one building, because at the moment

:26:32.:26:34.

if you want to provide services, you have to provide 3 or 4

:26:35.:26:36.

of everything - instead of a team instead of a team of two or three

:26:37.:26:40.

people who could provide You could have more equipment.

:26:41.:26:43.

Better use of IT if everybody worked together, but if you did that,

:26:44.:26:48.

you'd lose the spark of individualism, you see on show

:26:49.:26:53.

here today, so the challenge Back in Rhosllanerchrugog

:26:54.:26:55.

near Wrexham, the surgery is going to be relying much more

:26:56.:27:07.

heavily soon on part-time GPs. They are determined to carry

:27:08.:27:12.

on as an independent practice, and are looking at new ways

:27:13.:27:14.

of running the business. Dr Coward is looking forward

:27:15.:27:17.

to semi-retirement, but after so long in the same place

:27:18.:27:21.

he says he can't just walk away. It is not just coming

:27:22.:27:26.

up to retirement age, It would be a dreadful thing

:27:27.:27:28.

to the legacy of previous senior partners going back 90 years

:27:29.:27:42.

even if we did anything less than our very best,

:27:43.:27:45.

even in retirement. The Welsh Government says it

:27:46.:27:50.

will prioritise plans to boost the recruitment and training

:27:51.:27:53.

of additional GPs and Last week doctors' leaders met

:27:54.:27:55.

with the Health Secretary for the first time since

:27:56.:28:02.

the election, saying they'd been encouraged by his latest comments

:28:03.:28:05.

about wanting to see a greater transfer of resources

:28:06.:28:08.

from hospitals to primary care. Back in Pembrokeshire,

:28:09.:28:12.

Hywel Dda Health Board admit there are recruitment difficulties,

:28:13.:28:16.

but told us they were committed to ensuring patients

:28:17.:28:20.

could access clinicians. As for the queues we filmed

:28:21.:28:24.

in Tenby, the Health Board said they are telling patients they can

:28:25.:28:27.

book appointments on the phone. And at the Argyle St Practice,

:28:28.:28:37.

they'll will be looking I didn't realise the difficulties

:28:38.:28:39.

GPs have in rural settings. Being here, I have got the skills

:28:40.:28:52.

I need to be an independent And Juliet ? who's worked

:28:53.:28:56.

at the surgery for a decade is saying goodbye too ?

:28:57.:29:02.

she's just retiring. My hope is that the doctors

:29:03.:29:05.

who work here stay here I think it has to be raised in

:29:06.:29:17.

doctor 's consciousness is that becoming a GP can be a good career

:29:18.:29:21.

option and isn't the poisoned chalice they perhaps think that it

:29:22.:29:23.

is. I've brought you all here

:29:24.:29:50.

to lay out a vision - a team of radio presenters

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without equal. Actually, we're already...

:29:53.:29:55.

Wynne Evans - singer, raconteur. I'm betting you'd also

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be funny on radio.

:29:58.:30:00.

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