Consultation Summary

In October 2009, Hywel Dda Local Health Board (known as Hywel Dda Health Board) became fully operational. As an integrated health body, it is responsible for the health and wellbeing of people across Carmarthenshire, Ceredigion and Pembrokeshire. The health board also provides a range of services for people who live in south Gwynedd and Powys. As the Minister for Health and Social Services made it clear in Together for Health (2011), establishing integrated health boards was only the first step in creating a world class NHS in .

Hywel Dda Health Board has a population Our vision for the future of 375,000 and covers over a quarter of the As well as supporting the vision the Welsh landmass in Wales. We have 9,500 staff. Government has for NHS Wales, we want to: Primary care and community services are • improve health and wellbeing for all delivered through: • move from a sickness service to a wellness service 55 GP practices 51 Dental practices • deliver quality healthcare in the best setting 100 Community pharmacies 52 Optometry premises • have high quality, safe and sustainable 8 Community services 11 Health centres • be recognised as Wales’ leading integrated Our in-hospital services are currently rural health and social care system delivered through: We want to provide integrated healthcare with 4 Hospitals (Bronglais, Glangwili, 80% of NHS services being delivered locally, Prince Philip, Withybush) through primary, community and social care teams. Integrated care means all agencies and people In response to the challenge identified in working together to deliver services where the Together for Health, the health board has journey through the system of care is made as published a consultation document setting out simple as possible. These will be provided locally, what it wants to achieve in the next 3-5 years. It by doctors, dentists, pharmacists, opticians is consulting on the proposals highlighted in that (the primary care team), nurses and therapists document from 6 August 2012 to 29 October (the community team) and social care teams all 2012. This summary document tells you about working together. the plans we want you to consider for the future We will provide this care either at home, close of healthcare services in Hywel Dda Health Board. to home or in the community. Delivering this The full version of the consultation document, vision will support care for the frail and elderly, questionnaire and detailed technical documents whilst allowing our hospitals to concentrate on can be found at www.hywelddahb.wales.nhs. what they do best – providing both planned and uk/Consultation or requested by calling 01437 emergency care when it is needed. 771232.

1 Consultation Summary

What integrated care will mean for Health inequality – people live longer in different people parts of our area and we need to make sure that everyone gets the same high quality and Working across boundaries – by teams working consistent standard of care. closer together it will be easier for patients to move between services - which will result in care Rural location – quite a lot of the population live being given in the right place at the right time. in the country or small towns and face problems getting the right services at the right time. Supporting patients in the community – by providing faster diagnostic tests in the community Waiting times – people are sometimes waiting too and by proactively managing patients we believe long for treatment. we will have less people needing to go into Recruitment – we need to make sure we have hospital. a constant flow of well-trained doctors and Chronic disease management – we will continue specialists, especially as almost half of our senior to support patients to manage their conditions doctors are able to retire within the next few with the help of community and practice nurses, years. preventing them having to go to hospital unless New technologies and medicines – our patients absolutely necessary. should be receiving the benefit of new Self care – patients and their carers will be offered technologies and drugs as soon as possible to advice, encouragement and support to do more achieve the best outcomes possible. for themselves in their home. Value for money – we need to make sure we use our resources in the best way. What this will mean for our workforce Best configuration of hospital services for Wales: For this to work we need to have everyone A Review of the Evidence published in May 2012, working together delivering services. There will be www.glam.ac.uk, concluded that patients in Wales new and exciting opportunities for parts of our are not getting the best possible outcomes from workforce, such as nurses and therapists, with their hospital care and there is a strong case for clinicians taking on major roles. All the hospitals changing the way hospital services are organised. in Hywel Dda Health Board will operate as one because we want the best for the community By not dealing with these challenges, we could be from our resources - both staff and money. We putting the future sustainability of services at risk. will carry on finding best practice from around the We also risk not having the right services available UK and around the world so we keep on getting for our population when they need them. better. We believe that by implementing the changes Why things have to change identified in the consultation document, we expect to see a number of benefits: Although people living in this area in the main have healthier lifestyles than other places across • Improved services Wales, there are still many different issues and challenges to address, including: • Improved health outcomes for patients Safety and quality – whilst we perform well • Providing more care closer to home in many areas standards can vary across our • Efficiencies across the organisation hospitals . • Improved experiences and career A changing population – by 2026, the number opportunities for staff of people aged over 75 is going to double from 2008 levels.

2 What we have done so far We want: Between December 2011 and April 2012, the • to reduce hospital visits and stays health board undertook a wide ranging listening • more day case surgery in hospitals meaning and engagement exercise outlining what services less travel for patients and their families were provided at that time and what needed to be in place in the future. More detail on the • better public and community transport to activities undertaken and analysis of the feedback services on all our sites received during the process is contained in a • shorter journeys for patients because of report by Opinion Research Services (ORS) and mobile facilities in communities can be found at: www.hywelddahb.wales.nhs.uk/ Yourhealth-yourfuture • to involve families and carers when planning out-patient appointments and when and how We are now in the formal consultation period someone leaves hospital and are outlining our plans for the future of healthcare within Hywel Dda Health Board. • to have one telephone number to book The health board has reflected on the concerns transport raised during the engagement period and has considered carefully alternative proposals for We have discussed our plans with Welsh change. As a result, we have refined and shaped Ambulance Services NHS Trust and they are our proposals in light of what we heard. Any working with us to help deliver our new service proposed new or changed services will need to be plans alongside their plans. fit for purpose and fit for the future – they must be person-centered, high quality, modern, safe, Care closer to home sustainable and affordable. Our plan is to deliver services as close to home The health board proposals would be as possible. This includes moving some services implemented over a five year period - so you will previously only available in a hospital to GP only see changes to services when the health surgeries or the community. This will reduce the board is satisfied that we have the appropriate number of people who need to go to hospital. alternative services available in our communities. Better efficiency and improvements in primary and community services will reduce the overuse Transport of hospital beds; our evidence shows that up The listening and engagement exercise to 40% of patients in our hospital beds don’t highlighted that transport needs to be improved need to be there. By developing our primary so people can get to the care they need. Moving and community services and facilities further care closer to home is a major step forward in we can prevent this. The boundaries between in this. Themes highlighted during this exercise hospital and out of hospital services are still too included concerns over the long distances great. We need to ensure that all of our services families and carers sometimes have to travel – emergency, planned, primary, community and to visit patients in hospitals, the fact that over social care – are working together to meet local 90% of people find their own way to hospital needs. Meeting the chronic disease challenge will appointments, the difficulties with public and require us to bring together traditional hospital community transport over the weekend, returning services with community services and primary care home from an A&E department and difficulties services – to create integrated services. with parking at some hospitals. Our vision for care closer to home will enable us, in time, to reduce, by as much as 20%, the number of acute hospital beds. This will allow us to undertake an ambitious and comprehensive ward refurbishment programme to increase the 3 Consultation Summary

number of single occupancy side rooms and core hours, extended appointment times and single sex accommodation in our hospitals. improvements to the appointments process. The benefits of this will be fewer hospital- Pharmacists are an important point-of-contact acquired infections, significant improvements in for advice and treatment: we want to have an terms of dignity and respect and will ensure we ‘8 till late’ pharmacy within 30 minutes travel of have modern fit-for-purpose wards. all patients and 95% of them with consultation facilities. We know that before we change the way hospitals work, we need to make sure that we Better community care teams and services: each have the right services available in communities. locality area will have a team of professionals We have already started to make this happen who can provide care for patients in their own across the health board – and we must now homes. make sure that we have the same high level of Community resource teams: as they are already community services available for all. Hospitals will in place, we will expect them to continue to always be there for those who need them. bring all the services working in the community together, including social care and the third What this will mean for people: sector, to help support people to self care and Local planning, local delivery: keep their independence. Our proposals will mean that services are Community virtual wards: this will mean that organised across seven localities – which we have patients will be able to get the care they need already designated. The range of services in each at home from highly trained skilled professionals locality will be tailored to meet the needs of its and support staff. This could be through things population and community. The locality approach like telehealth monitoring. is the key to delivering 24-hour community care. Community Resource Centres (CRCs): these Quite a number of these services are already in centres are a major part of our plans to make place in some parts of Hywel Dda Health Board primary and community care better. Some of – our aim is to make these available for all our these centres could be based at community population. hospitals and used for a wide range of Primary care services: these services will be services, including diagnostic tests, outpatient available to all, and will include GPs providing appointments and mental health services. We a range of general medical services, with some are proposing to invest £40million into primary offering extra hours. We also want to see our and community care facilities, such as building population benefiting from the services of new community resource centres in Aberaeron, pharmacists, dentists and others. Cardigan, Carmarthen, Cross Hands, Crymych and Whitland over the next 5 years. Working Making primary care teams and services better: in partnership with Ceredigion County Council for example, making it possible for GPs and their and other agencies, we will also progress with teams to carry out an assessment or check up plans for a new health and social care facility in before a patient goes into hospital for surgery Tregaron (the Cylch Caron project). to optimise their condition, so there are fewer cancelled operations; or by letting patients home Community hospitals: we have eight community quicker after surgery into the care of their GP and hospitals, but some of them are old. We now community care teams. have the chance to rethink the way we use these resources. Improving access to primary care services: although we already have high levels of patient Redefining community beds: our aim is to provide satisfaction in Wales on accessing a GP surgery, community beds that will help us focus on we need to move resources to ensure easier helping people get better and get home quicker. access to your GP practice on the phone during 4 Improving care for frail elderly patients: we want Mental health and learning disability to create a new model of care for those patients services in hospital with a medical problem who need to access adult mental health services, if required. The aim of the health board’s Mental Health Similarly, mental health inpatients requiring and Wellbeing Strategy (2012) is to deliver medical support can be quickly supported. better care, closer to home, to recruit and keep The intention is to provide this at Prince high quality staff; to help people stay well and Philip Hospital in a co-located elderly medical to integrate mental health and well-being into rehabilitation and adult mental health facility. all services - to ensure the health board has a This will enable improved care to be provided for community and hospital service that suits the elderly frail patients and will mean that Mynydd needs of our population, now and well into the Mawr Hospital, which served a clear purpose future. As the implementation plan for delivering historically, will no longer be required. the strategy is developed, we will consult with staff and service users, as necessary. Minor Injury Units (MIUs): we want, as part of our care closer to home services, to support all of our Specific actions in the strategy include: GP practices in providing a minor injury service • Extending and expanding our current range of during surgery opening hours. community services across all three counties • Developing a Psychiatric Intensive and What we need your views on Assessment Care Unit (PIACU) in Carmarthen • Services currently provided from Mynydd that will provide an ‘assess to admit’ facility for Mawr Hospital will in the future be provided Hywel Dda Health Board and will support those in other ways, particularly through the in crisis requiring assessment and support and development of services at Prince Philip reduce the need for out of area referrals Hospital referred to above and supported by • Developing a Primary Mental Health Support a new Community Resource Centre at Cross Service as part of the Mental Health (Wales) Hands. This means that we propose to close Measure 2010 to be integrated within primary Mynydd Mawr Hospital once the necessary care alternative services are in place • Extending the Rehabilitation and Recovery Unit • Re-provide the Minor Injury Services at in Carmarthen to include dedicated single sex Tenby and South Pembrokeshire Hospitals accommodation. This will increase our ability to to be delivered through GP practices - with return out of area patients to local care staff redeployed into frontline emergency • Extending our therapeutic day services, services at Withybush Hospital (once the currently only available in Carmarthenshire, minor injury services within GP practices are across all three counties. This will provide the in place) opportunity for psychological therapies for all our patients

For learning disability services, we will provide services in tandem with existing acute mental health services, where appropriate, and will create new opportunities to provide services locally for individuals with complex needs. We will also develop specialist residential services within the area for those currently cared for outside of Hywel Dda Health Board. There are no specific service change options requiring consultation at this time. 5 Consultation Summary

Hospital Services What we need your views on In May 2012, a national report said that patients Whether to locate the new Level 2 Neonatal in Wales were not getting the best possible Unit, the Complex Obstetric Unit and the outcomes from their hospital care. This means Paediatric High Dependency Unit at: Glangwili we need to change the way we do some things. Hospital (our preferred option) or Withybush Below are a number of our services that present Hospital. us with challenges - both in proving safe, Why do we recommend Glangwili Hospital? effective services and in recruiting and retaining a strong clinical workforce. We can only have one specialist unit. We believe that this new unit would be more Women and children’s services sustainable in Glangwili Hospital, as locating the unit at Withybush Hospital would not Most pregnancies are straight forward, however provide a critical mass of births due to the the health board does not have a ‘high risk’ loss of mothers and babies to Swansea obstetrics unit for women who have deliveries based services. There are currently more that are not more complicated. In addition, births at Glangwili Hospital than Withybush none of the health board’s Special Care Baby Hospital and it is more accessible for the Units (SCBUs) fully comply with Royal College three counties. It is also closer to the Level 3 guidelines and it does not have a Level 2 Neonatal Unit in Swansea, which would mean Neonatal Unit to provide specialist care to sick faster transfer of a baby from the Level 2 babies. It also does not have a High Dependency Neonatal Unit to the Level 3 Neonatal Unit, Unit for children who are very unwell. should it be required. What we will do: • Continue to provide antenatal care to check Emergency departments and that pregnancies are progressing safely and as unplanned care planned to ensure babies are delivered in the None of the Emergency and Urgent Care safest location Departments within the health board comply • Continue to provide consultant-led obstetric fully with Royal College of Emergency Medicine services in Bronglais, Glangwili and Withybush guidelines and people often have to wait for Hospitals long times due to too many people accessing them when care could be provided elsewhere. It • On the rare occasion when a baby is born is also clear that best outcomes for patients with in any of these locations and unexpectedly emergency surgery are achieved when the service requires more intensive support, a stabilisation is provided by a consultant who is free from other and transfer service to the Neonatal Unit is commitments and there is no delay in accessing already available theatres. • Continue to provide paediatric intensive care for those babies born early or those in need of What we will do: extra help at the Level 3 Unit in Swansea • Patients with severe head injuries or major trauma will continue to be stablised in • Continue to have paediatric assessment Hywel Dda Health Board hospitals and units in Bronglais, Glangwili and Withybush then transferred to major trauma centres in Hospitals Swansea or Cardiff • Continue to have short stay paediatric units in • Continue to transfer patients to specialist Bronglais and Withybush Hospitals centres for certain specialised treatments, such as some modern heart attack treatments that are assessed and treated in Swansea 6 • Surgical services delivered by consultants working in all three counties, supported by • Medical assessment and short stay service Adult Clinical Decision Units (ACDUs) at Bronglais and Withybush Hospitals, with complex care transferred to Glangwili • Provide consultant-led emergency surgical and Hospital, as well as providing inpatient trauma assessment and treatment services services for Carmarthenshire residents in each of the three counties through Hywel Dda Health Board acute surgery and trauma • Nurse-led Local Accident Centre at Prince networks Philip Hospital • Provide access to the latest advances in medical Or treatments OPTION B (our preferred option) • Subject to the final model, to develop the A model that adapts the standards to meet Hywel Dda Health Board emergency surgery local geography and needs and would mean: and trauma centre(s) to ensure an operating • 24/7 Emergency Departments and Accident theatre and team is available at Bronglais, Centres co-located with purpose-built Glangwili and Withybush Hospitals during clinical decision and assessment facilities at daylight hours wherever possible Bronglais, Glangwili and Withybush Hospitals • Rapid access to specialist doctors and to • 24/7 Local Accident Centre at Prince Philip diagnostic facilities on all 4 hospital sites to Hospital; this service will be provided by reduce hospital admissions through consultant skilled emergency nurse practitioners and ‘hot clinics’ provide a similar level of service to the current department • Develop network protocols for complex cases and complex major trauma to be treated in • Emergency Medical Admission Units to be specialist unit(s) where full sub-specialty services located in each of the four hospital sites (see are readily available questionnaire) Why do we recommend OPTION B? What we need your views on Our geography and transport infrastructure In considering the options for the future of dictates that despite the challenges of emergency care we have two options: sustaining several emergency departments OPTION A we believe we need to retain 24/7 emergency services in each county. A model that applies the standards required in a strict sense to our area, this would mean: • One Emergency Department and Accident Planned care Centre at Glangwili Hospital. The department Only one of the health board’s hospitals has would provide a consultant-led service, beds or operating theatres dedicated to planned with 24-hour resuscitation, assessment surgery (Prince Philip Hospital); not having this in and treatment of acute illness and ongoing all hospitals results in longer waiting times and emergency treatment by experienced doctors cancellations if trauma or emergency surgery in dedicated facilities e.g. beds and theatres is needed. There is also a lot of duplication of • Local Accident Centres at Bronglais and services and patients receive different levels of Withybush Hospitals, supporting local care throughout the three counties. management of acute medicine, with surgery or the transfer of patients to Glangwili What we will do Hospital using a 24-hour paramedic transfer • Continue to provide in-patient services at all service four hospitals, and increase the range of clinical services through clinical teams 7 Consultation Summary

• Continue to provide orthopaedic services in Cancer services Bronglais Hospital and create a new centre of The health board wants to ensure everyone has excellence for orthopaedic surgery in the south access to the care they need when they need it, of the health board area with acceptable waiting times and with reduced • Develop a new cardiac catheter laboratory at cancellations. The health board wants rapid Glangwili Hospital diagnosis and follow-up treatment nearer to home and we want to ensure excellent services • Invest in our community and diagnostic for the cancers we know we can treat well. The services - to be provided from Community health board will continue to improve cancer Resource Centres services. For example we will:

• Continue to work closely with our neighboring • Improve cancer screening services in health boards to transform our diagnostic partnership with Public Health Wales services • Develop outpatient clinics, supported by • Focus on early intervention diagnostic tests, which will be offered locally • Complete the new front of house scheme at and, wherever possible, delivered through a Bronglais to provide dedicated overnight and ‘One Stop Clinic’ short stay theatres and beds • Develop a single multi-disciplinary team for • Provide day and short stay surgery in all three each cancer group (e.g. lung, breast etc) with counties and create a new short stay surgical guidelines and treatment pathways for surgical unit at Prince Philip Hospital procedures on all sites • Deliver surgery in dedicated areas where • Deliver assessment, diagnosis, chemotherapy, beds and theatres are used solely for planned and follow up care locally surgery • Develop a Hywel Dda Specialist Breast Cancer Team to support breast cancer surgery on all What we need your views on main hospital sites - with the specialist centre being located in Prince Philip Hospital Whether to locate the new Orthopaedic There are no specific service change options Centre of Excellence for those who live in requiring consultation at this time. Carmarthenshire and Pembrokeshire and increasingly from other parts of South Wales together with a leading edge rehabilitation Making every penny count unit at Prince Philip Hospital (our preferred There are funding challenges for the NHS in option) or Withybush Hospital. Wales. Making sure we can afford good quality Why are we recommending Prince Philip health service into the future is really important. Hospital? Like many other health boards we face a number of financial pressures. However, we face the There already is an elective centre for additional challenge of giving care in a largely inpatient orthopaedic services, and there is rural area. Every year the Welsh Government sets the capacity and space to develop a new unit out a number of key targets that all health boards on this site. across Wales must hit - we are currently one of the best.

How much will the changes cost? Not only will these plans improve the care we offer, but they will also make us more efficient and better value for money. These proposals 8 are about using our funding more effectively, Public meetings moving money from secondary care to primary There will be a public meeting held in each county, and community care - making sure we use the where people will be able to put questions to the beds we have in a better way whilst at the same health board. Attendance at these meetings will time improving quality and safety and outcomes be on a first come first served basis: for patients. We are clear that no changes will be effected until suitable and appropriate services County Time and Location are available elsewhere. Carmarthenshire 7 - 9 pm How we will deliver the 4 September 2012 changes Parc Y Scarlets, Llanelli Ceredigion 7 - 9 pm Services will only be changed following 5 September 2012 consultation - when full plans and pathways have Morlan Centre, Aberystwyth been designed and developed by our clinicians, service users and partners. Any change will be Pembrokeshire 7 - 9 pm checked against a series of standards known as 20 September 2012 service delivery models. Sir Thomas Picton School, Haverfordwest At the heart of the programme, an implementation board will be formed. This Or attend one of our Meet the Health Board board will have an independent chair and will drop-in public events, for one-to-one discussions: be responsible for the initiation of clinical work streams and for providing robust scrutiny through Llanelli 2 - 7.30 pm a gateway assessment process - to ensure that 2 October 2012 individual service change proposals can be Memorial Hall, Burry Port recommended for approval to the health board. South Ceredigion 2 - 7.30 pm We also intend to establish a patients’ council 4 October 2012 drawn from membership of our involvement The Guildhall, Cardigan and engagement scheme (Siarad Iechyd/Talking Health) to be linked to the implementation board Amman 2 - 7.30 pm to oversee and assure the process. Gwendraeth 9 October 2012 Pontyberem Memorial Hall Collectively, they will make sure that changes are patient focused, high quality, modern, safe, Taf Myrddin, 2 - 7.30 pm sustainable and affordable. Teifi, 16 October 2012 Tywi, St Peter’s Civic Hall, How to give us your Carmarthen comments North 2 - 7.30 pm Pembrokeshire 17 October 2012 Answer the consultation questions at www.hywelddahb.wales.nhs.uk/Consultation Fishguard Town Hall, Fishguard Write a letter to the Health Board: North Ceredigion 2 - 7.30 pm FREEPOST HYWEL DDA HEALTH BOARD 22 October 2012 Email the Health Board: Holy Trinity Church Hall, [email protected] Aberaeron Leave your comments on the telephone South 2 - 7.30 pm answer machine: 01437 771232 Pembrokeshire 24 October 2012 ALL VIEWS MUST BE GIVEN BY Kilgetty Community Centre, 29 OCTOBER 2012 Kilgetty 9