Written responses to the South Programme engagement

Written responses received by health boards between September 26 and December 19

CONTENTS

Written responses received by Cwm Taf Health Board p3

Written responses received by the South Wales Programme board p71 on behalf of all South Wales health boards

Written responses received by and Vale University Health Board p95

Written responses received by Aneurin Bevan Health Board p104

Written responses received by Teaching Health Board p120

Written responses received by Abertawe Bro Morgannwg p126 University Health Board

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DATE FROM WRITTEN RESPONSE WRITTEN RESPONSES RECEIVED BY CWM TAF HEALTH BOARD 27/9/12 Local councillor On considering the various proposals I am in agreement that the combining of services to make centres of excellence in trauma care and the associated services is certainly the way to go especially if this improves the likelihood of better outcomes and more attractive facilities to prospective new doctors. Looking at the options I am sure that the five hospital options are without doubt the only way to go if you are to provide the coverage required by such a large area. Looking at the valleys to be served, especially in Cynon Taf, they are built on a transport system with a North - South alignment with very difficult links between East - West so the only option that would provide the services needed by our residents would be option 5.2 including the Royal . Even with this option, or any of the new proposals, you will need to make sure that a far more efficient ambulance service is in place before going ahead because it is not fit for the current purpose let alone serving people further afield. Lastly I hope you also take into account the visitors of patients who don't have their own transportation; the poor to non- existent public transportation East - West in the valleys and finally the deprivation in the valleys and the fact that the further people have to travel the more this will cost and a great number of residents simply can't afford it at the moment and the prospects are that this will get worse in the near future.

27/9/12 NHS staff member I have attended a meeting today at RGH about the challenges facing the NHS. I am very impressed at how well thought out the whole proposition being put forward has been addressed and presented. My personal view after listening to the possible scenarios are - there should be 5 hospital sites in South Wales, and the RGH should become one of theses sites. The RGH would become the perfect "safety net " or "the link", that the other 4 hospitals can rely on. It is more central for people in many areas of Wales to use should the hospital nearest to them become unavailable due to traffic congestion, over load of A&E departments etc. It is perfectly position with the motorway links from most areas in Wales and many people are already choosing to use the RGH already for its accessibility and efficiency. It also has the room for expansion should a bigger A&E department be needed in the future as the population grows. There is so much more that the RGH can give to make services safe and sustainable and I believe it should be given a position in the future of our changing NHS.

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29/9/12 Member of public My will suffer if Royal Glamorgan Hospital is downgraded. I live up the top of the valleys, right by the Rhigos mountain road, and say for instance Royal Glamorgan is downgraded and we have to go to Prince Charles Hospital, for a start there is no direct public transport route from here we would have to get to first then back up to Merthyr [which would take forever] but if you are lucky enough to own and drive a car it would not be so bad. However during winter months the Rhigos road could be closed for numerous reasons therefore putting us in a dangerous scenario if in an emergency. Please listen to my plea. 3/10/12 Member of public There has to be a large-ish district general hospital (DGH) to west of UHW between Cardiff and Morriston; there has to be a large-ish DGH north of M4 corridor to meet needs of the Valleys ,Powys, south Herefordshire. So wise choice is 5.1 or 5.2. But will trainees continue to be supplied by Deanery to Nevill Hall Hospital whilst waiting six years for completion of SCCC in ? 4/10/12 NHS staff member Having attended one of the meetings for the engagement process my concerns are less from a professional point of view and more as a member of the public living in mid Wales (). Even though the population in this area is low it feels as though people living here are not being considered. For me the only option is to ensure we get consultant led care 24/7 in Prince Charles Hospital as this is the closest hospital for us to attend especially as services at Nevill Hall are being downgraded. If all services were to go further south then patients living in mid to south Powys would surely have less chance of survival due to the delay in care because of the long distances that we would need to travel. (Currently PCH is around an hour’s drive from Builth Wells however a journey to any of the other hospitals would take in excess of an hour an a half). I would consider option 5.2 to be the safest and most suitable option. I think it is imperative that the residents of Powys are involved in this engagement process as so far I am unaware of any local press to raise awareness in Powys. 5/10/12 Member of public The chaos surrounding the treatment at A&E at Prince Charles borders on chronic and dangerous to proper care in an emergency . There does need a better solution than travelling the golden hour. Matters would be improved if services at A&E say at Cardiff were effective and prompt. Will this be a "given" if people were to support this proposal? If the proposal is adopted it would mean a percentage of accident and emergency cases will not travel the distance needed to seek help. That will include those who are genuine and will cause a problem to the health service thereafter and those who seek a bed overnight and are swinging it to simply find immediate shelter or treatment but will be a trouble maker and be aggressive whilst there. 5/10/12 Member of public I have read the key documents: particularly the one relating to Cwm Taf Health Board proposals. I live in Mountain Ash near a splendid new Community Hospital and have cause to visit there regularly after a bout of serious illnesses. I am now attending there and use its gym facilities.

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In principle I would support the main thrust of the proposals and accept the pressures that are creating the need for a review and restructuring. The proposals for infant care are pressing to introduce quickly as well as for A/E if there is a guarantee that services will improve and become stable and effective . If we are to prioritise (and our debt and dire economic problems are predicted to plague us for a further decade) then realistically we have a major problems of continued deficit in public finances for some time to come.

I will add my voice to what I am sure will be a " dog barking in the night" sought of comments:

(a) services will become more remote to those living in the valleys and hinterlands there will be access problems to the services.

(b) there are sure to be internal squables and in what will be a "bun fight" over who gets what and where. There needs to be an independent panel or a body one step removed organisation to arbitrate over how its effectively carved up ie outside the health service .

(c) because of excessive travel ( more than what we are used to) this will also apply to ambulance time travelling particularly in an emergency . Traffic in the larger conurbations eg Cardiff will be a struggle at peak road use times . This will be a pressure on ambulance services and much critical time taken up with journeys to and fro.

(d) There is a feeling ( real or imagined) that services and facilities are gravitating south from the valleys and the NHS is one of a number of services that are " circling their wagons" and centralising and targeting their services and HQs at main centres of populations.

(e) There is a serious need to have a major re-organisation of County Borough Councils and Health Boards and seek to have an integrated public service concentrating on Heads of the Valley and the south.

For the reasons above and a desire to see at least Prince Charles Hospital that has made significant improvements to the building is favoured in the allocation of services where its deemed suitable to do so in the models that have been outlined. I have personal experience of this hospital that has saved my life and many like me and continue to offer excellent services in its heart failure four-phased programme of recovery. I hope this has helped. 5/10/12 NHS staff member I have read the leaflet/flyer regarding the services and my opinion would be for scenario 4.3 if there were 4 sites and scenario 5.2 if there were 5 sites. 7/10/12 NHS staff member Last week I attended a consultation meeting on the proposed reorganisation of emergency care services in South Wales. Following this I

5 would like to offer a couple of opinions and thoughts to the feedback process.

It seems clear to me that South Wales needs five Emergency Departments rather then four. UHW, SCCC (or Gwent), and Morriston are clearly absolutely necessary, but these departments must be strengthened. UHW should be moulded into a leading trauma and teaching/training centre for the UK. SCCC and Morriston have the opportunity to become outstanding departments for delivery of Emergency care and training of Emergency Medicine trainee doctors.

Emergency Medicine as a specialty in its own right is still relatively young. The common training route that now exists in the form of ACCS-EM (Acute Care Common Stem - Emergency Medicine), means that there will be physicians now coming through who are highly trained and capable in all aspects of emergency care including airway and anaesthetic skills. In the near future these physicians will be leading the way in developing Emergency Medicine as a specialty and it will become more advanced and more self sufficient along the lines of the care delivered in Australia and America. Strong leadership is needed in EDs to facilitate this development but I firmly believe that the new generation of trainees dedicated to EM will soon be providing this drive.

There is an opportunity in South Wales to create excellent emergency care faciltiies. We must marry these proposed developments with the progression of the Emergency Medicine specialty which is being driven by the College of Emergency Medicine.

Bearing that in mind, if we have UHW, SCCC and Morriston which other EDs do we need? I would argue that Prince Charles is essential, particularly with the closure of as people along the heads of the valleys road and into Powys and the entire Merthyr Valley will need this department which is already busy.

This leaves RGH and POW. People living to the West/South West of have access to Morriston and people to the East/South East have access to UHW/RGH. The people of the RCT valleys up to , Treherbert and currently use RGH, there is a big population with significant healthcare needs. Access to PCH over the mountains is not guaranteed often in winter due to weather conditions and if these people had to head all the way down to the M4 and choose East or West even in an ambulance this would take well over an hour in many cases. So I would suggest that RGH not POW should remain open. I appreciate this would be a problem for the people of Bridgend town itself.

The key issue either way for me is that if one of the two EDs is kept (RGH

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or POW), then the remaining one must be strengthened using the staff/resources of the other. The department at RGH should be expanded and brought into line with the leading emergency care facilities in the UK. There should be a full Consultant rota with enough Consultants to maintain presence on the shop floor and supervsion/teaching of the junior medical staff. There should be a larger middle grade rota with training posts for Emergency Medicine registrars and ACCS-EM trainees. If this came about there would be such a difference and improvement in the way we deliver our Emergency care in South Wales.

There are currently only three ACCS-EM posts for CT1 in South Wales and very few registrar training posts. Do we want to bring South Wales in line with the best healthcare/training departments in the UK? I argue that we do, and we now have an opportunity to make this happen. 8/10/12 Chris Bryant We all welcome common sense co-operation between health boards to MP for Rhondda provide the best quality of healthcare in South Wales. I also support efforts to ensure that the benefits of new technology and advanced training are available to everyone. But I strongly urge you to ensure that in any reorganisation local health services remain precisely that – local to where people live. The geography of the Valleys does not make this easy but looking at the number of hospital referrals from different areas and the distances involved, I think it highly unlikely that four specialist hospitals would be sufficient to cover the population of such a large area. I urge you therefore only to consider proposals based on five hospitals rather than four.

As you know, Rhondda, in common with the rest of the Valleys, suffers from a wide range of long-term health problems, including diabetes, ischaemic heart disease and stroke. Many of these require not just long- term care but rapid emergency treatment. Considering the fact that all the roads in and out of the Rhondda are single carriageways it is difficult enough for the Welsh Ambulance Trust to get to people in an emergency and to take them to the Royal Glamorgan within an acceptable time. Even more importantly, though, since the roads to Merthyr and Bridgend over the mountains are often closed during the winter, my fear is that were we to lose accident and emergency services at the Royal Glamorgan, delivery times to and from the Rhonnda to either of the other hospitals would lengthen significantly and Rhondda people would be put at a significant disadvantage. Those at the top end of either Rhondda valley – in , Treherbert, Maerdy or Ferndale – could well be facing a one- way journey to hospital of significantly more than an hour from when an ambulance was requested, which I regard as excessive and unacceptable.

In addition, I worry that the Welsh Ambulance Trust would not be able to cope and would need a major overhaul, including more local stations to enable faster point-to-point journeys and major investment in up-skilling of current ambulance staff to allow them to deal with major trauma cases

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being transported over longer distances.

In recent years there have been dramatic improvements in local healthcare. The new surgeries in Ferndale, Ynyshir and in Porth, the new dental facility in Porth, the new hospital in Llwynypia, new services in Treorchy and Treherbert, all these are important innovations. But the Rhondda has some of the highest levels of deprivation in the UK, with households unable either to afford their own transport or to pay the exorbitant fares on public transport, which would leave patients in distant hospitals without visitors if the Royal Glamorgan were to be excluded.

For all these reasons, I would urge you in the strongest possible terms to reject any proposals that meant the loss of A&E services at the Royal Glamorgan Hospital as I know I and the Rhondda will resist any such proposal with all our strength. 10/10/12 Member of public It was good to hear that the geography of the area in which we live was being taken into consideration and that collaboration across health boards was taking place. The proposals put forward appear quite logical and seem to be aimed at providing a reasonably equitable service to all in South Wales with regard to A&E/paeds/obs.& gynae. I agree that we need five centres to provide this service with Prince Charles Hospital being one of these due to its location however I think we need to leave the choice between Royal Glamorgan/Princess of Wales to the people who have been chosen to complete this redesign. 11/10/12 Member of public I write to you about the proposed changes considered for the Merthyr area hospitals.

I firmly believe that there is a necessity to keep the paediatric department at Prince Charles Hospital.

The Merthyr area is one of the most deprived areas in South Wales and as such it is the children of these areas that suffer the most. Having a paediatric department 'on the doorstep' is vital for such children.

If the department were to be moved to another hospital I am sure parents who are already living on the bread line would not make as much effort to seek medical care.

I therefore believe that closing the paediatric department at Prince Charles hospital would have a detrimental effect on the children of the area. 11/10/12 Member of public I am writing to give me concerns over the proposal to close maternity, neonatal & paediatric services at Prince Charles Hospital, geographically for this hospital to close these services would put huge pressure on other services such as the ambulance services as the people living in the surrounding areas will struggle fir transport to receive medical treatment

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as all the other hospitals are close together along the M4 corridor. Merthyr & the surrounding areas are vulnerable communities that need services close to hand, I an afraid that some people will not seek medical advice early enough, which increases the well being of paediatric patients. Prince Charles is currently providing a huge service from to Gwent areas as well as Merthyr itself and some and Cynon areas, where will all these patients go and how will they get there??? the new children’s a&e dept currently treat 40-50 paediatric patient "a day" !!! The transfer of these children will put huge pressure on the ambulance services if they need a paediatric doctor input which the majority do. I feel that geographically the best strategy would be to have hospitals spread equally on distance such as UHW, the new Cwmbran hospital, Merthyr prince Charles, Bridgend princess of Wales and Morriston , this way all easy will have easy access to hospital services .' 12/10/12 Member of public I recently had to attend A&E in the Royal Glamorgan Hospital, it was over run with a 2 hour wait! Surely this is enough to suggest that there is a Major need for that department! If you close it and send us elsewhere then other hospitals that already have a 2+ hour wait their waiting times will be extended! Which means peoples health is at risk!!!! You are there to help us not make us sit around suffering!

I live in Llwynypia, you wasted a fortune building a hospital down the road from me and knocking down the old one, which was going to supposedly alleviate the stress from The Royal Glamorgan Hospital! All it has done is swallow a load of money and never does anything! It actually does less and has less parking than the old one!

Why don't you sell that building, invest the money into getting more doctors in the Royal Glamorgan Hospital! That way it will run more efficiently and be able to see more people!

Also from several visits to the hospital over the years as part of my job as a support worker for disabled people, as a patient, and as a visitor I can never help but notice the doctors and nurses that are always sat around either chatting about their personal lives, or just sat there! Maybe you could get your management to whip them into some shape, get them doing some work. That could possibly help with clearing some of the work load. Then you would not need to employ so many people therefore save some money! Which we all know this is what it comes down to is saving money!

Also have you considered that by shutting A&E in the Royal Glam people have to travel approximately an hour to the next hospital? This in some cases is the risk of life or death? I would not want to be the person signing to say death for these people!!! I hope if you do sign it you can live with yourselves.

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Most waiting lists for operations are 2-4 years! If you join the departments to other hospitals, you will be giving them a bigger catchment area making the waiting lists even longer! Which means making people suffer for longer! How is that helping?

I m guessing if you close Royal Glamorgan upper Rhondda will have to go to Merthyr hospital? Have you considered how bad the Rhigos mountain gets in the winter? Or the amount of accidents the mountain has all year round? Both these circumstances mean that road closes! So then these people will have to travel down to Pontypridd to the A470 and then up to Merthyr! Not really ideal is it in the case of an emergency!

As ambulances will be having to travel so much further will you be putting more ambulances on the road as the ones we have now can not always get to us quick enough as they are already tied up in other emergencies! If they will be taking longer to get to hospitals then it will take them even longer to get to us again!

I really think you need to consider other options! You say you can not get doctors to want to work in these hospitals, have you considered why? Maybe the pay isnt good enough, maybe the security is not high enough, whatever it is you need to deal with that, get the appropriate doctors in some how and then we have a fighting chance! By closing departments in hospitals all your doing is moving the problem around and making the waiting lists longer! 12/10/12 NHS staff members As members of staff at the Maternity Unit, Prince Charles Hospital we are desperately concerned about the changes being made to the hospital services and how it will affect us as staff. Our five main points of concern are as follows: 1. Patient Safety - transfers to other hospitals, the length of time and distance for emergency transfers 2. The volume of activity on the Maternity Unit- the majority of which are high risk patients 3. The valleys and bordering towns being an area of high deprivation 4. The nearest hospital being 50 mins away 5. The waste of resources spent on a brand new A&E, if closed, which could have been better spent elsewhere We would be grateful if these points are taken into consideration when a decision is being made. 12/10/12 Member of public I really think keeping Royal Glamorgan full functioning is essential . I find royal glam very helpful as my daughter was born in the neonatal ward and was there for a few weeks . I think if it was in a different hospital i would of struggled to visit her and care for my other to children . Please keep royal open as I’m a single mum of three and would struggle to take them to a different hospital as i rely on public transport . I fear that many people in a similar situation would struggle to travel to another hospital

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and peoples medical needs would be seriously neglected or worse . 13/10/12 Member of public It would be such a shame if the A&E and other depts have to close. I live out of area, and requested to come to the Royal Glam for the birth of my second child. I had an awful experience back in 2005 with the University Hospital of Wales, and my local GP recommended The Royal Glamorgan. I had fantastic care off all staff. It would be such a shame. Please save the services for all local people and out of area people. There are so many good staff in that hospital. Thanks for taking the time to read this. 14/10/12 Member of public My son has had nearly 50 admissions to hospital in the last fourteen years with his asthma. The doctors and nurses of ward 17 and 18 have been exceptional over the years my son knows the nurses very well and talks highly of them and is never afraid to go in to hospital. We have received fantastic support from the nurses and respiratory nurses and also one to one nursing when in high dependency. If this ward was to close my son would be heartbroken 14/10/12 Member of public My comments regarding the proposals to, effectively, downgrade services at the Royal Glamorgan Hospital are as follows: This hospital was only built in 2000. To suggest that it should lose some of its services is ludicrous. It's location is vital to the community. I question to what extent Cwm Taf Board is giving full consideration to the needs of the people within the catchment area for this hospital. It is too much to expect people to travel to Merthyr or Bridgend for vital services which should be provided within their own community - and this is apart from the additional travelling that family and friends would be required to make to in-patients. This is nothing short of callous disregard by the Board and they need to look very carefully at what they are proposing. I imagine that the people of Merthyr and Bridgend have the same concerns. Keep hospital services local - only in that way can you truly serve the local community. 15/10/12 Member of public I would be grateful for some clarity on this suggested reorganisation. The problem seems quite clear: there are not enough doctors to provide quality specialist services at all hospitals in South Wales. The solutions, or rather the reasons behind the solutions being suggested, are not so clear. Health boards claim the possible reduction in services at some hospitals will be driven by patient safety considerations. However, it is clearly the case that patient safety would be best served by having quality services available as locally as possible. To argue that reducing services improves patient safety is nonsensical.

The solutions being suggested are treating the symptoms, not the cause. The cause of the problem is the lack of doctors. The obvious solution is to recruit more doctors. If these services and hospitals are not attractive enough to recruit doctors, make them more attractive by offering better terms of employment and improving standards. Alternatively, make it mandatory for doctors to work for some time in these areas as a condition of their training or employment. This is the obvious solution,

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but nobody seems to have considered it.

Having quality specialist services employing experienced doctors at every hospital is clearly the best solution as far as patient safety is concerned. Only once we start to consider finances does the suggested option of reducing services, concentrating them in fewer hospitals, become attractive.

I would like more honesty in this discussion. Financial considerations seem to be playing a large part in the solutions being put forward. The solution I have suggested above, of making these services more attractive to doctors, is not mentioned in the SWP literature produced by NHS Wales and the health boards. Recruitment problems are cited as the reason for this suggested reorganisation, but there is no clear statement of what has been done to solve these problems. Instead, the focus is on the secondary problem of poor service (symptom) caused by this primary problem of poor recruitment (cause).

In summary: Patient safety is best served by having quality specialist healthcare available in as many places as possible. Quality specialist healthcare can only be provided by having a certain number of experienced doctors. At present, there are not enough experienced doctors to provide quality specialist healthcare in every hospital in South Wales.

The obvious solution is to recruit more experienced doctors. The solution being suggested is to accept that there are not enough experienced doctors to staff every hospital and concentrate them in fewer hospitals.

It may be that the obvious solution is too expensive, or otherwise infeasible. If so, NHS Wales and the LHBs need to make this clear, rather than arguing that reducing services improves patient safety. The argument for reducing services to improve patient safety is only valid if it is first accepted that there are not enough doctors and more cannot be recruited. 16/10/12 Member of public I would like to express my reasons for wanting the royal Glamorgan hospital to keep their obstetric, a&e, paediatric and neonatal services open.

In 2007 I gave birth to my son 16 weeks prematurely, he was 24 weeks gestation and weighed 1lb 13oz, he was delivered by emergency caesarean section at the royal Glamorgan hospital and rushed straight to the royal Glamorgan neonatal intensive care unit (level 3) where he spent a total of 17 weeks before he was well enough to be discharged home! During this time he spent 12 weeks ventilated and in an incubator where

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he suffered a number of seizures and on a number of occasions, he aspirated and had to be resuscitated! If it wasn't for the wonderful medical and nursing staff at the royal Glamorgan, I dread to think what may have happened! Thanks to them he is here now and we are about to celebrate his 5th birthday! It was a very anxious, stressful and heart breaking time and something I will never ever forget and I am still so very grateful to the staff at this hospital. In 2008 the neonatal unit had its services downgraded to a level 2 unit which saw babies born under 30 weeks gestation being transferred all over the UK, whilst their mothers recovered in different hospitals, how could this be justified when lives are at risk?! and even more worrying now, the royal Glamorgan may lose its paediatric and neonatal services altogether! This is so worrying for the people of ! When you have a borough as big as ours how can it be justified that our services are lost and we have to travel to different areas to receive medical care?!! Time spent Traveling to that different hospital could be the difference between life and death, especially with ambulance waiting times! And what about people from the very top of the rhondda who live on the breadline and do not have access to transport..this will massively affect them. Every borough needs and deserves their own a&e, obstetric, neonatal and paediatric services and we all pay our taxes to receive this!

Again in relation to my son, he has a heart condition and if anything was to happen I know that there is currently an a&e and paediatric ward close by at the royal Glamorgan where I know he would receive expert care, I am terrified at the thought that these services will be lost and we could end up travelling miles to receive medical care. We also attend the children's outpatients a number of times a year for appointments with paediatricians, where I now know the medical and nursing staff and feel safe that my son is under their care! Who and where would we see/go if the services are retracted?

Myself and my son are just ONE story in a massive area of Rhondda Cynon Taf!

Always in the news is stories of waiting times and no hospital beds at local hospitals, the royal Glamorgan A&E is a very busy unit with waiting times of upto 4 hours, imagine the waiting times and lack of beds once services are removed and you have all the people from RCT waiting to be seen at other hospitals along with patients from within that hospitals borough! This would be an accident waiting to happen... Please consider the views of all the people in RCT because it is them that this affects! 15/10/12 NHS staff member My concerns in relation to the south Wales plan:  Will the ambulance/paramedic service be able to support the change in a safe and timely manner to ensure patients are given optimum care during the transfer time?

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 Will delay in arrival, assessment, treatment and transfer of patients to appropriate site result in a detrimental situation?  Will existing resources be pooled to provide adequate and appropriate staff cover in the agreed sites? If so what service provision will be available at a local level e.g. minor injuries V A&E, Midwifery –led V obstetric care, OPD Paeds V paediatric/neonatal inpatient care? I have looked at the options:  I think scenario 5.2 fits the geography of the Merthyr and Rhondda valleys catering for the more rural aspects and boundaries for the area. Residents of Bridgend can access RGH, Cardiff and Swansea via the M4 and ambulance crews often wait on the M4 corridor as it is now. If PCH is removed from the equation residents of Merthyr will have more difficulty accessing these major services especially in bad weather and will rely more heavily on the ambulance service than at present. If RGH is removed residents of R&T will need to get to PCH, Cardiff or Swansea, the Rhondda clients will have greater difficulty and rely heavily on ambulance services.  Are there plans to increase beds at Cardiff & Swansea to meet higher demand? Has the new SCCC been designed to accommodate any changes that will be made?  Will local GP services improve/develop to meet the Gaps and who will staff these services?  Will hospital staff be moved to primary care to top up these services if local hospital services are reduced as the aim is still to provide community services which should impact on primary care?  What about training/up skilling etc for all staff as roles/responsibilities change? 16/10 NHS staff member Regarding the proposals outlined in the South Wales Programme I have several comments and observations to make both as a doctor, but more importantly as a resident of .

Firstly, I welcome the call for consultant led services and the 24 provision of specialist doctors/ consultants in A+E but I feel this must be guaranteed by all parties and assurances that there are enough specialist trainees available, as well as consultants supporting perhaps working out of hours and at night. For too long rotas have been staffed at night by junior trainees with little or no experience in Emergency Medicine and an over reliance on the good well of medical registrars to provide ON SITE support and advice

Secondly, having just invested significantly in the new A+E, ECC and theatres at prince Charles, it seems ludicrous to not include this centre in the core component of any SW programme. Surely to reduce the use and breadth of services at this site would be contrary to the purpose of expanding the centre.

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The third and most important issue is the demographic location of Merthyr and PCH. Serving not only the "Heads of the Valleys" road, it also covers the A470, the , other local rural areas and at times, even patients as far North as Brecon. Under reconfiguration the reliance on the population of Powys is likely to increase. Add to this the fact that patients attend the hospital from not only Merthyr, but the Cynon Valley, valley and other neighbouring Gwent Valleys, with patients from as far as Blackwood regularly being admitted as "out of area" patients. I question how a 4 hospital approach which would NOT include PCH as a hospital could cope with the demands of this population base, and the added pressure of two major roads and Mountain Range. Factor in the chronic ill health of these valleys and the pressure it places on services and PCH appears crucial to any future plan.

Training wise, the hospital is also second to none for trainees with a highly reputable Resuscitation centre where trainees from all over Wales and the UK strive to attend for course due to the excellent reputation.

Loosing core services would undoubtedly mean loosing others such as surgery, as has happened at Prince Phillip Hospital in . With the reputation of Professor Haray et al being amongst the finest in the UK and wider world now, surely this is another gem that cannot be lost.

With regard Paediatric and Obstetric services, a major missing cog in all the current discussions is where the added infrastructure and investment for the Welsh Ambulance Service will come from. This is imperative before any changes are made to ensure that the increased travel times can be met by increased personnel and ambulances. 17/10/12 Member of public I spent some time as well in the Royal Glamorgan as well for my asthma and sometimes they come to the house I live about 10 mins away and the nurses on the wards are amazing the made me laugh when I was down and make me happy when I was sad plz don't shut these services down because it means a lot and the next hospital near is 30 mins away and is hard to get to if you can't breath so plz again don't shut it down 17/10/12 Member of public I ask that you do NOT close the Royal Glamorgan Hospital.

Whilst the present service is far from ideal (5 hour wait in Accident and Emergency) the loss of this hospital would be catastrophic.

We have already seen Llwynypia hospital effectively mothballed for emergency services and simply can't afford to see another hospital closed. 20/10/12 NHS staff member The Royal Glamorgan isn't easily accessible to the people of Merthyr Tydfil, or even south Powys or even other towns on the Heads of the Valley's such as Tredegar, Brynmawr and Ebbw Vale. From personal experience I know that NHH has the contract with Brecon War Memorial Hospital for consultant led births, I think women are far more likely to

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want to come to Prince Charles Hospital than travel to Cwmbran or further. Also the Heads of the Valleys has massive investment and is decreasing journey times making PCH much more favourable than women travelling to Cwmbran etc. We already have women coming to PCH from Brecon, Rhymney, Tredegar, and I have noticed a massive increase in women transferring their care from YYF () to PCH instead of the Royal Gwent or NHH, as they traditionally would. Our birth rate is increasing, last year I think we delivered about 1900 babies at PCH. From a personal point of view I would like to be near a consultant led unit if I was about to give birth to my first child, If PCH didn't offer this then I would transfer my care to NHH or UHW as they are the nearest to me. Locality also applies to Emergency care, I understand the point about excellent care, however PCH is positioned in a prime location to care for injuries occurring on many of the main roads and proximity to Brecon Beacons. I really would prefer my local hospital to be PCH than UHW as I live in Merthyr Tydfil, but his would be the reality if PCH did not have the appropriate critical care ITU etc, as the Royal Glamorgan or Princess of Wales would not be an option! 22/10/12 Member of public The Royal Glamorgan Hospital should not lose any of its services as it is important to South Wales. it is important because as a diabetic (type 1) i rely on a sufficient hospital to acquire my needs if any things should happen. i know that this is not about me but the hospital itself is more modern out of the three and is in an excellent location, the Royal Glamorgan hospital is more or less in the middle to both Swansea and Cardiff hospital's and with a new by-pass connecting Talbot Green and the Rhondda, it is now half the time to get up the valleys. I have also been to all three hospitals for various treatment and visits, and the Royal Glam is defiantly the best hospital i have been too 22/10/12 Member of public My son has severe asthma and often has to stay in hospital overnight I have another child at home travelling to and from royal Glamorgan is hard enough it takes me about 25 mins to 30 mins to get there. To travel to other hospitals would take much longer to get to Bridgend Merthyr or Cardiff would take at least an hour if not more and that by car if you had to travel by bus, train it would take much longer. The quickest way to Bridgend or Merthyr is over the mountains which in the winter are nearly always closed and dangerous so u would have to go the other ways which take twice as long. Parents are worried enough having a sick child in hospital and shouldn't be worried about how to get back and forth. Travelling to these other hospitals with a child struggling to breathe is just not viable and when u have other children to think about you have to go home quickly to make Sure your taking care of they're needs. To travel an hour or more is awful when u have a hospital in ur community.

Please look in to these comments as I speak for nearly every parent grandparent in the Rhondda please do not take these facility's away from us they are much needed. There is no way I could get to these other

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hospitals as efficiently as I can get to the royal Glamorgan this hospital is essential to myself and others

25/10/12 Member of public I have looking in detail at the proposed plans and totally understand the need to change. There is a need to modernise and streamline services into speciality areas, which will provide the best care for patients. I wish to provide feedback, but I have been trying to think (along with colleagues in other clinical areas!) and haven’t really come up with a solution.

There are a couple of concerns: Whatever the changes, it really depends on the ambulance service. I am sure this has already been discussed, but without sufficient ambulances and paramedics staff. No matter what will be decided the ambulance service needs to be sorted out first. No small task!

The second concern is the stroke service. I am currently working in acute stroke and know all about the PCH/RGH decision for the stroke unit. I realise that this has been put on hold, until this current decision has been made. It would make sense that whichever hospital is decided, it would be logical to re-think this stroke unit. If Princess of Wales or RGH is to decided, then it would be logical to have a stroke unit at the site and another at PCH. This I understand would affect staffing, but I think they should be given a choice of where they wish to work, as not to waste the specialist training and expertise and we wouldn’t want to deny the patients this. We also have an excellent stroke awareness course in this health board, which could then be shared out. Health boards will need to be restructured or be more flexible with where staff work, crossing over health boards maybe.

I am doing this work for patients, to assist in the improvements of their condition and this should be the main drive for these changes. Not for any political gain etc.

I wish you all the best with these important decisions for Bridgend and RCT general public. 26/10/12 NHS staff member Reconfiguration of acute services Neonatal care Royal Glamorgan Hospital The proposal for 1 or 2 neonatal units in South Wales to close would see between 8-20 cots being redistributed amongst the remaining units. This does nothing to address the current shortage of neonatal cots in South Wales or improve the staffing issues within the units as all are currently working well below the current BAPM staffing guidelines and above their cot capacity.(Neonatal Capacity Review 2012) The rising birth rate will impact further on these available cots Royal Glamorgan Hospital is already experiencing a raise in neonatal admissions from 2010 to 2011.

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From all existing units in South Wales the Royal Glamorgan Hospital is the only unit which could double its current 10 cot capacity without the need for any structural changes. (This unit opened in 1999 with 20 interchangeable cots 6 ICU 6 HDU 6 NURSERY 2 ISOLATION) no structural change means less of a financial outlay to the Health Board. This unit has experienced neonatal nurses that have the skills and knowledge to care for the sickest of infants whilst supporting junior medical and nursing staff, (having worked effectively as a level 3 unit for many years). This is a valuable rare commodity as evidence highlights a national shortage of experienced neonatal staff. (BLISS 2012, Neonatal Care in Wales 2012). The Royal Glamorgan neonatal unit is in a good position to admit and care for High Dependency babies from UHW &other units, staff have undergone further training to equip them with the knowledge and skills required to care for post surgical and complex needs babies eg babies needing stoma care post gastro surgery and those born with spina bifida. Specialist consultants eg surgeons in other units can liaise with medical/nursing staff at Royal Glamorgan to ensure efficient transition to our level 2 unit thus freeing up cots in level 3 units. The maternity department at Royal Glamorgan Hospital has a whole ward currently closed which could be utilised to accommodate the increase in mothers giving birth at this hospital again without the need for any structural change/financial outlay. An increase in nursing staff would be required to allow this increase in neonatal admissions/birth rate, but the training of inexperienced neonatal nursing staff in house would make this transition a feasible prospect and a role which the RGH neonatal nursing staff have traditionally successfully undertaken. The Royal Glamorgan Hospital is the only hospital in South Wales which has a well developed robust transitional care service keeping babies with their mothers on the maternity ward thus freeing up neonatal unit cots. Midwives, nursing support assistants but most importantly experienced rotational nursery nurses ensure this service is maintained effectively. If the consultant led obstetric maternity unit was moved from the Royal Glamorgan Hospital this service would not be supported in other Health Boards leading to an unnecessary increase in admissions to neonatal units putting added pressure on available cots. We question who would follow up the infants’ medical care following discharge. Presently babies receive continuing care from their local hospital paediatric and neonatal outreach team regardless of where they have received their inpatient care eg a Royal Glamorgan baby born and discharged from uhw would have their follow up care at Royal Glamorgan. Where would continuing care be received If Royal Glamorgan had no paediatric team. BLISS has highlighted that neonatal units in South Wales rely too heavily on band 5 nurses and lower which is unacceptable. We argue that 90% of the staff employed on a band 5 at Royal Glamorgan Neonatal Unit have the expertise, knowledge and skills required to work at a higher grade.

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Their belief in the services they offer to the babies/families in their care and their loyalty to this unit has taken priority over their need to pursue career progression at other departments/health boards. This has given Cwm Taf an excellent value for money workforce. Staff working at the neonatal unit Royal Glamorgan do not work there because it is their ‘nearest’ neonatal unit many staff drive past 1 or even 2 neonatal units to get to work, they do this as they have belief that what we offer is the best in neonatal care. They have embraced the changes made from a level 3 to a level 2 unit and continue to support these changes to provide an excellent level 2 unit which can proudly be compared with the best. With support from the Health Board this unit can be held up as a centre of excellence which would attract junior medical staff. Many junior medical staff already return to work here at senior positions which speaks volumes. Audits from parental questionnaires which are given to parents following discharge show a high level of parent/family satisfaction, many of these families have experienced care from several neonatal units during their infants hospitalisation but their praise on the care, support and professionalism always feature highly. The Royal Glamorgan hospital is best placed geographically for the residents of Cwm Taf Health board and wider, to achieve the essential golden hour/platinum half hour of critical care. Suitability of road network particularly from the Rhondda during the winter months and poor ambulance response times will have a major impact on maintaining this gold standard of care resulting in poor long term outcomes for these very sickest of patients if this hospital was to lose its acute services. The Royal Glamorgan Hospital is already seeing an increase of mothers from out of area, particularly Vale of Glamorgan, Cardiff and Barry choosing to have their babies at this consultant led maternity unit, their choice based on their belief in the services/care we offer. These mothers return on subsequent pregnancies/ subsequent neonatal admissions. This continuing trend makes the catchment area for the Health Board much larger than defined. The neonatal unit at the Royal Glamorgan hospital is the only hospital in South Wales which utilises electronic technology for all its patient record data (ICIP). This contemporary method of working benefits all staff and provide ease of access to data for multiple uses this proves invaluable for audit which would otherwise have to be manually extracted. The NHS is becoming increasingly accountable for the services it supplies. One element of that accountability is clinical governance which depends on the availability of high quality clinical information. This relies on the data collected which this system supports; losing the neonatal unit from Royal Glamorgan hospital would see a loss of this system from South Wales. The Royal Glamorgan hospital neonatal team work closely with essential services allied to medicine which helps maintain an effective multidisciplinary clinical team. The services within the Royal Glamorgan hospital include those of a designated pharmacist, microbiologist, liaison health visitor, speech & language therapist and physiotherapist who all

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have valuable input into each babies care. We also receive WAG funding for a neonatal breastfeeding co-ordinator. This nurse supports & trains staff whilst supporting mothers who are breastfeeding/expressing breast milk. The role covers both mums of inpatients and those who have been discharged into the community.

Accident & Emergency The importance of Royal Glamorgan A&E department was highlighted recently when UHW A&E department closed due to a major incident. Acute admissions unrelated to the incident, were transferred to Royal Glamorgan. It was fortunate during this incident that The Royal Glamorgan Hospital still had its acute services intact to assist during this time. 26/10/12 Rhondda 50-plus Why We Should Keep - ROYAL GLAMORGAN Forum  On the map The Royal Glamorgan is in a vital position to accommodate large areas in and around the M4 corridor.  Some of the most deprived areas are in the Rhondda we have many difficulties: a) Social mobility – we have a very large older population who have no access to cars. The price and of taxis makes them unobtainable for many residents to afford. b) The poverty level is amongst the highest in Wales c) The demographics of the valley are very important we are surrounded by mountains which in the winter are impassable. This would restrict any movement to Princess of Wales and Prince Charles. There would be no way to get to either of these hospitals in the long winter months.  The Royal Glamorgan would be assessable in any weather conditions. This would be for all people from the Cynon Valley to the Vale of Glamorgan.  The Royal Glamorgan needs investment which would pay for itself in years to come. Make it a training hospital for Doctors and Nurses. It is ideally situated for the valleys and the Vale of Glamorgan to enrich the lives of many of its residents. Take over the land at the front of the hospital where you have the blood service and bowel screening. Make an extra part there with a walk way to the main hospital.  Start a Cwm Taf Health Lottery. This would ensure that the money came into the LHB.  Have a ‘Dial a Ride’ hospital car. Where people would have to telephone 48 hours before an appointment so that if they did have to attend Prince Charles for a specialist service the transport would be there for them. Start a ‘Dial a Ride’ raffle (through the friends of the hospital if there are any) to keep the car on the road, charge a nominal sum eg. £10 return. If people are on benefits make it a smaller charge. Sell the raffle tickets in the shop and on the wards people do not mind paying a £1 now and

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again if it is going to a worthwhile course. Use some of the money that the staff are donating from their salaries to help fund this.  Extend the hours to 10.00 pm at the MIU in Ysbyty Cwm Rhondda (Llwynypia) as it is phone first many people would use this service rather than wait at RG A+E. You could find that people who think they have an A+E problem could possibly only have to go to MIU and this would relieve the service at the A+E. The phone first service needs to looked at, people have been sent to RG after using the phone first and they have been told that they could have been seen at YCR They do have the facilities there to x-ray people and also to look at minor skin injuries but this is not happening at the present time. Please look at this service when it works it works well and you have the facilities at this hospital to do this.  It is known that people are coming to the Royal Glamorgan from as far as Penarth. One of the reasons is the standard of care in the UHW and the conditions on the wards. Parking is also a problem. Parking at any hospital is a problem but at the UHW it is the worst place ever. I know someone who’s daughter had a premature baby took his wife to visit her and had to leave his wife go in to see their daughter while he looked for somewhere to park. His wife came out after seeing their daughter before he had found somewhere to park the car. What is going to happen if this is the only A+E hospital for us. What are they going to do about the parking problem, and the conditions in the hospital? A friend’s daughter was a nurse in UHW and even though she should have stayed in hospital longer after having her baby insisted on going home because of the conditions in the ward and lack of care by the staff, I know that this is not A+E but this problem is throughout the hospital.  On the 19th October the A+E in UHW was closed due to an emergency in Leckwith in Cardiff where 12 people were injured one fatally. How are they going to cope with all the Cwm Taf area using their A+E facilities. Most of the people from Cardiff and the surrounding areas who would have used UHW where transferred to Royal Glamorgan. This again proves this hospital should be kept as a 24 hour A+E hospital.  Prince Charles hospital is better situated for the people who live around the heads of the valleys, but even so in bad weather this hospital would become impassable to ordinary vehicles. Based at the top of the heads of the valleys road in a council estate with roads so steep that would be treacherous in the winter months if we get any snow and ice. To get to Prince Charles from the Rhondda by public transport could take you at least 3 hours to get there. To hire a taxi would be too costly for the majority of people to afford. It could cost up to £60 to get there and back.  Princess of Wales hospital is too small to cope with any more patients that it already deals with. Car Park is too small any extra

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patients added to this would be totally unacceptable. If travelling by Taxi this again would be so costly that most people would not be able to afford the fare. No direct bus route is available to this hospital from the Rhondda. It would take hours to get there by public transport. The lack of doctors we have been told is due to the European Working Time Directive, whereas a junior doctor would have worked over a 100 hours a week this has been restricted to just over 40 hours and rightly so for the safety of the patients and the junior doctors health. We have also been told that to become a specialist they have to carry out procedures on over a 1000 patients and this means that they cannot do this in a smaller hospital environment; the need is to make the hospital bigger and mainstream the services. More facilities are needed to ensure that the Doctors get to the specialist grade quicker.

Students who train in Wales should be made to sign a contract to stay in Wales for x about of years. Why are we paying out all this money in training doctors for many years then losing them to England or worst still letting them go abroad.

As people who have lived in the Rhondda all their lives, please do not make the end of our lives so difficult that it could even be shorten through lack of medical care. 29/10/12 Member of public My view is that consultant led services must be delivered from the main hospitals plus Prince Charles Hospital covering the heads of the Valleys area. I would therefore support options 4.1 and either 5.1or 5.2 for the following reasons:

- The high levels of multiple deprivation affecting peoples’ health in this part of South Wales should mean that Prince Charles Hospital is given priority. - Comparatively high percentage of population suffering from long term and chronic illnesses - Low car ownership / poor public transport to get to other hospitals - Also, the improvements to the A465 Heads of the Valleys road may mean that it is easier for people living in parts of Rhymney, Tredegar and Ebbw Vale to use Prince Charles Hospital rather than the new SCCC near Cwmbran. 29/10/12 Member of public I feel strongly that consultant led services should be delivered from the main hospital including Prince Charles Hospital to cover the heads of the valleys. We have a high percentage of people suffering from long term health problems We have high levels of deprivation Transport is a problem, patients face huge problems when having to travel to Royal Glamorgan Hospital as there is no direct route. Alongside

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the travel problem lies the cost implication. People who live in Rhymney, Tredegar and Ebbw Vale would reach Prince Charles Hospital quicker and easier than travelling to the new SCC near Cwmbran, so this should be taken into consideration. Therefore I would support the following options. 1st choice 4.1 2nd choice 5.1 3rd choice 5.2 29/10/12 Further to the publication of the South Wales Programme, I would make AM for Merthyr the following points regarding the importance of Prince Charles Hospital: Tydfil and  Reiteration of strategic location at the cross point of A470 and Rhymney Heads of the Valleys road cannot be overemphasised  The urgent need to develop a medical model for the ambulance service needs to be met alongside the current South Wales proposals  The obstetric and level of neonatal services provided at Prince Charles Hospital will be even more important and pressing with the development of the SCCC in Pontypool. This should be strongly driven and brought rapidly to fruition to meet the formidable challenge posed by the high levels of births in deprived and disadvantaged communities sorely requiring expert clinical interventions and support  It is well overtime that these challenges which confront disadvantaged communities harbouring high levels of health inequities and inequalities are vigorously and speedily addressed with a robust, coherent strategy, rather than relying upon knee- jerk, fragmented and uncoordinated reactions, often of limited success  Options which do not include PCH (ie five centres versus four) would be impracticable because of the difficulties of patient flow within and between the most deprived communities. The realisation of five centres which includes PCH would strongly ensure equity of access and delivery of enhanced quality of services and patient safety  It is imperative not only that the importance of providing a quality health service (comparable with the best anywhere else) is achieved but that the overall patient experience within the healthcare system is substantially enhanced  The current economic climate has had devastating effects on the population, particularly in areas of social disadvantage. Increasing stress and deteriorating economic conditions will have serious adverse effects upon mental health, crime, substance abuse, nutrition and general wellbeing. We can expect deleterious effects on life expectancy, mortality rates and the duration of disability- free lives. Many in disadvantaged communities will have little opportunity for employment, many will be blighted by loss of benefits, welfare and social support and have the most bleak

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futures facing them. These incontestable consequences of tough economic stringencies must not be allowed to be further burdened by ant plan which further aggravates the inverse care law  Moreover, the spurious distinction between health and social care is anathema. The new Keir Hardie Health Park here in Merthyr Tydfil demonstrates the way forward towards effective integration between hospital, primary, community and social care. This development of enormous benefit to the constituent population cannot be frustrated by failure to build-on, develop and enhance the role of Prince Charles Hospital. I believe the case for Prince Charles Hospital has long been proven and that it is now time to improve, develop and enhance Prince Charles Hospital as an integral part of a joined-up health and social care service that is within and meets the desperate needs of my communities. 1/11/12 Cwm Taf staff-side Staffside have been actively working with management in partnership to organisations ensure that the engagement process rolls out to as many staff as possible within the Health Board. We are confident that we have first class staff and services available within Cwm Taf and believe these should be maintained and developed. We are firmly committed to supporting the Health Board position that, for the benefit of our patients, staff and general community, the A&E, paediatric, neonatal and obstetric services within Cwm Taf should remain available at both our District General Hospitals. This stance takes into account the geographical, population volume and medical staffing issues which exist. Whilst we recognise the impact that this would have on our colleagues at PoW, we regard this as an opportunity for closer working between the 2 Health Boards to benefit patient care. We would therefore support option 5.2 as outlined in Together for Health: South Wales Programme 5/11/12 Local councillor Prince Charles Hospital in Merthyr Tydfil is strategically located alongside the A465 Heads of the Valleys trunk road and close to its intersection with the A470 trunk road at Cefn Coed. It has the potential to service communities along the Heads of the Valleys road from Abergavenny to Hirwaun as well as those communities situated in southern Powys. The A465 is scheduled to be improved into a by 2020, further improving access times to the hospital when the work is completed. A major refurbishment of the A&E unit has recently been completed and PCH provides essential obstetric and neonatal services in the locality. PCH was the only district general hospital qualifying for consideration in both the four and five hospital scenarios put forward. My preference is to support PCH in the five-centre option. This would address the over-concentration of district general hospitals near to/along the M4 corridor, which can be difficult to access via public transport from the Heads of the Valleys sub-region.

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PCH is the last district general hospital north of the M4 corridor providing A&E, obstetric and neonatal services before you reach those in . I am aware of the huge public investment there has been in both primary and secondary healthcare in Merthyr Tydfil in recent years. Those who are amongst the most deprived and sick people in Wales need and deserve the best conveniently located healthcare provision. It would be both the sensible, financial and practical option for these secondary healthcare consultancies to be provided at PCH if this investment is not to be wasted. I look forward to the next consultation phase and trust that your engagement with all stakeholders has strengthened the case for PCH to continue to provide these and the other services it currently provides. 6/11/12 Member of public The purpose of this letter (concerning closure of Royal Glamorgan Hospital) is to hopefully get your help and support to stop this closure. My reasons for writing this letter is as follows: the treatment that me and my family have received at Royal Glam has been excellent. My wife had melanoma cancer. The aftercare from Dr Ashworth (surgeon) plus nurses and staff was second to none. I’ve had three heart attacks, also wonderful care I’ve had at Royal Glam. Other reasons for writing this letter is, people like ourselves in their late seventies, if they have a consultation at Prince Charles at Merthyr (morning) they won’t get there in time by bus. So Allison, my request is hopefully that you take action to keep this wonderful hospital open. Your help would be greatly appreciated. 12/11/12 Primary school in After attending my local PACT meeting and cascading the information to Rhondda Cynon my school colleagues and children, the children on our school council Taf were so dismayed at the news that the Royal Glamorgan A&E and obstetrics, paediatrics and neonatal department were under threat of closure that they decided to draw a picture and send it to you. The picture is of injured children having to go a long way to another hospital. This decision, if it goes ahead, is going to affect a lot of people in the Rhondda Valley and especially their children. As a school we will be monitoring the situation very closely and hope that this does not happen to us. 14/11 Cwm Taf Hospital All members of Cwm Taf LHB Hospital Medical Staff Committees (HMSCs) Medical Services have had the opportunity to hear about the South Wales Plan and to Committees comment. There is a strong consensus as to the following points:

■ Healthcare for the heads of the valleys communities will be significantly impaired in the absence of an acute hospital with the full range of services that is easily accessible. The restricted transport options for many living in material deprivation and/or rural communities needs to be taken in to account when accessibility is assessed. ■ Population and patient flow data indicate the need for an acute hospital. With the full range of services between UHW and Morriston on the M4 corridor.

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■ In view of the above it is extremely hard to see how a 4 hospital model would work whilst continuing to provide equitable care throughout South Wales. The 5 hospital model has overwhelming support from the HMSCs with Prince Charles Hospital’s inclusion necessary to support the heads of the valleys communities and Southern Powys. Population and patient flow data also support the inclusion of Royal Glamorgan Hospital between UHW and Morriston. ■ The implications for training rotas have yet to be worked through. ■ The implications for other acute specialties, (unselected medical intake, unselected surgical intake, OMFS, elective surgery requiring ITU etc.) have yet to be worked through. Clinical involvement in this process is vital to ensure development of sustainable and effective solutions for the medium and long term. We would be happy to meet with you and/or colleagues to discuss this further. Executive team members are already planning to attend forthcoming meetings of both HMSCs to continue the engagement process. 17/11/12 Member of public In view of the amount of money being spent on the refurbishment and updating of the Prince Charles Hospital and taking into account the wide area it serves it would seem vital that PCH is included in both scenarios, ie:4.1 and 4.2 and 5.1 and 5.2. I would oppose any scenario that would cause it to be downgraded. Having been in need of the A&E department and are still receiving treatment from the chest and lung specialist I would be very unhappy if PCH lost any of the services it offers 19/11/12 Member of public I am absolutely disgusted with the intention of closing various departments at the Royal Glamorgan hospital. Living at the top end of the Rhondda Fawr our only real access to the proposed A+E obstetric unit, paediatric & neonatal is at the Prince Charles hospital Merthyr. I would like to argue a few points The Health board states that sustainability should mean that Keep people safe. To gain access to the Departments from the either Rhondda’s during bad weather e.g. snow ice & fog we would have to traverse the Rhigos or Maerdy mountain roads which during these weather conditions are often closed (and the closures are never found out about until you hit the bottom of either mountain) and also theoretically this could be for a 2 month stretch. Therefore the journey has to be via Pontypridd, which from the top end of the Rhondda Fawr is 13 miles. This is exactly the same distance as it is to the Royal Glamorgan, but this would only be a third of the journey as now you would have to go up the A470 and then along the heads of the valley road, the distance for the total journey is approx 40 miles plus would take an additional 40 minutes, so from your first point of Keeping People Safe has been ignored as lives are now put at risk by traversing the mountain roads or the increase in journey distance and time. This is of course providing the Local Authority keep both mountain roads open as it has been muted in the past of their wish to close the Rhigos mountain road due to costs.

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 Offer care that respects everyone’s dignity In the Valleys a strong community spirit is still alive and it is not uncommon for those who have no access to their own vehicle often ask neighbours/friends or family to drive them to hospital, which is only a 30 minute drive to Llantrisant but to go to Prince Charles hospital would now take approximately 1 hour, and many would feel embarrassed to ask their neighbour/friend or family to take them this far due to the price of fuel etc and to go by taxi would be a week’s wage to many (considering they are fortunate to have savings or a wage that would cover this extra cost) so as to the statement that you offer care that respects everyone’s dignity this too is now just words to make it look like people care about the population in the valleys  Can be used by all the community Well basically if you have the money/means of transport I suppose it could be, but I think my above point explains this, so therefore this fact is also superfluous.  Offer effective treatments I can see that yes you would be offering effective treatments if we had to travel to the Prince Charles hospital. As many people now would probably not wish to worry neighbours/friends and family by asking them to help them attend appointments etc so the trust saves money on treatments and can therefore offer more effective treatment to those that can travel easily to the top of the Merthyr Valley To use public transport from the Rhondda valley’s to Llantrisant it is a single bus ride, but to get to Prince Charles it is a 3 bus journey and as to whether the buses are actually synchronised to join up so that getting from here to the hospital with minimum of fuss is another thing and also do we know what buses to catch and do we have the correct change. Has the Welsh Ambulance service been notified of your intentions? as I suspect more people will be using their services. It is stated that the A+E department is facing reduced hours due to alcohol related injuries/illnesses but by concentrating these into a single A+E department would this not make a busy dept even more so and as for the abuse to staff and public would this not increase? And if this is so are you not actually putting those people that can actually get to A+E in even more danger ? I would also like to know how the figures have been arrived at that states this proposed move would save money, as the units are already built, so therefore the building costs have already been spent. Staff I assume would have to be transferred from the Royal Glamorgan to help Prince Charles staff cope with the extra workload, or are these positions in the Royal Glamorgan being restructured, and the Assembly and Local Health Trust board come up with a new system of treating people as a paperwork exercise? I would like a copy of this report for my own study,

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you never know another idea/option might be given that saves you from cutting services from the Royal Glamorgan What do the frontline staff at the Royal Glamorgan & Prince Charles think of this proposal, and of course the respective unions, and have the policy makers ever tried to commute to the proposed A+E dept from the Rhondda Valleys? 20/11/12 Member of public We welcome this public engagement exercise. The fact that the Health Boards presently serving South Wales have decided to work together on reconfiguring hospital services suggest that they will be working more co- operatively together in the future and this can only be good for patients.

The radical solution of creating four or five specialist care centres from the existing nine district hospitals to overcome the present over- stretched staff position appears eminently sensible, but lays great importance on the right selection for future delivery of hospital services.

Living as we do in Merthyr Tydfil, we believe the establishment of a specialist care centre at Prince Charles Hospital is a compelling one. The reasons are: (1) Its unmatched geographical position in the north of the area with a wide catchment area already serving patients in three other adjoining health boards, Aneurin Bevan, Powys, Abertawe Bro Morgannwg. Omitting PCH would leave patients in the north isolated, in an area where car ownership is relatively low, placing a high dependency on a public transport system with limited and difficult communicating links. (2) While patient numbers at PCH are slightly lower in some instances compared with other hospitals, it is important to remember the effect of: [a] the diminishing significance of Neville Hall presently covering the Abergavenny area, as a result of the new hospital at Cwmbran, and [b] the ongoing changes of hospital locations along the English border counties and its effects on those living in South East Powys, presently using cross border hospital services. The outcome of these changes could see PCH offering a better prospect for its use by new patients. (3) From statistics provided there is a need to look further behind some of these bare figures. For example, the ratio of births to paediatric inpatient at PCH 1,750 to 1,700 indicates a high level of acute illness and babies requiring specialist support. It reinforces the fact that PCH serves an area with one of the highest levels of deprivation with accompanying levels of sickness and morbidity in Wales. (4) If PCH is not selected as one of the specialist care centres, the result will be a concentration of them along the M4 corridor. Leaving aside transport problems for patients and relatives with a need to visit frequently, importantly there will be more time consuming longer journeys for an ambulance service already under strain to meet patient call out targets. (5) Over the last few years a substantial modernisation programme,

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including a new A & E department, has been carried out at PCH. Its selection as a specialist care centre will only then begin to fully realise the potential of this considerable investment funded by the Welsh Assembly Government.

The case for Prince Charles Hospital is well demonstrated and its selection as a specialist care centre would act as a part of a two prong attack, coupled with good health education, to raise the standards of people living here, long overdue and sadly trailing behind most of Wales. 20/11/12 Member of public I am writing to express my concern and disappointment at the proposed changes to specialist services in Cwm Taf. Fact . only four of the seven A&E facilities in South Wales will be fully equipped , unless this plan is defeated, patients from Bridgend, Llantrisant and possible Merthyr will lose their local services and have to travel long distances and delays to access life saving care. I feel this plan is about money and cuts , and we need to demand more funding to keep our services, this plan is driven by underfunding ,instead of opposing cuts , the assembly is passing them on with no real opposition. the politicians are using the current shortage of specialist doctors in some Ares to try and reduce how much they’re spending on services , I have even heard some ill-informed people say that doctors are generally over played and wont work full time . The plan will turn a temporary difficulty in recruiting doctors into a permanent shortage of trained A&E and other specialists, yes there are shortages in specialists, but the real cause is the long term underfunding, to few doctors are and were being trained to meet the demand. The South Wales plan ,far from solving problems in the NHS will in my opinion ,will turn a temporary shortage of specialists into a permanent one . The proposed “engagement “projects the health boards have launched ahead of next years consultation plans must involve as many people participating in it to be a true reflection of opposition to the plan. I do not support the proposition . 23/11/12 Member of public Below are my thoughts on the South Wales Programme proposed by the South Wales LHBs. I have great respect for the work done by the Cwm Taf Health Board and have made that clear on a number of occasions when praise has been earned and deserved. On this occasion, I feel the LHBs have failed to support their arguments and analysis with sound evidence and have, therefore, weakened the case they seek to promote. This is not to say that the Programme lacks merit or to question the honesty and sincerity of those who promote it. If the Programme had been proposed as an interim measure whilst a full, comprehensive investigation and analysis of the reasons for arguably temporary shortages of staff was carried out, I would have little quarrel with it. However, as it is a Programme proposing fundamental long-term change, I believe the

29 evidence supporting it should be sound and able to withstand close analysis. In my view, the evidence offered on this occasion falls woefully short of that standard. I have heard people say "we must be realistic"; actually, that is an opinion with which I fully agree. Being realistic, it is obvious that no other options are going to be considered outside of the Four and Five Centre Scenarios outlined in the South Wales Programme. To avoid any misinterpretation of that statement, I am not just referring to the LHBs but include all the other bodies which have been asked to comment on the Programme. All, it seems, are focussing solely on arguing the merits of the various options within the South Wales Programme or, perhaps to be more honest, are focussing on promoting the case for their own local hospital. If, as I believe is the case, accepting that these are the only options to be considered also implies an acceptance of the 'evidence' provided in the South Wales Programme, then surely there is little need to get intensely agitated on the choice of option? Accepting the South Wales Programme implies accepting that no patient, no matter where they are when they require the treatments in question, will be deprived of those treatments whichever option is chosen. The South Wales Programme, in the FAQ section, allays such fears repeatedly and makes the point: "Taking the patient to the right hospital the first time will ensure they receive specialist care on arrival and do not need a secondary transfer to another hospital afterwards. This could mean a patient travels further in an ambulance to hospital but overall this will save time in the patient receiving the correct care." Surely, if that position is accepted, there is little to become agitated about? If you accept that a patient will always receive the best treatment no matter where they are or which hospital they are taken to, then what is the problem? If you do not accept that then your opposition to the Programme should be total, as you surely, as a human being, would not wish to foist a risk on people in other areas of South Wales that you are not happy taking yourself? So, let me be clear about my position. If the South Wales Programme leads to choosing between the Four and Five Centre options, and I am certain that is precisely where it will lead, my preference would be for a Five Centre option. Having said that, I now want to return to what I believe is a more important aspect of this whole matter. The South Wales Programme is based on a belief that shortages of medical staff in certain specialities are 'a fact of life' and fundamental long-term changes have to be made to accommodate that situation. Time and again, the authors of the Programme assert that 'all the evidence' proves this to be the case. It is this aspect that I take serious issue with for I believe the South Wales Programme actually produces little hard evidence to support its case. I do not accept what evidence there is (and exactly what 'evidence' there is, I will return to) shows that such shortages are always present, are not of a temporary nature, and cannot be corrected in the longer term if a full

30 appraisal and analysis of the situation is first carried out. Of course, I am not challenging that shortages of medical staff exist in certain specialities at present. Of course they do. Neither do I challenge that the LHBs have made strenuous efforts to recruit staff in those specialities. Of course they have and perhaps Cwm Taf Health Board has made more efforts than most in that direction. What I challenge is the seemingly unquestioning assumption that such shortages are permanently present in the same specialities, are a 'fact of life' that we have to learn to live with, and cannot be overcome. On what do I base that challenge? Well, as astonishing as it may seem, on the very same 'evidence' that the LHBs cite in support of the South Wales Programme! In support of its proposals, the South Wales Programme leans heavily on a report entitled "The best configuration of hospital services for Wales: a review of the evidence". The report was produced by the very highly respected Professor Marcus Longley of the equally respected Welsh Institute for Health and Social Care. The previous sentence is not written in any sense 'tongue in cheek' as I have the utmost respect for Professor Longley and his team. (His recent report on Community Health Councils in Wales is yet another excellent piece of work). The report that the South Wales Programme leans heavily on is called "a review of the evidence". It is surely therefore only reasonable to point to Professor Longley's own assessment of the evidence as written very early on in his report: "It is the nature of this evidence sometimes to be frustratingly vague, inconclusive, contradictory, or simply non-existent, and not always to point to a single answer. However, as this summary and the accompanying papers show, there is now convincing evidence that hospital services in Wales are not always configured optimally, and that patient care may suffer; and that some key staff groups, in some hospitals, are unsustainable, with the risk of imminent service collapse. Readers therefore have to weigh the evidence for themselves, taking into account the interpretations placed upon it, and applying their own common sense. Health policy decisions are usually like this - in part about value judgements - and striking an acceptable compromise between different objectives is something else readers must do for themselves." Towards the end of the report, Professor Longley observes: Through this review of the evidence, two themes recur. First the evidence is seldom so unequivocal that the answer is immediately clear. It therefore requires interpretation and application to particular circumstances, and needs to be set in the context of the complex inter-dependencies which are typical of modern health-care, both in hospital and outside. Second, health policy is usually about working out acceptable compromises between competing objectives - quality and safety, accessibility and cost." I was struck by the language used here which is surely quite stark in its judgements - inconclusive, contradictory, simply non-existent etc. My concerns about the 'evidence' were heightened when I heard Professor Gallen, Dean of the Wales Deanery, comment on BBC Wales, when questioned about shortages of medical staff in certain specialities, "These

31 things come and go. Ten years ago, everyone wanted to be in paediatrics, now they want to be in something else." I contacted Professor Gallen's office to verify those comments and received the response "Specialities go in and out of fashion for a myriad of reasons." Following on from that, I asked if the Dean's office could refer me to information sources on the subject of shortages of clinicians and was told "none is known." Am I alone in finding potential decisions on fundamental long-term changes in the NHS being based on such shaky 'evidence' to be a matter of great concern? (I have also contacted the BMA who tried their best to be helpful but referred me to bodies like the WIHSC - where, of course, the whole thing started). I have supported the Health Board in the past on various measures. For example, on the temporary closure of the Minor Injuries Unit at YCR Hospital. On this occasion, I find the South Wales Programme to be woefully lacking in solid, supporting evidence and therefore believe it needs to be rigorously examined. I repeat what I wrote earlier, I am not saying the Programme is without merit; it is the status it claims as a long-term answer to a chronic problem that I object to, for there is no evidence provided to substantiate the claim that such a problem exists. The Longley review the Programme is based on, as I have already demonstrated, does not, by its own admission, provide such evidence. And the Dean of the Wales Deanery would appear to refute that shortages are permanent in any speciality. My own view is that nobody knows for certain because proper research into shortages of clinicians in Wales has never been carried out. If the South Wales Programme had been proposed as an interim measure to cope with an undoubtedly serious situation whilst an in-depth research programme is carried out into the causes of shortages, I would have little or no quarrel with it. As it stands, decisions will now be taken on what may turn out to be temporary shortages in four specialities and a few years down the line we will be faced with the same situation in other specialities. The BMA, for example, already identifies psychiatry as one of the specialities suffering most from shortages - can we be sure that won't be a South Wales problem in the coming years and there will be another Programme to deal with that? I have already stated that I believe the realistic prognosis is that one of the options in the South Wales Programme will become reality. I see no benefit in trying to stop that - if I want to tilt at windmills there will shortly be over 90 of them to have a go at stretching from the Rhondda into the far horizon. What I hope there might be some support for is my proposal that Professor Longley and his colleagues be asked to undertake a serious research project into the causes of clinical shortages in South Wales. Amongst the areas I would like that research to cover are: every doctor qualifying anywhere in the UK, not just from the Wales Deanery, over a three year period, be asked why they did not consider a career in Wales, if that be the case; what financial inducements might persuade them to stay in, or come to, Wales e.g. financial assistance with housing,

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undergraduate debts etc. what training opportunities would motivate them. These are just my immediate thoughts as a layman; I would expect someone of the experience and expertise of Professor Longley to provide a more educated and exhaustive method of research. What is vital is that decisions on the future provision of health services in South Wales are based on far more comprehensive and sounder evidence than is the case with the South Wales Programme 27/11/12 Rhondda Cynon This response is in two parts. The first deals with the overall proposals Taf Welsh Liberal and reasoning behind the programme, whilst the second expresses our Democrats concern at the possible repercussions for patients in Rhondda Cynon Taff specifically. 1. Overall proposals In much of the over-arching theory behind these proposals there is little to argue with. Medicine and technology have moved on, and there is a need to adapt. Nobody could disagree with having centres of excellence for major trauma and highly specialised services. – If the patient’s need is that urgent and severe then they need to be in the place where they will receive the best treatment and their survival rate is greatest. However, there is some way to go in educating the public, and also in ensuring that the community based services which are referred to are actually provided to an acceptable standard. Doubling the travel distance to ensure you have the best chance of recovering from a stroke, heart attack, or major trauma is one thing, but to double it for someone who needs two or three stitches in a wound is a different matter. Most people would find it difficult to see the logic in your assertion that “there are too many A&E departments in South Wales.” Anyone who has been along to their local A&E department lately and seen the signs warning them of waiting times of five, six, seven hours would no doubt think the answer is more centres. The staffing situation of course makes this impossible – not to mention the cost, which has to be a factor, the budget is not infinite. We also accept the argument that for training purposes doctors want and need to train in busy departments where they can gain specialist knowledge. It must be said, however, that this state of affairs is not new, and it is disappointing that the have failed to come to terms with the situation across Wales in relation to this. One major concern is that there will be an amalgamation of services across fewer hospital sites with none of the promised increase in more community based services. The preamble on the Cwm Taf website says that many of those who currently turn up at A&E “do not have an accident or an emergency and would be better treated at a minor injuries unit or by their GP.” Many of those who attend A&E would not disagree that their injury / illness is not strictly speaking one they should take there, but currently they have little option. The Minor Injuries Units in Cwm Taf do not function adequately, the hours of operation are severely limited, and in the case of Cwm

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Rhondda people have to ring for an appointment. As for being treated by a GP then this we would submit is simply not an option in many areas and in a substantial number of cases. Even during opening hours GPs’ surgeries are often unwilling or unable to take in ‘emergency’ cases – patients have to ring for an appointment by a certain time in the morning, and if the incident happens after the allotted time then what is that patient to do? Outside of surgery opening times the situation gets worse, and there are numerous cases that have been brought to our attention of people ringing only to be told by the out of hours service that they have no appointments left. There is also confusion over which is the best course of action – MIU, GP or A&E. Someone who has slipped in the street and hurt their ankle doesn’t know if it is broken or not – that is why they seek medical advice. Yet under the current system they can turn up at the MIU in, for example Cwm Rhondda – after phoning for an appointment and waiting until the allotted time of course – only to be told that they do not deal with breaks there, and they have no X Ray facilities, so they have to go to A&E. The outline plans are likely to cause even more confusion, as they talk of consolidating services and cutting down the number of consultant led centres, but at the same time say most patients will be able to access A&E as they do now. Greater clarification is needed as to what this means, although we accept that this submission is coming before the public meeting and there is already a commitment to undertake further consultation with more detailed proposals at a later stage. Public education is vital but the range of minor injuries services has to be improved too. Similarly we accept the argument that obstetrics, paediatrics, neo natal care need to be of a high standard, and where specialist services are required then it is better to have those services available and have to travel slightly further for them than to have a range of services that do not meet the required standards. There has been significant concern over the provision of neonatal services in particular for some time. Given the concerns raised by the National Assembly’s Children & Young People Committee recently surely there is a question over whether a significant improvement will be guaranteed even with centralisation of services. Their inquiry into Neonatal Care, the report of which was published in September 2012, outlines a number of issues. Staffing shortages are again a major problem across Wales. Can we be assured that if these changes go ahead and fewer units are spread across the area that those units will be adequately staffed? Will they provide the promised specialist services, and what guarantees do we have of that? What of the other units which are not consultant led? We would not argue that most births can safely take place under the supervision of a midwife but will there be sufficient staff in those units to cater for the needs of expectant mothers and new born babies? The Committee report states

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• Although the local health boards have stated that they are taking the increasing birth rate into consideration in their future planning, given that local health boards are already facing staffing shortages and capacity issues, the Committee is apprehensive that unless these issues are dealt with effectively they will intensify in the future. Can we be assured that future planning in Cwm Taf and across South Wales will take this into account? Evidence to the committee from the Neonatal Nurses Association stated: • Support for parents can vary from unit to unit. Ideally all units should offer accommodation for parents with appropriate facilities, quiet rooms where parents can have updates on their babies away from the activity of the ward area. Also a dedicated counselling service for bereaved families to help them through the traumatic events of a baby‘s death and support them in any further investigations e.g. post mortem. Again, has this aspect been looked into, and can we be assured that the units which will remain after the proposed consolidation of services will meet these standards? Bliss expressed the opinion that more community outreach nurses would help alleviate pressure on special care units as more babies could be discharged earlier. Again this reinforces a point made earlier with regard to A&E services which is that if specialist services are to be centralised then there needs to be an improvement across the board in community based services. The two need to be looked at and implemented simultaneously. The fear is that due to staff shortages this will not happen and we will merely end up creating increased pressures on fewer hospitals. 2. Retaining hospital services in Rhondda Cynon Taff. Obviously where there is a danger of some services being wholly or partially removed from a DGH then residents who are affected are going to fight to keep services locally. As mentioned previously there needs to be greater clarification as to precisely which elements of each service area we are taking about, and what services will continue to be offered at each hospital. There also needs to be reassurance that in those hospitals where acute services are removed the standards in the much reduced departments left behind will be of a suitably high standard. In the light of the issues over staffing then how can patients be assured that these hospitals will not be adversely affected as staff are drawn to the new specialist centres? Taking into account geographical and transport infrastructure issue then we would agree that services certainly should not be condensed at fewer than five sites, and not surprisingly we would contend that they should include the Royal Glamorgan and Prince Charles hospitals. The location and number of trauma centre(s) we would say should be guided by professional advice. To remove services from two of the three hospitals that are under consideration would be completely unacceptable in terms of patient accessibility. Whilst patient care and health outcomes must be of

35 paramount importance then we also need to consider issues of accessibility for families. Transport links are so poor as to be virtually non existent in some instances – public transport is appalling, and road links and traffic problems mean there is considerable difficulty in travelling from one area to another in many cases. Whilst it could be argued that currently Prince Charles is not too great a distance from Neville Hall and so would not be too great an imposition, when the new critical care centre opens in Cwmbran then it is a different matter, and travel to the nearest hospital offering consultant led services then becomes a much greater problem for people in the Cynon Valley. Likewise there are transport issues for those who currently access services at the Royal Glamorgan if they were to lose those services and have to travel to Bridgend. Not everyone has access to a car and many have to rely on public transport – especially the elderly. It takes one and a half hours by bus from Pontypridd to Bridgend, and buses do not operate along that route in the late evening (at the end of hospital visiting times.) It has to be borne in mind that there is a much higher number of elderly people in the Rhondda than the Wales average. STATS Wales places it at 23.45% of the population as opposed to a Welsh average of 22.83%. The percentage of older people with limiting long term disabilities across all three constituencies – Rhondda, Cynon and Pontypridd – is given as 64.84% against an average of 54.81%. They are more likely to require access to A&E services. The All Wales Neo-Natal Network report of 2012 stated that a significant part of the intensive care capacity problems relate to inappropriate distribution of critical care cots, resulting in some being under used whilst there are extreme pressures in other areas. There was a great deal of anger and concern in 2008 when the special care unit at the Royal Glamorgan was downgraded from a level 3 facility to a level 2. There is likely to be even more public resistance to any moves to take away neonatal and paediatric services from this hospital. The demand is evident in the area. The same Neo-Natal report gives the combined occupancy figures for high and low dependency cots. At the Princess of Wales in Bridgend the occupancy level was only 20.5% in 2011, whilst at the Royal Glamorgan the occupancy level is given as 174.5%. So it would seem that if the plan is going to take into account demand and the provision of services where they are more convenient for the largest number of users then it would seem that an expansion of the service at the Royal Glamorgan would be sensible. The Royal Glamorgan is the newest hospital in the region, it was supposed to offer improved facilities for the people of the area. Prince Charles has had a significant amount of investment in recent years, again with the promise of better provision for patients. Rhondda Cynon Taff is the second biggest Local Authority by population in Wales it is inconceivable that it should be left without a major A&E department within its

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boundaries. 7/12/12 Merthyr Tydfil Firstly, we as a council recognise that Cwm Taf is currently engaging with Council key stakeholders on outline proposals for change in local health services as part of the overall South Wales Programme for that the council is grateful. In this context, we also understand that we will have a further opportunity to comment on definitive options for change as part of a formal public consultation early next year. We welcome the fact health boards in South Wales are working together to look at the configuration of services across the whole of the region recognising that organisational boundaries are not necessarily the determining factor in deciding where people will access their healthcare. We are also encouraged by the emerging view that the needs of the heads of the valleys population should be looked at together to support the people of Merthyr Tydfil, south Powys, north Gwent and the valley. There are a number of key issues that we believe are critical factors in determining any preferred options for change. These include:  Health need and deprivation  Access and travel times  Road and transport infrastructure  Sustainability of services. When considering the needs of the population of Merthyr Tydfil (an indeed the wider heads of the valleys communities), in the context of all the above factors, it is inconceivable to consider a model that makes no local provision for A&E/trauma, consultant-led obstetrics, level two neonatology and 24-7 paediatrics on the heads of the valleys. We therefore believe that for the citizens of Merthyr Tydfil and its wider surrounds that whether the four or five acute model is looked at, Prince Charles Hospital must be one of these. You will be aware that Merthyr Tydfil with its excellent transportation links (A470 and A465) is seen by many as the regional centre for the heads of the valleys and as mentioned above, it provides many services for the wider community. The town of Merthyr Tydfil has also been recognised as a regional transport hub, which in itself brings many benefits. In taking all of the above into consideration, we believe that the NHS must do everything possible to secure Prince Charles Hospital in Merthyr Tydfil to serve the wider heads of the valleys population and support sustainability. We recognise also the need to pursue the development of the proposed Critical Care Centre in Gwent, however, in light of the above, the assumptions made about the number of patients going there will need, in our opinion to be revisited. In considering all the options currently available, the council considers option 5.2 will best meet the needs of the South Wales population. Our reasoning for this is as follows:

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 Prince Charles Hospital is in a strategic location to serve the populations of Merthyr Tydfil and its communities, south Powys, north Gwent and the Neath valley  In establishing five rather than four acute centres, the needs of the Heads of the Valleys and M4 corridor populations (between Cardiff and Morriston) are fairly and more equitably addressed  The strategic importance of Cardiff to the whole of South Wales is recognised and the need to protect higher-level capacity assured so that it is available to all health boards when needed. This does not happen currently, whereby acutely ill people often have to wait for several weeks in Prince Charles Hospital for a bed to become available in UHW for them to access appropriate specialist care  To protect capacity in Cardiff, some activity will need to be displaced out and so as not to disadvantage that population in terms of access, the Royal Glamorgan Hospital should provide acute services to a wider population  If the acute services being engaged upon are removed from Royal Glamorgan, and centred in Princess of Wales, natural patient flow from Taff Ely and Rhondda valleys will be into Cardiff not Bridgend. This will compromise access for specialist and tertiary care in UHW for all residents of South Wales. 7/12/12 Local councillor Whilst I support and understand the need to reconfigure services so that the best medical service is provided to people, I firmly believe that option 4.1 would be the most favourable option for us and then secondly option 5.2, not only here in the county borough of Merthyr Tydfil but to meet the needs of those people in surrounding local authorities who use the services at Prince Charles Hospital. I have considered the options and believe this one to be the most appropriate, the population that use PCH is due to expand, firstly because of the situation arising in /Telford and therefore demand will increase from those areas where PCH is nearer and also with the closure of Nevill Hall and most importantly the minister’s £300m partnership to widen the final two sections of the A465 will surely increase the amount of people who will choose to travel to PCH. The hospital itself is in a prime location, situated at the Heads of the Valleys with excellent transport links around it and also considering the high number of RTAs the hospital deals with due to it being located alongside two of the most treacherous roads in Wales, namely the A465 and A470 northbound. Residents in Merthyr Tydfil have found it increasingly difficult to attend appointments and visit relatives in Royal Glamorgan Hospital because we do not have the transport infrastructure in place to allow people to easily visit. If people don’t drive then the expectation is a very costly taxi fare, an increase on the pressures already faced by the ambulance service or the need to catch at least three buses and that’s just one way. Surely these points must be taken into consideration.

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Finally, I was approached by a young couple whose newborn babay had spent some time in the special care baby unit at PCH – they were aware that PCH and some of its acute services were being considered by the South Wales Programme and handed me a petition of over 2,500 names, signed by people who wish to retain the services at PCH. Whilst I don’t believe the wards are threatened with closure, I still believe they are at risk of losing 24-hour consultant-led care and therefore support this petition. The petition was handed to Merthyr Tydfil County Borough Council’s full council meeting on December 5. I trust the above is all in order and hope that we here in Merthyr Tydfil have a positive outcome which will safeguard Prince Charles Hospital and its future. 7/12/12 Rhondda Cynon Firstly, I wish to stress that we realise this is a process of engagement at Taf Council this stage and that there are no proposals that have been put forward as the basis for consultation, although clearly this is to follow early next year. It is our understanding therefore that a model has been agreed upon following clinical and professional advice for the delivery of certain specialist services, namely those involving pregnancy and childbirth, neonatal and paediatric, A&E; furthermore that this model consists of four or five specialist centres in South Wales to provide these. Looking at the possible scenarios that are set out and the presumed inference that three of the four or five centres will be Cardiff (UHW and Llandough), Swansea (Morriston and Singleton) and the new single specialist and critical care centre within the Gwent area, we wish to make the case for retaining these specialist services at both Royal Glamorgan and Prince Charles (scenario 5.2). Although a case could be made for each of the hospitals in South Wales, including the Princess of Wales in Bridgend, we wish to highlight the qualities of Prince Charles Hospital in Merthyr Tydfil and the Royal Glamorgan Hospital at Llantrisant. Prince Charles is vitally important given its strategic location in the Heads of the Valleys corridor and deprived population base of Merthyr Tydfil and the Cynon Valley, whilst the Royal Glamorgan benefits from its proximity to the M4, whilst serving the Rhondda and Taff Ely areas, not to mention the fact it only opened in 2000. As this engagement process with the public evolves into a consultation exercise, I expect transport will be a frequently raised theme and this is one of the main concerns of the residents of Rhondda Cynon Taf if their access to local hospital services is unduly affected. I appreciate that this is a highly-emotive issue which will arouse considerable interest and clearly we do not want to generate a debate which pitches community against community. Nevertheless, I wish to stress that on behalf of Rhondda Cynon Taf, we belive that services at both the hospitals currently serving our population should be absolutely retained as far as possible. 8/12/12 Member of public I wish to make my views known in support of retaining all existing services at Prince Charles Hospital. Its prime location, easy access for transport

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and catchment areas should all be taken into consideration. Through personal experiences these services are vital to the area. Deprivation, chronic illnesses, low income families must all come into the equation. I hope all these views can be taken on board. 11/12/12 Member of public I support the scenario 4.1 with regard to the south wales programme 11/12/12 Member of public We welcome this public engagement exercise. The fact that the health boards presently serving South Wales have decided to work together on reconfiguring hospital services suggest that they will be working more cooperatively together in the future and this can only be good for patients. The radical solution of creating four or five specialist care centres from the existing nine district hospitals to overcome the present over- stretched staff position appears eminently sensible but lays great important on the fight selection for the future delivery of hospital services. Living as we do in Merthyr Tydfil, we believe the establishment of a specialist care centre at PCH is a compelling one. The reasons are:  Its unmatched geographical position in the north of the area with a wide catchment area already serving patients in three other surrounding health boards – Aneurin Bevan, Powys, Abertawe Bro Morgannwg. Omitting PCH would leave patients in the north isolated in an area where care ownership is relatively low, placing a high dependency on a public transport system with limited and difficult communicating links  While patient numbers at PCH are slightly lower in some instances compared with other hospitals, it is important to remember the effect of: The diminishing significance of Nevill Hall presently covering the Abergavenny area, as a result of the new hospital in Cwmbran and the ongoing changes of hospital locations along the English border counties and its effects on those living in south east Powys, presently using cross-border hospital services. The outcome of these changes could see PCH offering a better prospect for use by new patients  From statistics provided, there is a need to look further behind some of these bare figures. For example, the ratio of births to paediatric inpatients at PCH 1,750 to 1,700 indicates a high level of acute illness and babies requiring specialist support. It reinforces the fact that PCH serves an area with one of the highest levels of deprivation with accompanying levels of sickness and morbidity in Wales  If PCH is not selected as one of the specialist care centres, the result will be a concentration of them along the M4 corridor. Leaving aside transport problems for patients and relatives with a need to visit frequently, importantly there will be more time- consuming longer journeys for an ambulance service already under strain to meet patient call out targets  Over the last few years a substantial modernisation programme

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including a new A&E department has been carried out at PCH. Its selection as a specialist care centre will only then begin to fully realise the potential of this considerable investment funded by the Welsh Assembly Government. The case for Prince Charles Hospital is well demonstrated and its selection as a specialist care centre would act as part of a two-prong attack, coupled with good health education, to raise the standards of people living here, long overdue and sadly trailing behind most of Wales. 12/12/12 Member of public Having considered the information received relating to the proposed change in services, I would support, without reservation, that Prince Charles Hospital in Merthyr Tydfil be retained - therefore Scenario 5.1 or 5.2.

I am a retired NHS Manager and know how important Prince Charles Hospital is. Its location is of prime importance being at the Heads of the Valley and should remain so. So much money has been spent on the facilities and I have had to use them in the course of the last two years with my elderly parents. Transport to the Royal Glamorgan is very difficult without a car and many people in Merthyr are finding it so. This was one of the problems highlighted when RGH was being built and before the merger took place.

I accept the reasons for this consultation and the need to make services stable, safe and sustainable wholeheartedly but I would ask that consideration be given to all and that PCH remains and is given the opportunity to improve its quality and standard of care. 11/12/12 Cwm Taf Regional With the financial and resource pressures currently being experienced by Collaborative public services across Wales, it is vitally important whatever service Board delivery model is developed that it makes the most effective use of the those limited resources and the outcome for the community, or patients, in the case of the health service, is the development of a sustainable and efficient service that provides the same standard of quality care across a regional and national footprint. The board has considered a number of factors that lead us to support a five-centre model with 24/7 consultant-led care in A&E, obstetrics and paediatrics and neonatal services being retained at the following hospitals – UHW/University Hospital Llandough, Cardiff; Specialist and Critical Care Centre; Morriston Hospital, Swansea; Prince Charles Hospital, Merthyr Tydfil and Royal Glamorgan Hospital, Llantrisant. The factors we have considered in coming to this conclusion lead us to believe that this scenario will provide the most sustainable and safe option, that will provide equality of care to a wider population including the whole of Cwm Taf region and the populations of Cardiff, Vale of Glamorgan and Bridgend county. The Cwm Taf region has two excellent hospitals with a good record of clinical delivery and their locations give them a level of strategic importance in the delivery of consultant-led healthcare services across existing regional footprints. The relative ease

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for population, centre on along the A470 and M4 corridor to access both hospitals in Cwm Taf through the existing transport and roads network infrastructure, also makes a strong case to retain their 24/7 consultant- led status. We believe that the five centre model will make the most of the hospitals we enjoy within the region and ensure that the NHS (Wales) is best placed to face the challenges ahead. I trust this will assist the Cwm Taf Health Board in their considerations. 12/12/12 Member of public I have read your notice "Facing the Challenges Facing Hospital Services" and looked at the Scenarios for different areas. I believe Scenario 5.2 to be the best option. With this option Cwmbran, and the surrounded areas would be accessible where the Swansea area and west would be covered. Prince Charles would cover the valley areas and has good road networks for valley people to go to the hospital which they are familiar with anyway. You would cover the Cardiff /Bridgend Areas by making the Royal Glamorgan the fourth hospital. These four areas of South Wales would thus be covered having the hospital placed in these four areas. 12/12/12 Member of public I would like to add my support for Prince Charles Hospital in Matching the Best in the World - Challenges Facing Hospital Services 13/12/12 Response following A public meeting was held in Maerdy on December 6 to discuss the a public meeting proposals set out by the health board as part of their engagement phase. held in Maerdy The community were made aware of the current pressures faced by our local trust and also neighbouring trusts and were supportive of the emphasis the health service was putting on providing world class care. There were, however, a number of concerns surrounding the proposals. The community unanimously supported the proposal that there should be five main hospitals with the Royal Glamorgan being one of these sites. The attendees were concerned with:  Time and cost of transport to other sites making them almost out of reach for many members of the community  The time taken to get to a hospital in an emergency  Other locations do not take into account the natural movement of people in the Rhondda and the transport links available  Inclement weather would make other locations even more problematic  Capacity at other sites The community also felt we need to champion the major advantages of the Royal Glamorgan Hospital – large area covered with excellent transport links (M4); new facility with good parking’ good public transport links.

13/12/12 AS AM for the Rhondda, I strongly urge you to consider proposals based AM for Rhondda on five hospitals rather than four in the current reconfiguration discussions. I would like to see a five-centre model with Royal Glamorgan Hospital retaining consultant-led services in A&E, paediatrics, neonatal care and obstetrics. The demand for services at RGH demonstrates the need to keep 24-hour

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consultant-led services at the site. The figures provided by the LHB show there are 66,193 A&E attendances per annum at RGH compared to 56,217 at Prince Charles Hospital. 3.8% A&E attendances, or 2,350 cases, were Cardiff and Vale residents. It is evident that RGH is the preferred hospital in accident and emergency situation and is a crucial facility for ensuring that pressure on major regional facilities like UHW in Cardiff is kept to a minimum. Demand for other services at RGH also supports this argument. Additional figures, from the LHB, show that RGH is the choice for expectant mothers to give birth with 2,357 births per annum at RGH, compared to 1,659 at PCH. In summary, the high volume of cases dealt with by RGH show it to be a well-used and much-needed facility. The topography of the valleys does not make travel to the other proposed hospital sites easy and with people suffering from a wide range of long- term health problems, access to services at a well-resourced district general hospital needs to be sustained as a priority. Routes in and out of the Rhondda to Merthyr and Bridgend are via mountain roads such as the Bwlch, the Rhigos and the Maerdy mountain road, which are often closed during the winter and at other times, and which do not allow for speedy travel times in any case. Closure of these roads could significantly disadvantage my constituents in terms of travel times to and from other hospitals, which is unacceptable. Another factor to take into account is the cost of public transport to other hospitals for those who are unable to afford their own transport. These factors combined highlight the importance of a local, easily accessible hospital to my constituents. Were RGH to lose these facilities, then looking at travel times, it seems to me overwhelmingly the case that my constituents would travel to UHW in Cardiff rather than Princess of Wales in Bridgend or Prince Charles Hospital in Merthyr – that would be the case even for those living right at the top of the Rhondda Fawr and the Rhondda Fach. This would add significantly to the pressure on the relevant services at UHW in Cardiff. Pressures on UHW could also increase significantly, of course, if the Royal Gwent were to close in the future and services move to a new hospital elsewhere in Gwent. I am very concerned with how the Welsh Ambulance Trust will cope with any reorganisation of local health services and I welcome the Health Minister’s recent announcement of a review of the Welsh Ambulance Services. Based on the figures shown and the reasons provided, I strongly urge the LHB to press for the maintenance of consultant-led services at RGH. 14/12/12 I welcome the opportunity to contribute to the 12-week engagement AM for Cynon process on the future of specialist hospital services in South Wales. Valley I am pleased that people have been given the opportunity to get involved with the debate and discuss the initial proposals through the Cynon Valley health forum and online media. I believe that there is acknowledgement that the status quo is not an option and that services need to change if we are to ensure patient and

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clinical safety. Having looked in detail at the proposals and listened to the arguments, it is evident that the five-centre model would be more sustainable and accessible than four. As the Am for Cynon Valley, I represent some of the most deprived wards in Wales and as a result health inequalities are high. For my constituents, access to both Prince Charles and Royal Glamorgan hospitals is vital so I would therefore urge scenario 5.2. 16/12/12 Rhondda Labour The above programme involves the considered views of over 300 Party clinicians – midwives, doctors, nurses and therapists – in order to improve patient care in the provision of specialist hospital services in obstetrics, paediatrics and neonatal care and accident and emergency services. This entails providing 24/7 consultancy services at 4 or 5 major hospitals.

These services are essential to the most sick and seriously injured children and adults in our community and it is important that they are accessed at the most efficient and effective location.

As demand for these services increases, and there may be a requirement to invest in new facilities or expand some departments, the Royal Glamorgan Hospital is best suited to deliver future changes in a modern building that has potential for enlargement. The Royal Glamorgan Hospital is also a key provider in support services for the University Hospital of Wales, in areas involving the highest risk patients with the most complex care needs.

Cwm Taf Health Board has entered into an engagement process to ascertain the views of various organisations and bodies, which ends on 19th December, 2012, before the formal consultation process commences in 2013.

A decision is then likely to mean implementation of the proposals from 2014.

The view of the Rhondda Constituency Labour Party is, as follows:-

The Rhondda Constituency Labour Party supports scenario 5.2. of the proposals contained in the above document. The loss of 24/7 consultancy led services at the Royal Glamorgan Hospital would be a disaster for the residents of the Rhondda and severely detrimental to their future health and well-being, particularly the very sick and vulnerable.

It is important that the Royal Glamorgan Hospital is a vital, strategic part of future hospital services in South Wales, thus benefitting from further investment to ensure the retention and development of modern, care services for patients in Rhondda Cynon Taff and beyond.

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As a result of recent meetings, it is likely that a 5 model solution may be preferred and, within the model, the following hospitals are likely to be the optimum choice viz., UHW/University Hospital Llandough, Cardiff; Specialist and Critical Care Centre (SCCC), Cwmbran (due for completion 2018); Morriston Hospital, Swansea; Prince Charles Hospital, Merthyr. Therefore, the choice for the final place is likely to be between Royal Glamorgan Hospital, Llantrisant and Princess of Wales, Bridgend. The Rhondda Constituency Labour Party believes that the case for providing 24/7 consultancy led services at the Royal Glamorgan Hospital is overwhelming on both health and strategic grounds. The following issues should be considered in your deliberations:- 1. The RGH is a relatively new hospital, opened in 2000, which replaced the former World War Two, East Glamorgan General Hospital based in Church Village. The hospital is situated in a strategic location, near the M4, in order to provide the most effective and efficient services for the care of patients in the Rhondda and beyond, including the Vale of Glamorgan and Cardiff. It should be noted that the Princess of Wales is an older hospital opened in 1985. 2. The RGH provides key support services for Cardiff in providing some complex services. Also, future changes in hospital provision in Gwent would undoubtedly mean more use of services, at the RGH, from that area. 3. The RGH already possesses state of the art facilities and modern innovation characteristics, as well as providing critical care services, including an Intensive Care Unit, a High Dependency Unit, a Special Baby Care Unit and a Neonatal Intensive Care Unit. 4. The Rhondda has a high ratio of residents suffering from a wide range of long-term health problems including diabetes, ischemic heart disease and strokes. The location of the RGH ensures easy access for those requiring long term care as well as rapid and local emergency treatment. 5. The road infrastructure of the Rhondda Valleys already provides difficulties for the Ambulance Services to transport patients, in an emergency, to the RGH. This is exacerbated by the fact that the current performance of the Welsh Ambulance Trust for services to the Rhondda is the second worse in Wales. Furthermore, roads to the Prince Charles Hospital in Merthyr and even the Princess of Wales in Bridgend are difficult to pass, or closed, during inclement weather. Delays in reaching the patients destination are a matter of life and death. Major incidents in the Rhondda at any time, let alone during poor weather conditions, would be a major operation if these essential services were not based at the RGH e.g. a major

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accident on the Tonypandy or Tonyrefail By-pass involving a multiple vehicle pile-up. This suggests that 24/7 consultancy led A&E services are vital at the RGH. It should be noted that during a recent incident in Cardiff many victims of a road traffic accident were treated at the University Hospital. Such was the number of victims injured, about twelve, that the UHW A&E was closed for some time. During this period, other A&E patients were relocated to the RGH. 6. The Rhondda has some of the highest levels of deprivation in the UK with a low ratio of car ownership. This means that many households are unable to afford the high public transport fares to attend, or visit, hospitals if the RGH were excluded from the provision of certain services. Furthermore, journey times to hospitals such as Prince Charles and the Princess of Wales would be significantly long, arduous and require a number of changes by both bus and train. A visit to Bridgend (visiting times 18:30 – 20:00 hrs.) from Maerdy would take approximately 5 hours (route 172) and cost approximately £7. A visit to Merthyr (visiting times 18:00 – 20:00 hrs.) from Maerdy would take approximately 7 hours and cost nearly £10. 7. The future retention of the stroke team dealing with rehabilitation, currently based at Cwm Rhondda, may be affected if the RGH does not possess 24/7 consultancy led services. Also affected may be Alzheimer’s Unit at Y Bwthyn and other services at Dewi Sant. In conclusion, failure to include the Royal Glamorgan Hospital as one of the 5 preferred centres for 24/7 consultancy led services would, undoubtedly, lead to a decrease in investment on new equipment, training, capital and revenue investment on refurbishing existing buildings, expansion plans etc., particularly in times of reduced budgets and financial pressures and as resources are prioritised for the preferred 5 hospitals. Also, there would be a dramatic effect on the provision of efficient and effective ambulance services to the Rhondda. The long term effect will be the stagnation of an important hospital and a slow reduction in services to the residents of the Rhondda and beyond. Such a result would mean that the Royal Glamorgan Hospital would be effectively “downgraded” in comparison to the preferred 5 hospitals. I trust that the Local Health Boards will take all these matters into account and ensure the future of the Royal Glamorgan Hospital. 17/12/12 I am writing concerning the proposed reorganisation of the NHS hospital AM South Wales services in South Wales. The proposals do seem very similar to ones Central which first surfaced (and I opposed) when I first became an Assembly leader Member in 2003. Since the new plans are very reminiscent of the previous plans it will be no surprise to you that I have concerns. I will explain why in this consultation response. I am acutely aware of the need to reflect the concerns I, and many of my constituents, have about a model of healthcare being proposed by the

46 health boards throughout South Wales. Several members of the Welsh Government appear to share these concerns. Although my region covers the areas of both Cardiff and Vale and Cwm Taff health boards, many of my constituents will also be affected by proposed changes in Anuerin Bevan and Abertawe Bro Morgannwg. As such, my comments apply to all health boards involved in the South Wales programme. The general principles could equally apply throughout Wales. Healthcare is constantly changing and technology improves the way treatments can be delivered. New techniques that lead to better outcomes will be established, and the ways some services are delivered will change a result. It is therefore misleading for health boards to pretend that the NHS operates from a 50-year-old model since the health service in Wales looks a great deal different now to how it operated even 15 years ago when the Cardiff Royal Infirmary offered a much broader range of services. There are four things that follow from this observation, which I hope the health board will agree should form part of any proposals for changes; (1) That if changes do occur the health boards should put in place robust and independent monitoring of the impact of such changes, (2) that if this monitoring reveals an adverse impact on patients, changes are immediately halted and reversed, (3) health boards do not establish irreversible plans that bind the health service in Wales in a direction that is irreversible and oblivious to future changes in medicine and evidence of the optimal configuration of services and (4) that transition arrangements are put in place before any services are removed. Moving onto the actual proposals for change, I shall begin by noting what is not in any of the documentation that forms the pre-engagement phase:  There are no financial details or modelling of the financial costs and financial benefits of various future plans.

 There is no detailed consideration of the impact of various proposed changes on health inequalities.

 Although much is made of the intention to ‘move services into the community’ there is little detail on what this means, the impact on local authorities of such changes, and what changes in governance need to happen to ensure this works effectively (for example, merging health and social care budgets).

 At all times, only two options are presented – the health board’s proposals and the status quo. To be a genuine consultation, I would have expected several options to be outlined alongside full cost/benefit analysis of each option.

Therefore although there are aspects to the programme that are, in principle, welcomed, the lack of detail undermines the credibility of the

47 actual proposals contained in the programme. I would have expected far more details to be contained in any actual proposals, and will be advising my constituents not to support any changes until these details are provided.

My greatest concern regarding the main proposed changes contained in the various documents, and certainly the changes that are causing the greatest concern to my constituents, are the proposals to move to a 4 or 5 site model of provision of specialist obstetric, neonatal, paediatric and accident and emergency services. Given that three of the locations have been decided already, this would mean one or two of the hospitals in Bridgend, Llantrisant, or Merthyr losing these services. It is important in any proposal, a distinction is made between ‘planned’ and ‘unplanned(emergency) treatment’. There may well be benefits towards having planned treatment operating from fewer sites if as a result of these changes units can develop expertise, and I would be prepared to support such changes if; (1) alternatives such as multi-site working were clearly demonstrated to not be as effective, (2) plans for a far better patient transport system were in place, and (3) travel time was mitigated through use of ICT and remote consulting where possible to replace the need for patients to travel to see a consultant. I would also expect deprivation of an area and impact on the poorest communities to form part of the decision making process of where such services should be located. However when it comes to unplanned and emergency treatment I feel that moves to a 4 or 5 site model operating across South Wales would impose unnecessary risks to patients, particularly to the poorest people living in the . I would ask the health boards to consider the following points: (1) The concept of the ‘golden hour’ is still used widely, and unless health boards are prepared to offer substantial evidence to the contrary, any move that would increase the distances and times patients would face in an emergency situation could not be justified. Research by the University of Sheffield in 20071 established a direct relationship between distance and mortality in emergency situations.

(2) The transport links in many areas of the South Wales Valleys are poor, with single track roads, urban speed limits and frequent build ups of traffic presenting a substantial challenge for an ambulance or car carrying an ill patient. Poor weather conditions can easily add to this, and it would not be surprising to see patients living in Treherbert, Maerdy and Glyncorrwg facing

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journeys of more than hour to reach A+E services within the current model of service provision let alone a future health service with fewer accident and emergency departments. If one or two of the current three A+E sites that serve the valleys to close, then patients may be facing delays of 3 to 4 hours between the onset of a heart attack, stroke or asthma attack, and receiving treatment in a hospital during winter. (As symptoms need to first be identified, an ambulance called, the ambulance arriving at the patient, then the journey to hospital).

(3) The population of the valleys typically contains more deprived areas, with a history of workplace related and chronic illnesses associated with the industrial past of the area. These are the communities that should be closer to hospitals, not further away.

(4) The Welsh Ambulance service is itself underperforming. It has failed to meet its response times targets – targets already lower than England – for most of the past year. Two winters ago, performance was dangerously lacking in poor weather. It lacks an all-weather air ambulance service, and the fleet is older than in other countries where ambulances can act as mobile treatment centres. I am surprised therefore that the South Wales programme contains no specific plans for investing in the service, merely stating that work has begun to identify what changes are needed in the service. Has the ambulance service been regarded as an afterthought?

(5) Very little thought has been given to what happens to those sites that lose A+ E services. With no alternatives available, it is likely the remaining A+E centres will be swamped with patients suffering from non-life threatening conditions.

For these reasons, and more, I could not recommend supporting the centralisation of emergency treatment, in particular of A+ E services, at this time. Until the health board is able to; (1) address these concerns with detailed and costed proposals to mitigate the negative effects caused by poor transport and lengthier journey times to hospitals, and (2) produce a detailed a timescale for change that ensures mitigating measures are in place before any centralisation occurs, then I cannot support this aspect of the proposal. Furthermore I have concerns that the move towards operating services from fewer sites will lead to diseconomies of scale and impose an

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unnecessary financial cost on the Welsh public purse. Research by the Health Evidence Network2 concluded that the optimum size of a hospital is between 200 to 600 beds. Larger hospitals suffer from excessive management costs and other diseconomies of scale. It is important to note that the Heath hospital already has 1000 beds. Furthermore, construction of a new unit in Cwmbran in the current financial climate would be an inappropriate use of resources unless the benefits from such a project outweighed the costs. If the resources were instead used to support existing facilities then outcomes may also improve but we simply don’t know from the evidence available. Again, the lack of detail in the documentation risks letting this entire process down. This leaves us with staffing rotas as the remaining issue to consider. Clearly there are serious problems with staffing within the NHS. However many of the reasons given for this don’t hold up to scrutiny. Managers of health boards should have been aware of the impact of the working time directive for at least a decade, and failure to address this says more about a lack of workforce planning than it does about the current configuration of services. Furthermore, to offer staff shortages as a justification for changes is not persuasive – staff shortages will adversely affect any type of health service model the health board and government wishes to implement, not least the undetailed proposals for ‘moving services into the community’. I do not believe the health boards have made a strong and persuasive case for the kind of changes they are proposing. I would like to see more options, consideration of alternatives to centralisation, and above all far more detail in the formal plans when they are produced in the New Year. 17/12/12 Merthyr Tydfil On behalf of the Merthyr Tydfil Local Service Board (LSB), I would like to Local Service Board thank you for the opportunity to respond to the engagement on the outline proposals for change in local health services as part of the overall South Wales Programme. We also understand that we will have a further opportunity to comment on definitive options for change as part of a formal public consultation early next year. It is pleasing that Health Boards in South Wales are working together to look at the configuration of services across the whole of the region and they recognise that LHB boundaries should not be the main consideration in the provision of health care services. We are also pleased by the emerging view of the strategic importance of the “Heads of the Valleys” and the needs of the “Heads of the Valleys” population. The LSB feels that the critical factors in determining preferred options for change include; the health needs and deprivation levels of our communities, access to services and travel times, road and public transport infrastructure and sustainability of services. Considering the above, it is inconceivable to consider a model that makes no local provision for A & E / Trauma, Consultant-led Obstetrics, Level 2

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Neonatology and 24/7 Paediatrics on the Heads of the Valley. Particularly when the needs of the population of Merthyr Tydfil and also the wider Heads of the Valleys Communities including, South Powys, North Gwent and Neath Valley is taken into account. We therefore believe that for the citizens of Merthyr Tydfil and the surrounding area that whether the 4 or 5 acute centre model is looked at, Prince Charles Hospital must be one of these centres. You will be aware that Merthyr Tydfil with its excellent transportation links (A470 and A465) is seen by many as the Regional Centre for the Heads of the Valleys and as mentioned above it provides many services for the wider community. The town of Merthyr Tydfil has also been recognised as a ‘Regional Transport Hub’ which in itself brings many benefits. Following the recent announcement by the Welsh Government regarding confirmation of funding for the dualling of the remaining sections of the A465 – Heads of the Valleys Road, communication links will be further improved. We believe that the NHS must do everything possible to secure Prince Charles Hospital in Merthyr Tydfil to serve this wider Heads of the Valleys population and to support sustainability and safety of services. There is a need to pursue the development of the proposed Critical Care Centre in Gwent however and the assumptions made about the number of patients going there will need, in our opinion, to be revisited. The LSB considers that Option 5.2 will best meet the needs of the South Wales population. The key reasons for this are:  The strategic location of Prince Charles Hospital enables it to serve the wider “Heads of the Valleys” communities, including, South Powys, North Gwent and Neath Valley.  By having 5 rather than 4 Acute Centres, the needs of the Heads of the Valleys and the M4 corridor populations are more fairly addressed.  The importance of more specialist hospital services in Cardiff to the whole of South Wales is recognised. The need to protect higher-level capacity must be assured so that it is available to all health boards when needed. This does not happen currently whereby acutely ill people often have to wait for several weeks in Prince Charles Hospital for a bed to become available in UHW for them to access appropriate specialist care.  To protect capacity in Cardiff, some activity will need to be displaced out and so as not to disadvantage that population in terms of access, the Royal Glamorgan Hospital should provide acute services to a wider population.  If the acute services being engaged upon are removed from Royal Glamorgan and centred in Princess of Wales, natural patient flow from Taff Ely and Rhondda valleys will be into Cardiff and not Bridgend. This will compromise access for specialist and tertiary care in UHW for all residents of South Wales.

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18/12/12 Member of public My late husband was a GP in , and having lived in Merthyr Tydfil for 60 years, I have been proud of Prince Charles Hospital and feel it is an essential facility for this part pf South Wales. If the sickest and most seriously injured patients were treated out of the area, it would be extremely hard on their families for visiting. I am already having to travel to the Rhondda for Lucentis treatment, and it is very time-consuming for my daughters who transport me, as well as for myself 18/12/12 Cwm Taf Medical Cwm Taf Medical Advisory Group (MAG) has discussed the possible Advisory Group scenarios for concentrating 24/7 consultant led paediatrics, obstetrics, neonatal and A&E services on either four or five hospital sites, from:- UHW/UHL (Cardiff) Specialist Critical Care Centre (Newport/Cwmbran) Morriston Hospital (Swansea) Princess of Wales Hospital (Bridgend) Prince Charles Hospital Royal Glamorgan Hospital We have been given to understand that there are three “given” sites, namely:- Cardiff Swansea Gwent The MAG has discussed its preferred options for the fourth and fifth sites, having agreed that service provision on only four sites will not meet patients’ needs, with reference to population centres and patient flows. Having supported the five site option and considered the patient flow data, the MAG’s preferred sites are:- - Prince Charles - Princess of Wales or Royal Glamorgan Hospital or networked/hybrid provision between them. The MAG has discussed how the ambulance service will manage with specialist provision concentrated on these sites and this is a potential major concern. The Health Minister has commissioned an all Wales ambulance service review and although the service is gradually modernising and developing as a clinical service, we do not believe that the ambulance service will be in a position to transport and repatriate patients in the new service reconfiguration with its current operational policies. The flying limitations of the air ambulance, which mean that in the prevalent weather conditions in Cwm Taf the service is often not available, must be taken into account, even though the specialist service reconfiguration will only affect relatively small numbers of patients at the high end of service delivery. The ability of the ambulance service to deliver is a crucial point that must be addressed in this consultation and in the forthcoming ambulance service review. The ability of the ambulance service to deliver is our key concern, given the ongoing and historical problems with ambulance transport in the area even without these proposed specialist service changes. In relation to the medical workforce and training issues behind the need

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to reconfigure, the MAG will need more information about how the Deanery will support the five centre model, which will presumably rely on an agreement for co-operative working between the specialist sites. We have also discussed staff skill mixes, staff training and the new models that are being used to change working practices and manage the current problems with the traditional staffing structures. In summary, Cwm Taf MAG supports a five centre option that includes Prince Charles and Royal Glamorgan or a RGH/Princess of Wales hybrid. The key message of the reconfiguration for patients must be that it is about improving the quality and safety of targeted services to patients, not about cutting services or saving money. 18/12/12 Plaid Cymru – I am writing as secretary of and on behalf of the Treorci branch of Plaid Treorchy branch Cymru to express our concerns about the possible changes planned to hospital services in South Wales. Our concern is with the potential threat to consultant-led services (A+E, paediatric, obstetric) at the Royal Glamorgan Hospital at Llantrisant. Were these services to be lost from Llantrisant, journey times from the Rhondda for patients needing these services would increase considerably. This could put the lives of some individuals at considerable risk. Furthermore, the burden to relatives and friends would increase significantly. Here in the Rhondda, people without access to a car already face very long and costly journeys by public transport to reach Llantrisant. Having to go to Cardiff, Bridgend or Merthyr Tydfil would make these journeys even longer. As you are no doubt aware, only about one third of households in the Rhondda own a car or van and it is one of the most economically depressed regions in Wales. Furthermore, this region has a higher proportion of health problems other parts of Wales. We ask you to give serious considerations to the problems of the Rhondda, particularly the Upper Rhondda and not to add further to the burden of these communities by moving services from an already not so local hospital to an even more distant one. 19/12/12 Bro Taf LMC Bro Taf LMC represents GPs in two health board areas: Cardiff and Vale and (this was also sent Cwm Taf. to Cardiff and Vale  Specialist services and associated hospital services will only be UHB) viable if the five centre option is chosen. We believe that this is the only configuration that can accommodate natural patient flows. The preferred configuration is Cardiff, Swansea, Gwent, Prince Charles and Princess of Wales or Royal Glamorgan Hospital (or networked/hybrid provision between them).  Even without the proposed reconfiguration, other recent changes to hospital services mean that many patients have greater difficulty getting to hospital appointments because they have to travel further without ambulance service transport being provided. Services are already stretched and any further contraction would be disastrous for local populations, especially for those with limited mobility and means who are living in deprived areas. We therefore assume that the South Wales Programme is about service reconfiguration, not

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about cutting services or bed numbers.  The ability of the ambulance service to cope with the reconfigured services is a crucial point and, frankly, a major concern given its current performance levels. We recognise that there is going to be another all Wales ambulance service review which may result in improvements and we acknowledge that the service is gradually modernising, but we are not confident that the ambulance service will be able to cope with the new service reconfiguration in its current state. There are flying limitations on the air ambulance service which mean that in the weather conditions that are often prevalent in South Wales the service is not always available. The ability of the ambulance service to deliver is a crucial point that must be addressed in this consultation and in the forthcoming ambulance service review.  The impact of the planned acute changes on “cold” work will result in patients travelling further for some routine treatment, which will in turn result in the more routine hospital work being done in general practice (e.g. rheumatology monitoring), so there must be adequate investment in primary care for that work to be provided by GPs.  We have asked the Health Boards to confirm what work is being done to resolve the identified doctor training and recruitment problems. The Health Boards and the Deanery must find out why doctors do not want to train in Wales. We appreciate that the LHBs are working collaboratively with the Deanery to solve this problem, but some of the training and recruitment problems are long standing, well documented and particular to Wales, but they have not been fully addressed in the past. We hope that the renewed efforts to solve this problem will this time bring the desired results. The pattern of training placements and even the names of the Welsh LHBs have been identified as discouraging trainee doctors to train in Wales.  We have asked where the specialists will be recruited from to staff the specialist centres and how confident the Health Boards are that the clinical staff already working in the affected specialties are willing to relocate to the new sites as needed. We have been assured that workforce profiling has been completed and there is sufficient manpower and cover available for the reconfiguration to work as planned. This is reassuring, but we believe that for the longer term future it will be vital to develop and retain more home grown doctors and attract doctors from outside Wales. We also think it is vital that there is more investment in things like hospital infrastructure and IT to attract and keep doctors in Wales.  It would inform and improve the quality of discussion and debate about the reconfiguration if the Health Boards headlined which elective services might have to move in order to accommodate the additional specialist capacity that is going to be provided in the

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various hospital sites.  We would like to know how the Health Boards are going to inform and educate patients about the new service configuration when it is decided. We hope that the responsibility for this will not lie primarily with GPs, who do not have the time or expertise to manage patient expectations on their own.  The impact of the planned acute changes on elective work will result in patients travelling further for some routine treatment, which will in turn result in the more routine hospital work being done in general practice (e.g. rheumatology monitoring), so there must be adequate investment in primary care for that work to be provided by GPs. We also want to highlight the implications for primary care and GP workload when there are more early discharges and more patients being cared for in the community. This being the case, we would like to know what extra provision the Health Boards will make to manage that, especially as the current experience in Cardiff and the Vale of Glamorgan is that the GMS and enhanced services budgets are going to be cut next year, not expanded.  We perceive that the paediatric service appears to have a perennial bed crisis and so moving more acute work to UHW from other hospitals is only going to exacerbate the situation. The paediatricians are already pressured into sending many patients home a little sooner than they would like in order to release beds, so we will need to be reassured that bed numbers will increase sufficiently to cope with the increased activity, including paediatric nurse resources which are also stretched.  We would like more information about the specific timeline for the reconfiguration. In summary, there appears to be a general understanding of the need for change and support from the GP community for the planned reconfiguration, but it we cannot emphasise strongly enough that for this to work the Health Boards must sustain and improve their support for the GP community when its workload increases as a result of the changes, not cut GP enhanced services, which is the current experience (at least in Cardiff and the Vale of Glamorgan). 19/12/12 Merthyr Youth This is a collective response from the young people of Merthyr Tydfil. We Forum are a group of young people aged 11-25years who meet on a regular basis to discuss issues that affect us. Article 12 of The United Nations Convention on the Rights of the Child states: That all children and young people have the right to have their say in issues that affect them. Various consultations have been in held in Youth Forums held around the Borough. 71 young people have been involved in workshops to consider the impact of your proposals. We believe that Prince Charles should be chosen as one of the hospitals where specialist services are based in South Wales. Merthyr Tydfil has the road network required for access from all directions.

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The ambulance service is already stretched to capacity, what will the implication be of ambulances having to travel further to neighbouring hospitals. Will this put lives at risk? Do you have a filter system for 999 calls to prevent unnecessary trips? Are staff trained to determine what calls should result in an ambulance attending? Transport is an important concern; we as a group have had personal experiences with transport difficulties since services have been moved to the Royal Glamorgan. Why can’t existing hospitals be used and more staff recruited? Prince Charles hospital has just been renovated, what was the cost of that? and why is it not suitable to house specialist services. It would damage the area, to loose specialist roles, meaning that higher paid work will be lost from the town. Merthyr attracts visitors from all around the country, carry out a postcode survey to establish the towns that visitors travel from already with out the town’s hospital housing specialist services. As a group we also believe that whatever it takes for the individual to get the best treatment when needed, should be the priority. 19/12/12 Rhondda Cynon The impact of deprivation and the burden of ill health faced by our Taf Health, Social communities in Cwm Taf highlight the need to ensure that our patients Care and Wellbeing have access to the highest quality care and receive the best clinical Partnership Board outcomes. We therefore welcome the opportunity to comment on this new programme and the opportunity to shape the future of our local healthcare service. The Health, Social Care and Well-being Partnership Board clearly recognise that the present healthcare system is unsustainable and that a mature view is needed to secure the successful future of health services across the South Wales region. The Board recognises the need for us to address health inequalities and provide the best services to our local population wherever they may live. The HSCWB Partnership Board agrees with the recommendation that good local access to services should be provided for the majority of services but that some specialist services and emergency care need to be concentrated in fewer centres. Scenario 5.2 is emerging as the preferred option. The Board however have raised some issues about the new programme and need assurance that consideration will be given to the following: Transport and access The geography of Cwm Taf continues to provide challenges in terms of transport and access. We have low car ownership amongst our population and existing issues relating to public transport networks and travel times to our hospitals. We feel that careful consideration must be given to this issue when determining the future service model to ensure people have access to health services wherever they may live in Cwm Taf. Ambulance services The Board recognises the likely impact and improvements that are needed to our ambulance services to meet the needs of the new service models and would like to be assured that this issue will be addressed.

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Deliverability and clinical sustainability We want to be reassured that the service model relating to the five centre model can be sustained and emphasise the need for careful workforce planning when details of the chosen model are made clearer. Timescale The timescales need to be defined. Health and social care The Board have made reference to “Setting the Direction” and locality work that is ongoing and are concerned that this work may be pushed back as a result of the need to focus on delivering the South Wales Programme. It recognises that locality work is an important component of the “whole systems” approach to health and social care and is key to avoiding inappropriate pressure on the hospital system. It is apparent that further debate is required to ensure that the social care element of the “whole systems” approach is considered within the South Wales Programme and this debate is had at a regional level with Local Authority Social Services Departments across the region. 19/12/12 Third sector Third Sector Engagement Event engagement event South Wales Programme response 28th November 2012 9.00am-12.30pm Abercwmboi Rugby Club Event Feedback

@Home Service questions from floor; Cross boundary working? How are the other Health Boards in South Wales acquiring knowledge and awareness of health and social care services in Cwm Taf such as the @Home service? Awareness raised via communication-working with 4 care homes at present Are primary care colleagues aware of the @Home service? Locality working key to raising awareness of the service along with positive feedback from patients to G.P.’s, GP engagement vital-district nurses pinpointed as a good point of contact for marketing the service. Macmillan has the Cancer Information in Libraries service that could raise awareness along with third sector organisations and CVC’s. What about services for 60-65 age group? Age is not a barrier to reablement services. Is it a medical model? No @Home is an integrated social model of care. @Home is for 6 weeks, what about longer term? There are existing links with other services in localities where can be referred to. Mental Health issues-do they fit into the @Home service model? A holistic view of needs is required as oppose to looking the problem in isolation. Reablement does wrap around other existing core services but more development is required.

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@Home service could be the default setting? Requires communication so that the service is referred to first as oppose to after an event. What about weekend/evening services? This is currently being looked at in particular with regard to therapies. South Wales Programme; Will there be a move towards more community based services? Yes, however complex care e.g. specialist dermatology services more difficult to base in communities. Neonatal units-why are patients sent to hospitals further from their homes as oppose to nearest hospital? SCBU Level 3- babies that require ventilation Level 2-babies that require additional support It could be that the nearest hospital doesn’t have Level 3 services. Service user involvement versus engagement and consultation? Legally obliged to consult and it’s vitally important to engage before formal consultation to gather views and inform public. Service users have the opportunity to be involved in engagement process via events, public for a, questionnaire and health board colleagues will visit community groups on request. Why do patients need to be in hospital just to be monitored? New technological advances mean that a hospital stay could be circumvented with monitoring of stable conditions at home. Citizens have a responsibility for their health and to work towards prevention of ill health and management of their conditions. How will the reorganisation affect the ambulance service? One longer journey is preferable to several journeys ensuring that patients get to the right place in a timely manner. There is an ambulance service review coming soon-looking at the inappropriate use of ambulance service which is a clinical service not purely a transport service. What Political and media engagement has there been? Over three thousand people engaged with so far, with media articles in local press. Live ‘facebook chats’ and communication officer in touch with local media. Suggest “do make the most of” as a campaign strapline. Is it better to separate children services from A&E services and have two separate centres of excellence? No-need paediatric doctors to support A&E and particularly in suspected child abuse cases. Is there adequate information and advice regarding benefits for travel particularly in the light of welfare reform? Talks are in progress with the Local Authority regarding the impact of welfare reform. What about transport? Welsh Ambulance Trust key in planning service models-they need to

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know when, where and which hospitals patients need to be taken to and likewise patients need to know where they need to go to. Public transport needs to be included. @Home service important in reducing the need for transport. Communication will be pivotal. Third sector have a key role to play in non-emergency transport eg as in reconfiguration of mental health services. 45 minute travel time questionable-inflexible and expensive- more innovative methods need to be explored. Call for consistency of approach between the different Health Boards particularly in consideration of four or five hospital sites. Concluding remarks; In consideration of the possible scenarios for concentrating consultant led paediatrics, obstetrics, neonatal and A&E care on four or five hospital sites, the feedback from the floor indicated that five hospital sites were preferable to four and that with a need to protect and provide for the Heads of the Valleys areas and other areas of considerable deprivation scenario 5.2 would fulfil such needs. 19/12/12 Plaid Cymru I'm responding on behalf of the Plaid Cymru Pontypridd constituency written response party. following a public We held a cross party open meeting in Tonyrefail as part of our meeting in engagement process on Monday 10th December to listen to the views of Tonyrefail local people. 10/12/12 A number of questions came out of that meeting and in our discussions with the RCN and the BMA. As health boards what investments do you plan to make in the Ambulance service to mitigate journey times? How much money will be invested? What are the proposals for those places that lose Accident and Emergency services? What investments are specified? What account have you made of deprivation? We also discussed the document at our constituency party meeting on Thursday 13th December. Regarding the questionnaire issued it contains a number of leading questions based on unreasonable assumptions. The questionnaire fails to distinguish between planned treatment and emergency treatment. People have different views on how prepared they are to travel for planned and emergency treatment. 19/12/12 Member of Public We would wish to see PCH as one of the hospitals with specialist services available to patients. This hospital serves a large area well-served by the road network. An ageing population having to travel further afield presents a daunting prospect especially with a refurbished hospital so much nearer. We have both had excellent treatment in PCH. Petition (paper) The petition states: We the undersigned residents of Rhondda Cynon Taf Rhondda Labour strongly support option 5.2 under the proposals outlined in the Party consultation document for the reconfiguration of health services

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Signed by 1,242 Matching the Best in the World – Challenges Facing Hospital Service in people South Wales. We further support the retention and development of the Royal Glamorgan Hospital facilities and services, especially A&E, to ensure the people of Rhondda Cynon Taf can access the services they deserve within these county boundaries. Petition (online – The petition states: We call on the National Assembly for Wales to urge National Assembly the Welsh Government to save our health services at the Royal petitions website) Glamorgan Hospital. A decision is being made by that, if implemented, Councillor Mark this will result in the loss of some paediatric, obstetric, neonatal, and Adams accident and emergency care. Signed by 1,077 Put simply, if you require intensive care, have a very sick child or are likely people to have a pregnancy that is not straight forward you will have to travel to Cardiff, Merthyr, or Bridgend. For RCT residents reliant on public transportation, this could result in travel times in excess of two hours to attend vital appointments. We the undersigned residents of Rhondda Cynon Taff strongly support option 5.2 under the proposals outlined in the consultation document for the reconfiguration of health services, "Matching the Best in the World - Challenges facing Hospital Services in South Wales". We further support the retention and development of the Royal Glamorgan Hospital facilities and services to ensure the people of Rhondda Cynon Taff can receive and access the services they deserve within these county boundaries. Petition (paper) The petition states: We the undersigned want the Royal Glamorgan Signed by 46 Hospital to keep the widest range of services, including full consultant-led people accident and emergency, neonatal and paediatric service. Petition (paper) The petition states: Royal Glamorgan Proposed Closure. Opposition to the from the Teify closure of A&E facilities at the hospital. House Ladies Guild, Maerdy Signed by 35 people Petition (paper) The petition states: We the undersigned want to pledge our support to Signed by 97 the Royal Glamorgan Hospital keeping the widest range of services, people including full consultant-led accident and emergency, neonatal and paediatric services. Petition (paper) The petition states: Save Our Children’s Services. Is your child sick or Signed by 1,950 badly hurt? Are you pregnant? Our paediatric, obstetric and A&E services people are at risk of closure in Prince Charles Hospital. We need your support to help us ensure that no lives are lost. If we lose our services the nearest hospitals are the UHW (Heath in Cardiff) or Royal Glamorgan, in Llantrisant. Petition (paper) Petition states: Loss of Children’s Services, PCH Signed by 203 people These 37 1 Ambulance response time to patient and transporting to hospital. The statements were Royal Glamorgan best suited for most of RCT patients re roads, bus

60 submitted to Cwm services, time, distance and travelling time for patients and family. Taf Health Board via Leighton 2 The distance we would need to travel to get to A&E in the nights would Andrews’ office be very frightening should the worst happen if the A&E were to be moved from members of away from Royal Glamorgan.. the public 3 In the winter people from the Rhondda would find it very difficult to get to the Prince Charles Hospital. There are no night buses or Sunday buses and you would have to change buses three times.

4 As we are old age pensioners we are strongly against our A&E being moved further away as we have no transport.

5 How can the health board justify transferring these vital services to somewhere like Merthyr Tydfil – three buses from Maerdy, four from Blaellechau. What will happen at the Royal Glamorfgan and as far as Ysbyty Cwm Rhondda. Well I am speechless. Whoever heard of appointments for A&E.

6 The slightest fall of snow and we at the top of the Rhondda Valley suffer dramatically. Imagine!! Trying to go over the Rhigos of Bwlch mountain in an emergency… I don’t think so. The Rhigos is more often than not closed after a shower of snow.

7 I feel that a loss of these services at the hospital will affect a lot of people, obviously I am a OAP and cannot get transport to any other hospitals.

8 I think they should keep the services going in Royal Glamorgan Hospital as some people haven’t got transport for other hospitals especially older people like me.

9 I definitely believe we need this facilty at Royal Glam Hospital – it could mean the difference between life and death, not only because of the distance but also that a consultant be to hand.

10 Some people have no public transport and the closure will make it difficult for them.

11 Living in Treherbert I am very concerned over the journey times to the proposed sites for A&E. With a bad winter forecast it would be extremely difficult to get to Merthyr if the Rhigos road is closed, also to get to Bridgend if the Bwlch road is closed. The travelling time going down the valley for alternative sites would be doubled adding worry and stress in an emergency. 12 The Rhondda is an area of deprivation and poor health. People regularly rely on hospital services but often cannot afford to buy a car,

61 having to rely on public transport. The geography of the area means travelling times are excessive and costs are high. How are people to get to hospitals many miles away?

13 I think it is a disgrace even considering closing the A&E in the Royal Glamorgan Hospital. The nearest hospital they are saying is Merthyr. How are we suppose to go to Merthyr Hospital when the snow and bad weather comes, the Rhigos will be closed and also the edge of the valley roads. It will be impossible to get to. They haven’t even got buses going over Merthyr Hospital it is absolutely disgusting, I have very strong views against closing the in Royal. I live in Llwynwpia near a perfectly good hospital – Cwm Rhondda – but I cannot even go there in an emergency to have to go to Merthyr or Bridgend is ridiculous, absolutely ridiculous.

14 Once again it is the people of the Rhondda who have to suffer. When the mountain roads are closed in winter, -people are going to die by the time they get to Bridgend or Merthyr. Why should the people of the valleys have to travel so far for what should be basic care. It is totally unacceptable for these services to merge. Patient care will suffer tremendously.

15 Will the ambulance service be able to cope? They are stretched serving RGH and PCH so how will they manage driving people to centres over several extra locations?

16 As I have no transport I am concerned about the distance I would have to travel if A&E were moved to proposed sites.

17 I would be concerned about the cost of the journey as well as the time it takes from the Rhondda to these other hospitals. We have very little in the Rhondda now, to take more things from us would be wrong in my view.

18 We need to keep our local hospitals as we have not all got transport to get to some of these hospitals.

19 It will cost the NHS a lot more money to put on transport for to take people like myself to these faraway hospitals as we can’t get there ourselves.

20 I would just like to say that it would be a complete nightmare to lose A&E and other services mentioned from the Royal Glamorgan Hospital. Not everyone has transport and is able to travel long distances – we have already lost services from Ysbyty Cwm Rhondda, please let’s fight to keep them at Royal Glamorgan. 21 I have deep concerns that people will be unable to get to other hospitals and therefore put themselves in danger health wise.

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22 We need our hospital as it is close with all departments. People do not want to travel when they are unwell or had an accident.

23 Please, please keep all facilities at RGH. Having no transport I rely on public transport for visiting and also all outpatient appointments I have to attend. So please for myself and also many other people concerned, please keep all depts open.

24 The former Llwynypia hospital was first class. Accident and emergency catered for and other services. The new one is poor in comparison. As regards the Royal Glamorgan, I want to keep all facilities. We don’t want to travel to Merthyr.

25 Dear Leighton, we need all that we have at the Royal Glamorgan Hospital, Llantrisant. We need more not less. To go farther away is far too much to ask patients and outpatient to travel further away. When we need to keep the widest range of services at Llantrisant.

26 As a constant user of Royal Glam, Llwynypia, Dewi Sant, I want all facility kept in RCT. Would be fatal if we had to travel much further than it is now. We also attend the Heath Hospital, Cardiff, which is horrendous.

27 I feel strongly that accident and emergency services should be retained at Royal Glamorgan Hospital. The area has a large population with more older people and lower car ownership than other areas. This would make travel out of the area to the other proposed sites particularly difficult.

28 We do not want to see any downgrading of the Royal Glam as the extra travelling would cause problems and we are not second class people.

29 I totally oppose the closure of Royal Glam. There are thousands of thousands of people living in the Rhondda who don’t have the transport to travel to other valleys. You might as well close the valley down, we are losing so many public places it’s getting ridiculous. If the intention is to make people move out of the valleys we are going the right way.

30 I am against this, there are not enough transport for people to get to these hospitals. I have to catch two buses to get to the Royal and not every body has a car and also the cost to get to them is too much.

31 The Royal Glamorgan Hospital should be made to keep the widest range of services as possible. With the University Hospital of Wales performing specialist heart operations. Also during the winter months the Rhigos mountain has been closed on a number of occasions in the last few years due to bad weather, which in emergencies ambulances would

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have to travel very long distances with possible loos of life to patients.

32 I am extremely concerned that our already over-stretched services will be centralised away from our homes. How will patients and visitors attend hospitals miles away. Inevitably deaths will occur.

33 To remove consultant-led A&E, neonatal and paediatric services from the Royal Glam Hospital would be foolish, it would increase travelling distance, cost and time across the whole of the Rhondda area and patient accessibility to direct transport links.

34 Keep consultant-led A&E at Royal Glam. We in the Rhondda already have to travel a good distance to this hospital. To ask us to travel even further would be a step too far. There is also the implications of the cost to travel that distance. Remember many, many older people still do not have their own transport and I guess the number of buses needed to attend appointments would be more than one.

35 You have our full support for Royal Glam. To travel to any other hospital will be for some impossible and will make life more difficult for everyone. Sadly someone will lose their life, with the reorganisation where distance can mean times of 20 mins approx to 50-60 not practical or fair.

36 I think it is imperative that the Royal Glam is one of these sites or we will be the forgotten people. Look after the people of RCT

37 If we lose the service of Royal Glam I despair for the young, disabled and aged. Make sure the best service is kept for RCT.

19/12/12 Rhondda Cynon I am writing to you as the Chair of the Rhondda Cynon Taf Local Service Taf Local Service Board, in response to the engagement on the South Wales Programme Board “Matching the best in the world – challenges facing hospital services in South Wales”.

We are grateful for the opportunity to respond and would like to take this opportunity to thank you for the extensive engagement that has been carried out to date within our partner organisations and communities.

As a Local Service Board, we share the sentiment that all people in Rhondda Cynon Taf should have an equal standard of quality care, irrespective of geography or time of day. However, we also recognise that we are facing significant challenges as public service providers; and for this standard of care to be sustainable, there must be a change to the way we structure and deliver services.

The challenges faced within accident and emergency care, paediatric and

64 neonatal and obstetric services have been clearly articulated. It is understood by the Board that the proposed changes relate only to these critical services that cater for the most sick and seriously injured members of our population. Of utmost importance within these specialist services is patient safety and clinical outcomes. Therefore, it is also understood that crucially, these services currently cannot be sustained due to recruitment and training issues.

We have heard evidence and opinion from various public forums that some key issues are affecting the clinical outcomes of people who live in the County Borough. Firstly, the staffing issues across hospitals in South Wales are affecting abilities to deliver a high standard of care at all times. Secondly, we acknowledge that the University Hospital of Wales in Cardiff is struggling to meet the demands placed upon it by surrounding populations in need of both routine, and more complex, care. We are also hearing examples that too many young children and babies in need of dedicated attention are being treated outside of Wales, causing distress and difficulty for their parents and families. The members of the Local Service Board agree that these key factors illustrate that the status quo cannot continue and is not sustainable. We strongly advocate that these services do not continue being delivered in isolation and that the configuration of these services needs to be looked at across the whole of South Wales.

It is the view of the Local Service Board that, going forward, five hospital sites should deliver these services and we agree with scenario 5.2 in the engagement documents. Firstly, we feel specialist services should remain in Morriston Hospital, Swansea providing the best possible care to patients in West Wales. It is hoped that the planned Specialist and Critical Care Centre will provide state-of-the-art services, previously based at the Royal Gwent and Neville Hall hospitals, to the populations East of Rhondda Cynon Taf.

The Local Service Board recognises the University Hospital of Wales as a key provider in being able to respond quickly and appropriately to the complex needs of people living in the City, and wider throughout South Wales. But in acknowledging the importance of this hospital, we also see the Royal Glamorgan Hospital in southern Cwm Taf as providing a vital service in supporting Cardiff. The Royal Glamorgan Hospital therefore could perform the dual purpose of providing additional acute services for a wider population, whilst also continuing to serve our local communities in Rhondda Cynon Taf.

Finally, the very nature of the demography and geography of Cwm Taf, and its neighbouring Local Authorities, indicates that Prince Charles Hospital, Merthyr Tydfil, is well placed in serving the wider Heads of the Valleys population as well as the communities in Cwm Taf. It is our view

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that the departure of specialist services from Neville Hall Hospital and the planned location of the Specialist and Critical Care Centre will mean a greater reliance on Prince Charles Hospital in Merthyr Tydfil. The Local Service Board therefore, suggests that specialist services are based at these five sites.

In addition, we would like to stress that any changes to services will be delivered in a backdrop of persistent deprivation, particularly experienced by the population of Cwm Taf. The effects of this on the people of Rhondda Cynon Taf are vast, often reflected by the levels of long-lasting ill health experienced by many in the area, and therefore there is a continuing need for high quality care and good access to services. Similarly, the members of the Board are keen to highlight the practical effects that deprivation has on our communities, such as the low levels of car ownership, which impacts on travel times to specialist centres, public transport links and local geography, all of which are a concern if services are located further away from the local population. In the same vein of access and transportation, the members of the Board feel strongly that there is a need for improvement within the Ambulance service to meet the needs of these new services.

I reiterate that as a Local Service Board, we share the sentiment that all people in Rhondda Cynon Taf should have an equal standard of quality care, irrespective of where they live or the time of day; and we feel that scenario 5.2 outlined above is the best solution to create a sustainable and deliverable model for the future. 19/12/12 Cwm Taf The CHC endorses Cwm Taf Health Board’s engagement process on the Community Health SWP proposals. We feel it was robust and wide-ranging, including local Council communities, patients, the third sector, local authorities, staff and the CHC itself. CHC Members and staff were present at a significant number of these engagement events, including the two rounds of public fora. We feel that these events have given very good opportunities for the public to make their views known.

The CHC also welcomes the time and input from the Health Board in engaging with the CHC on the SWP issues at a number of full council and service planning committee meetings.

The CHC is happy that the 12-week period of engagement was sufficient and in line with the requirements of the Welsh Government guidelines on engagement and consultation, and that the questions and observations raised at the public meetings were recorded.

The engagement process has generated a frank and open debate about the SWP proposals; as well as the positive comments, there have been some areas of concern raised, which any consultation document will need to address. To a certain extent, this summary tends to focus more on the

66 issues and questions that we feel will need to be addressed and answered in consultation to enable solutions to be agreed. The CHC also held a workshop on 14 December to discuss the issues and feedback emerging from the engagement process and hear members’ own views and comments. Both are reflected in this summary.

As this was an engagement process and not a formal public consultation, the CHC has not come to a formal position on any proposals. What this response attempts to do is feedback and highlight what we have heard thus far from the public fora, and also highlight members’ own views and comments.

2 Options and the case for change Options: The CHC recognises and heard the considerable and extensive support for the 5.2 option, with Royal Glamorgan Hospital (RGH) and Prince Charles Hospital (PCH) forming a key part of the future shape of services. In particular, members felt three issues raised strengthened the strategic case for PCH:  The planned work on developing further the A465 Heads of the Valleys road  Any changes in Aneurin Bevan which involve a shift of activity towards the new SCCC  The potential demand from south Powys in light of changes in Aneurin Bevan Similarly, the feedback heard was that RGH provides critical support for both Rhondda Cynon Taf and for UHW when demand is high. These factors need to be taken into account in any consultation document.

At the same time, any consultation will need to be very clear about any other options outside those set out thus far, and the feasibility or otherwise of other options.

The case for change: There was significant recognition in the public meetings of the case for change and the significant pressures being experienced by health services in South Wales. At the same time, we recognise there are also some very strong concerns expressed about the robustness and permanence of the case for change – especially in the area of medical staffing – and this will need to be picked up through the work on the consultation.

We also recognise there were questions raised over whether the work has been done by the SWP to show either a four or five solution is sustainable in terms of services, workforce and finance. Again, the consultation will need to be underpinned by robust evidence in these areas.

2 Ambulance services

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The feedback indicated the considerable and critical role the ambulance services would have in supporting the options outlined. There were major questions raised on the capacity and capability of ambulance services currently, as well as their ability to support any future shape of services.

A number of specific issues were raised:  the ability to deliver the necessary travel times  the ability to respond to emergencies across South Wales  how to balance and deliver the needs of emergency and non- emergency transport  how to ensure effective public information and education about the appropriate use of ambulance services  the role and capabilities of ambulance services in clinical delivery  their policies for transporting to district general hospitals

Again, these are issues for the consultation document and the all-Wales review of ambulance services.

3 Access There were very strong concerns expressed on the need to ensure that patients would still be able to get timely access to the services they need, including:  The need to ensure that patients are able to get to definitive treatment in a timely fashion if services are more centralised  How will the geography, traffic and winter months impact on this?  Cwm Taf contains some the most deprived areas in Wales, with high levels of ill-health, and where access to services is a major challenge

4 Medical staffing This issue has aroused considerable discussion and debate, especially within the CHC. It is recognised that the issues and concerns around medical staffing and training represent a crucial element of the case for change. As a CHC we therefore feel this issue is a key one; we heard arguments both for and against the evidence in relation to this.

The issues raised include:  We recognise that there have been notable difficulties in medical recruitment and staffing in a number of areas, especially A&E  At the same time, there have been hard questions raised about whether the medical staffing issues are permanent, merely short term or possibly subject to change over time  The SWP needs to be able to demonstrate that the evidence base is robust. In particular, there needs to be a very clear and specific view expressed by the Deanery, Royal Colleges and BMA. As a CHC, we felt the current evidence coming from these bodies in relation to the SWP is very ambiguous 68

 Are there alternative recruitment or other options that are being, or could be pursued to tackle medical staffing problems over and above the options laid in the SWP? This was an issue raised in a number of discussions.

The consultation document will need to address these issues both clearly and explicitly.

5 Site capacity There was clear and very strong support in Cwm Taf for a five-centre model, which includes both RGH and PCH. There were questions asked as to whether the sites in the five option have sufficient space to develop what’s needed, the supporting infrastructure and whether there would be sufficient capital funding available; the cost of the SCCC will have an impact on this.

6 Relationship to other LHBs It is recognised that decisions and patient flows in other LHBs will have an impact. A number of clear messages emerged from the engagement process and member discussions:  This is especially the case in relation to Powys and the proposed changes in Aneurin Bevan. Members felt that there would need to be clarity and openness about the activity, patient flow and finance assumptions of the SCCC in Aneurin Bevan and whether they needed to be revisited in the light of the SWP  PCH has a strategic importance for South and Mid Wales, both for access and health need  RGH provides critical support for Cwm Taf and UHW – will UHW be able to provide the specialist services appropriately?  What are the pros and cons of the various options, especially in relation to catchment populations, accessibility and travel times?

At the same time, there was clear support for the need to ensure we look and plan on a more regional basis where appropriate, maintaining a balance between local accessibility and clinical safety and quality.

7 Service profile One issue that has been raised is that of the service profile and role of hospitals who are not one of the four or five designated centres. There are some issues that will need to be addressed in consultation:  What will their services include and how will they differ from current services?  How will their services change?  The impact on their ability to recruit, retain and remain sustainable

The CHC would certainly not want to see a position where recruitment

69 and retention of key staff at these hospitals falters as this could have a negative impact on the services these hospitals are able to provide, and potentially have a knock-on impact on services in other, larger centres.

Similarly, the CHC felt there was a need for the SWP to reflect more the inter-relationship of the major hospitals with other elements of the service, including primary and community care, as well as community hospitals and social care. We believe that these relationships – and the whole-systems approach - will be critical in delivering any future shape of services, focusing on increased support in home and community settings.

7 Capacity There was a strong recognition expressed of the significant pressure that all district general hospitals across South Wales are experiencing. There was also enormous appreciation of the excellent work staff do in managing these demands. At the same time, a number of key questions emerged:  Will these proposed change options serve to further reduce capacity to manage these pressures?  The need for reassurances are available to show there will be enough capacity to manage pressures in the options set out  Will patient safety by compromised or put at risk by accepting either of the four or five-centre solutions?

8 Patient safety and good outcomes These are critical and must be the key driver for change. Cwm Taf has major problems in terms of ill health and deprivation and the services need to reflect this.

There was discussion of the pressing need also to ensure that services are able to recruit and retain key clinical staff across the board – not just medical - but including nursing, therapy and other staffing. The CHC feels there is value in the whole systems approach to staffing and skills development, and recognises the work Cwm Taf has undertaken in this respect.

9 Conclusions The CHC welcomes the open, honest and frank discussions that the engagement has generated. There has been strong and healthy discussion, and I hope this feedback echoes this. The level of support for services in Cwm Taf and the future role of RGH and PCH in the region have been clear to see. Equally, the SWP options raise a number of issues and areas to be tackled in more detail, and this will be a task for the consultation document and process.

We recognise that there are potentially some complex and testing challenges to be faced. At the same time, we look forward to continuing

70 our work and dialogue with the health board in this process.

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DATE FROM WRITTEN RESPONSE WRITTEN RESPONSES RECEIVED BY ALL HEALTH BOARDS VIA SOUTH WALES PROGRAMME BOARD 15/12/12 National The NCT and AIMS have between them over 100 years’ service in representing the Childbirth needs of women using the maternity services in the UK. We have consulted our Trust and the members and wish to comment on the proposals in the South Wales programme, Association insofar as they specifically impact on childbearing women. for Summary. Improvements We have two main concerns: in Childbirth 1. that specialist hospital services for women in pregnancy and childbirth should not only be excellent, safe and available at a high standard at all times, but also within reasonable travelling time for women in labour. We understand the arguments for some concentration of specialist services, but are anxious to see that all women particularly those in the north of the region and Powys should not have to travel large distances. We urge strongly that the needs of women and their families are met in this respect by careful siting of services taking into account the geography of the area, transport, and social deprivation and its impact on health and ability to travel. 2. that while the needs of the minority of women requiring specialist obstetric care are highlighted in this plan, the needs of the majority of women without risk factors are not sufficiently addressed, and indeed may be marginalised. Large centralised obstetric units are not the most suitable places for low risk women to give birth (Birthplace Study, 2011) and so we will concentrate most of our responses on the effect of the proposed changes on the majority of women who will not need specialist obstetric or paediatric care whose needs are not directly addressed in the Plan. There is an opportunity here to radically examine how best the service can meet the needs of users, and at the same time implement government policy. Our recommendations are: 1. for midwife-led units, (MLUs) to be opened to replace each obstetric unit that is closed and additional MLUs to be opened in appropriate areas to ensure that facilities are available close to home for all women to give birth. 2. for dedicated home birth teams to be set up so that home birth is realistically available to all women who currently request it with suitable qualified and experienced midwives and with capacity to increase the home birth rate substantially in line with areas where excellent facilities already exist in line with Welsh Government policy, for example in the Porthcawl area, where home birth rates exceed 20%. Introduction. The South Wales Plan centres on the need to change the way hospital services are organised, and argues for the reduction in the number of obstetric units on the grounds that most obstetric and paediatric services can be provided better in concentrated larger units where specialist care can be grouped. The document

72 suggests ‘keeping the current pattern of local antenatal and community midwifery services to make sure that women continue to have good access to advice and support’ it continues, ‘Continuing to offer the options of birth at home or birth in midwife led units’ while ‘concentrating obstetric services in four or five units.’ Women currently do not have sufficient access to antenatal education or postnatal care from midwives and for many women the recommended choice of birth place is not a reality, for a variety of reasons. The plan crucially does not address the question of where potentially nearly 5,000 displaced women will go to give birth, (the number depending on which closures go ahead); neither does it take into account the rising birth rate. Our view is that, without a significant increase in stand-alone midwife led units, (MLUs), and much greater support both for them and for dedicated home birth services, women will have little choice but to give birth in fewer large obstetric units: this would inevitably result in increased intervention, lower satisfaction and unnecessarily high cost (Anderson 1999). The ‘options of birth at home or birth in midwife –led units’ assumed in the South Wales Plan must be increased and supported to make them realistic options for more than a tiny minority of women. Furthermore where MLUs are provided, they must be protected from becoming a target for closure when trusts are short of money. We argued for the retention of an MLU at Llandough when the obstetric unit was closed only to see it closed several years later in 2010 resulting in overcrowding in UHW and subsequent user dissatisfaction. (One of our anxieties would be the impact on the maternity service in UHW if the Royal Glamorgan were closed: we have noted the relatively high caesarean section rate in the Royal Glamorgan hospital and would predict that a large number of repeat caesarean sections would relocate to UHW if it were closed.) We would not support planning that raised the possibility that almost all of the large population of women of Cardiff and the Vale would be channelled into giving birth within the confines of UHW, even though a small proportion of them could access the on-site MLU. Normal childbirth should not be driven by the needs of a high intensity tertiary site. Transfer during labour. Birth cannot be scheduled and however much screening is done there will inevitably be emergencies during labour wherever birth is planned, and prompt transfer will become even more crucial if the number of obstetric units is reduced. Ambulance services therefore would become even more important and dedicated vehicles capable of transporting mothers and babies together are necessary before any closures take place. The economic costs. Determining the costs of a home birth compared with the costs of a hospital birth is difficult because of the problems the National Health Service has in assessing the costs of individual care and treatments. However, an ‘Economic evaluation of home births' by Henderson and Mugford (1995), in the National Birthday Trust Fund report, concluded that the average cost of home birth (including transfers) was lower than that of hospital birth because of the reduced need for interventions and for hospital stays overall, even after accounting for the transfers to hospital: ‘The better outcome alongside the lower expected costs per case lead us to conclude that the recommendations in 'Changing Childbirth' of a real option of

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a home birth for all women who want it would also be a cost-effective option’. More recently the Birth Place Study, (2011), put the costs of home birth at £1067, and birth in an OU at £1631,with births in MLUs at £1461 for an alongside unit and £1435 in a freestanding unit. At the moment, the home birth rate in the UK is less than 3% of total births and if the numbers of home births increase significantly then there is the potential for considerable cost savings. Torbay Hospital, providing a home birth service for a mostly rural community spread over 300 square miles, has a home birth rate over 11% (Department of Health 2007). Their successful planned home birth service with community midwives resulted in the Head of Midwifery being able to close a post natal ward, because of the reduction in women needing postnatal care. Chamberlain in 1997 noted that, if home births continued to rise, the home birth service would become increasingly cost effective and there would be an overall reduction in costs.

Government policy. For most women, giving birth is a normal physiological process not an illness. (House of Commons health committee July 2003) The House of Commons Select Committee on Health in its report published in July 2003 sets out government policy very clearly, We feel that the current delivery of maternity services which is led by acute general hospitals over-medicalises birth. Through the NSF PCTs should be given a lead role in ensuring that there is choice and community led services for women wherever they live. This recommendation has been echoed in every government report and policy statement on maternity in the last two decades, whether emanating from Westminster or the Welsh Government.

Views of women. It is sometimes argued that MLUs are unnecessary since low risk women might just as safely give birth at home: while the evidence shows that this is absolutely the case for second time and subsequent mothers, MLUs are at present the best setting of all for first time mothers. Women’s confidence in home birth has been shaken by the claims that hospital is safer which continue to be made in the face of clear evidence to the contrary (Birthplace Study 2011). Although the apparent link between hospitalisation and falling perinatal mortality has been shown to be coincidental and not related, it will take some time before the views of some GPs, grandparents and the wider society change in line with well evidenced government policy. In this climate the MLU is a very satisfactory compromise between the perceived safety of hospital in an emergency and the psychological advantages of the home environment.

Conclusion. We would like to see any reduction in the number of obstetric units accompanied by a switch towards midwife-led care for most women in out of hospital settings, (MLUs or home) with improved antenatal education and care and improved postnatal care provided by midwives.

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Surveys of maternity service users consistently find that women want care where possible in a community setting, provision for homebirths and birth centres, information to make choices, individual care and follow up support from midwifery specialists and an environment fit for purpose. The recommendations here are absolutely consistent with all of these and are extremely cost effective. The South Wales Plan contains suggestions for improved care for the small number of patients with the most serious health needs. We support this but could not endorse the Plan without reassurance that the proposals would not be to the detriment of the majority.

References: Anderson RE; Anderson DA, The cost-effectiveness of home birth. Journal of Nurse Midwifery 1999: 44(1) 30-5 Audit Commission, First Class Delivery: improving maternity services in England and Wales, 1997. Department of Health, Changing Childbirth, Part 1: Report of the Expert Maternity Group, DOH, 1993. House of Commons Health Committee: Choice in Maternity Services, Ninth Report of Session 2002-3. The Stationary Office Ltd. Volume 1: ISBN 0 215 01227 5; Volume 11: Oral and Written Evidence, ISBN 0 215 01242 9. Lester A. The argument for caseload midwifery. Midwifery Matters 2004;(103):9- 12. Welsh Government, A strategic vision for Maternity Services in Wales, 2011 Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study, BMJ 2011.

17/12/12 Chartered The Chartered Society of Physiotherapy (CSP) in Wales is pleased to play an active Society for part in the consultation being undertaken by Cwm Taf Health Board. The Physiotherapy profession is very proud of the contribution made by physiotherapists, technicians and assistants in the health board and considers them to be an important asset to the organisation. Therapists are well placed to play an integral part in the reorganisation plans across the health board and indeed across the whole of Wales. General comments The CSP cautions that it is very difficult to comment on reconfiguration plans when the documentation does not include financial or workforce analysis clearly demonstrating the affordability of the plans or that the Health Board has the staff to deliver on the plans and if it does not then detailing how it will train, develop, recruit and reward its staff so that they will be able to deliver on the reconfiguration plans.

Feedback from members on the consultation indicates that there is an acknowledgement of why change is needed. The challenge will be how the vision will be achieved and how change will be managed across the Health Board so that the public can clearly see that the reconfigured services are fit for purpose and staff are fully equipped to deliver this new vision. Comments to the professional

75 body include the concern that “it’s not what’s in the consultation – it’s what’s not in the consultation” leading to some apprehension about the plans.

The profession welcomes the frequently asked questions document and considers this provides much information for the public to help them understand the need for change and what the changes might mean for them personally. Specific comments on the document – Cwm Taf consultation document (p3) The CSP supports the vision of the Health Board to enable more people to be treated closer to home. Being a mobile profession, physiotherapists will most likely be available in local settings as well as providing services to people in their own homes. The ability for physiotherapists to independently prescribe will enhance this provision. The profession supports the fact that the Health Board is doing all it can to avoid patients coming into hospital unnecessarily. The CSP would have liked to see reference to reablement services so that a full picture is provided of how people can be supported to remain in their own homes. The Health Board needs to demonstrate that a continuum is in place between home and hospital provision with an emphasis on keeping people enabled and out of hospital avoiding unnecessary admissions. Early supported discharge schemes for stroke survivors, for example, can reduce long term dependency and admission to institutional care, and release hospital beds by reducing length of stay1. The CSP notes that the Health Board has plans to develop early supported discharge as part of its re-design of stroke care (p13). (p5) The CSP notes the significant challenges in terms of recruiting, training and retaining doctors in some specialities. The profession considers this will provide opportunities for the Health Board to use other professions in new ways. This is an opportunity for the Health Board to consider using Allied Health Professionals and advanced practitioners to lead services. For example, Physiotherapy-led fragility fractures and falls prevention programmes targeting older people can significantly reduce hospital admissions and costs. Each hip fracture avoided saves approximately £10,000.002. (p5) The CSP notes reference to seven-day working. This will not be achieved without additional resources. There are dangers in spreading current services that deliver over five days into a seven-day model. The Health Board will need to work with trade unions, professional organisations and staff very carefully in this area of any plans. (p21) The CSP notes the question raised as to whether a major trauma centre should be provided on one hospital site or as a collaborative service provided across two sites – University Hospital of Wales, in Cardiff and Morriston, in Swansea. The professions is concerned about capacity issues on both sites were they to be preferred as the single provider. However, the arguments, in relation to adequately staffing a unit, for one site are equally well made. Safety will be the overarching consideration although members have raised the issue of transport and access in relation to patients and their families should one unit be the ultimate decision. The South Wales Programme In the profession’s view, any changes must have:  Adequate and appropriate staffing – fit for purpose for the reconfigured

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service

 Improved transport – to include a fully funded air ambulance, access in emergencies but also improved access as the public will be travelling further for some services. Also, consideration of repatriation transport requirements

 Fully integrated and properly resourced community services – delivering on ‘Setting the Agenda’

 Improved communications – to include telemedicine, information management and technology accessed and utilised by staff

Decisions made in relation to the four South Wales Health Boards which have published the plan must also take into account the requirements of Powys and Hywel Dda. Their requirements will impact on those hospitals in the North and the West of the Programme area. The profession considers that ‘patient flow’ will be an important factor here and will ultimately influence the decisions made. The consultation provides no specific data for the public to make an assessment in this regard. Cwm Taf specifics (p13) Decisions made as part of the South Wales Programme will affect the services that are ultimately delivered out of the Royal Glamorgan Hospital and Prince Charles Hospital, Merthyr. It may well be, for example, that there is an opportunity to develop the Royal Glamorgan Hospital as the centre for rehabilitation. It is difficult then to comment on the best placement for the 24- bed acute and early rehabilitation unit or the eight-bed specialist stroke unit. The profession notes the information provided in the Frequently Asked Questions (p14) outlining the case for early supported discharge and rehabilitation at home. These developments will need to be properly resourced but will have an important impact on the use of hospital beds. The approach taken will have a direct bearing on decisions about Ysbyty Cwm Rhondda, Ysbyty Cwm Cynon and Dewi Sant. (p14) The CSP notes that the Health Board will be consulting in the future on palliative care services. Physiotherapy and other therapy services are integral to palliative care and the profession will want to be assured that the very best use of therapists in made in any changes or developments in services. Access will be critical in deciding where services will be delivered. (p14) The CSP supports the development of community based services. Telemedicine will be crucial here and integrated health and social care services will need to become the norm. The CSP notes the emphasis placed on services for the increasing number of people with dementia. This is welcomed. It will be essential to ensure that those with dementia are able to access reablement and community based services that enable them to remain supported in their own homes or as close to their own homes and communities as possible3. Concluding comments The CSP is pleased to play an active part in this consultation process and looks

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forward to continuing to be engaged as developments go forward. 17/12/12 Royal College RCS Wales Professional Affairs Board Response to Public Engagement regarding of Surgeons the South Wales Programme for NHS Service Configuration Wales Introduction Professional The Wales PAB of the RCS England has a keen interest in the configuration of Affairs Board hospital services in South Wales. We have no particular political or ideological allegiances and our comments are based purely on what we believe will provide the best configuration of services for the public and provide the best outcomes for patients. We have previously submitted responses to the Betsi Cadwaladr University Health Board and Hywel Dda Local Health Board public consultations supporting some aspects of their proposals but drawing attention to significant concerns that we have regarding their sustainability and service configurations in terms of short and long term patient outcomes and the welfare of the services in those areas (Attachments 1 and 2). The case for change has already been investigated and established by Professor Marcus Longley and we accept the arguments he makes. In addition to this the evidence for better outcomes for major and emergency cases of larger groups of surgeons working together in teams is also compelling. The urgency for these changes is particularly strong in Wales where the outcomes for health care and the provision of service in a variety of elective and emergency areas is poor and worse than in England. It is also the case that there is a particular challenge in Wales where the financial austerity being placed upon the health service is much more severe than in the other nations of the UK. In this regard we need to make the absolute best of the diminishing resources available to us in order to try to avert a catastrophic crisis in service provision. In our view the various professional health bodies have a responsibility to challenge this Welsh Government policy and to point out the inevitable consequence of this reduction in resource on a system that is already falling behind the health outcomes in the rest of the UK. Clearly the rurality of Wales needs to be taken into consideration when designing services. However this cannot be used as an excuse for allowing patterns of service provision to be maintained that are known to result in poor outcomes. The people of rural Wales deserve access to the highest quality and standards of services that can be provided and cannot be discriminated against on the basis of their place of residence in more remote communities. The answer to this dilemma is to provide networks of service whereby diagnostic, out patient and short stay services are provided locally by a group of clinicians working together. In this model of care only major elective and emergency services need to be provided in a major centre. On average this will only involve a few days out of a patients lifetime and the benefits in terms of governance and outcomes greatly outweigh any other consideration. The corollary of this is that improving access through investment in transport, ambulance services and road infrastructure need to an integral part of the plan.

Pathways

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The development and monitoring of pathways of care for surgical conditions is crucial. When these are properly described it is clear that large parts of the pathway, including presentation, special investigation, secondary care opinion and follow up can all be performed locally. It is only high-risk events like major interventions or invasive investigations that would be performed in a centre. As part of this planning the RCS in collaboration with the Right Care Commission, the Federation of Surgical Specialty Associations and NICE are engaged in a project to develop evidence based pathways of care for common and high volume surgical conditions and procedures. These pathways will form the basis of commissioning advice in England. They serve the purposes of ensuring that evidenced clinical standards form part of the process and that the postcode variation in provision of services is abolished.

Patient involvement The voice of patients is crucial in considering these changes. It is often the case that this is stated but that lip service is paid in practical terms. Wales is fortunate in having an active system of Community Health Councils that should be actively engaged in providing their wisdom when considering service change. The RCS Professional Affairs Board has representation from the Wales CHCs as a full board member and we would recommend that executive groups considering these issues would benefit from a similar arrangement. In England Patient Reported Outcome Measures have become a major feature of the NHS and are becoming integral to its currency. The experience of patients within our systems is not paid sufficient attention and should have equal status with outcomes. The collection of such information will serve to ensure that the changes that are delivered add value to our communities.

Clinically Led Change Clinically led change is often stated and again is rarely meant. In the current round of reconfigurations this needs to change. The forthcoming Francis report on the events in Mid-Staffordshire will set the tone and agenda for the NHS nationally for the next several years. Part of the outcome from this will be about patient experience, standards of basic care and the causes of the failures that were exposed. The patient groups involved have identified the lack of clinical leadership as the fundamental cause of the failures. As a consequence there has to be a degree of re-balancing of authority between the management agenda and the clinical agenda. In particular in Wales the Royal Colleges should be engaged in advising on clinical standards and service configuration.

Transport The changes in service provision described in the South Wales Programme should allow for the vast majority of clinical contacts and services to be provided locally as they are at present. Indeed networking and regionalizing services should result in increased local provision of specialized services. However because of the increased central provision of some parts of the service there needs to be clear

79 planning of the transport provision that will be required to meet the needs of patients. Because of the relative rurality of parts of Wales and the limited access to satisfactory public transport systems, there will need to be increased resources for the ambulance service, the patient transport services and consideration of accommodation for patients who need to visit central units for treatment and investigation. However there are many other parts of the UK and other Western countries with equally disparate populations and this should not be used as a reason for not providing the top quality services the people in Wales deserve. With a reduced number of emergency surgical units there will be a great need for improved emergency ambulance services and well described protocols for triage of patients and “drive past” arrangements.

Managing change The management of change is never comfortable or easy, however once the necessity to change is clearly identified as it is within the NHS in Wales, change should be properly planned and managed. There has been a tendency for change to be successfully opposed by groups with local and personal interests. In these circumstances change is delayed and can happen as a consequence of services collapsing or by other crisis, such as training imperatives. Change by crisis is unpredictable and can result in unintended consequences. We should endeavor to avoid crises occurring even though this has been the mode of effecting change that has been used in Wales recently.

Consultant Based Services and Recruitment and Retention of Staff in Wales There is a national drive to change the way services are delivered to be more consultant based. Trainee doctors will deliver less service work in the future and services will be delivered mostly by a variety of permanent staff. However a range of circumstances are currently combining to create what has been described as a “perfect storm” for medical staff recruitment in Wales. These factors include the fact that the core of consultant staff are from the baby boomer generation and are approaching retirement. This generation of consultants has a uniquely wide skill set and strong work ethic and replacing them like for like will be impossible. The recent changes to terms and conditions, particularly pension changes, mean that many of these consultants are likely to take early retirement. This has been confirmed by the local survey of consultant surgeons performed by the Wales Professional Affairs Board in January 2012. There is an increasing proportion of female trainees and medical graduates compared to previous generations and many will have families during their careers. We also face challenges due to the changing demographics of the population that is ageing but staying fitter into later life. The great bulk of surgical work involves the diseases of the elderly (cancer, degenerative disease, cardiovascular disease).

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With improvements in surgical technique and pathways we are able to treat a greater number of patients safely and it is clear that the demand for surgical interventions will increase. There is clearly going to be a gap between the supply of surgeons and the demand for their skills and we are not going to be able to recruit form the traditional overseas source of doctors. The Welsh Government medical manpower planners concur with this analysis. We believe this is very urgent matter that needs to be addressed.

Integrated Services In our response (attachment 4) to the Welsh Government Health Strategy, Together for Health, we agreed with and approved of the strategy of integrating Primary Care and Secondary Care under single organizations. This gives an opportunity to remove some of the boundaries that have developed between the two parts of the NHS. However this will not be done easily either in organisational terms, or in terms of re-designing pathways of care. So far the Health Boards in Wales have made little practical progress to effectively integrate the services and how they achieve this is unclear. This may involve bringing primary and secondary care clinicians under a single clinically led management structure. As part of that development consultants in primary care who are direct employees, as in secondary care, may be required. The final stage of this process will be to increase the integration of health and social care, which possibly represents an even greater challenge.

Clinical Standards and the Centre for Surgical Commissioning Advice The RCS and the surgical Specialty Associations has a pivotal role in producing Standards for surgical practice These have been influential in guiding the Health Boards in Wales and the South Wales Programme with regard to Emergency Surgery, Trauma and Vascular Surgery in particular. The RCS is now involved in a major project in association with the Federation of Surgical Specialty Associations, the Right Care Commission and the National Institute for Clinical Excellence. This project is to develop a Centre for Commissioning Advice for Health care commissioners in England. It will develop clear, evidence-based guidance for the commissioning of surgical services and procedures. Initially it is concentrating on producing guidance on the common and high volume procedures in a variety of specialties. In England this work will result in the abolition of Post Code lotteries of health care provision and will have powerful financial levers attached. This methodology has already proven its power and worth in the establishment of the Level 1 Trauma Centres in England. The South Wales Programme should consider how this work and standard setting could be incorporated into the establishment of services in Wales.

Care Quality Regulator A fundamental difference between NHS England and NHS Wales is the regulatory and scrutiny frameworks. In England there are several external bodies charged with responsibility for various aspects of scrutiny of quality and outcomes,

81 including Monitor and the Care Quality Commission. Patient Safety is of paramount importance particularly under the shadow of the Francis Enquiry into Mid-Staffordshire. In Wales where we have poor outcomes compared to England and demonstrable gaps in service provision it is vital that we have a properly established Care Quality Regulatory framework. At present scrutiny of standards is primarily the responsibility of each individual Health Board. We believe this is not acceptable.

Leadership There has been much discussion about the changes that are planned under the South Wales Programme being led by clinicians and clinical perspectives. Its is essential that the professions are involved in debating and describing the change that is required if it is to be acceptable to the public. Consultants are in a unique position to provide such leadership. They are the most stable and committed group of staff to whom other staff members often look to for leadership. The RCS is well regarded by its constituents in Wales and survey work indicates significant support from consultant surgeons for the RCS to represent their views and play a significant role. The Welsh Government and its officers also have a key role here. Health is the major part of the devolved Welsh Government budget. We understand that this budget is under extreme pressure however in England, Scotland and Northern Ireland there is a planned small increase in the Health budget over the next period of time. In Wales there is a planned large reduction in the Health budget. The Welsh Government cannot expect the professions not to highlight this alongside the poor outcomes that we point to as the basis of the case for change. This is also an aspect of leadership.

Trauma The RCS has contributed to the discussions and debates regarding the provision of trauma services in South Wales. We agree with the planning that is taking place to have Trauma units collaborating to produce a service for the whole of South Wales based on the services in Swansea and Cardiff. Between these two sites all services are provided. We also agree with the principles surrounding the pathways to rehabilitation of patients without which the front-end services will fail to achieve satisfactory outcomes.

Primary Care Integrating primary and secondary will result in fundamental changes in the nature and work of both current sectors. Already there is a clear trend to minimize in-patient lengths of stay for surgical patients. Already more primary care based pre-operative assessment, patient optimization, referral pathways, enhanced recovery programmes and early discharge is having a profound effect on community services. What has not so far been effectively addressed is the educational needs of primary care and community staff to provide the skills to manage these patients.

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We have had some preliminary discussions with the RCGP regarding this. It would be of great value for the NHS in Wales to undertake an initiative to address the issue of education of community teams to allow better integration with secondary care surgical services

South Wales Programme Options The configuration of services across South Wales is clearly a contentious subject. We agree completely that there needs to be major acute sites based in Newport, Cardiff and Swansea. We also agree that there needs to be provision of acute services in the area but we do not have a view where this would be sited. We cannot see that it should be on more than a single site. If it would be of help the PAB could perform a visit to these sites to look at current services and facilities and examine the plans that exist in this regard. We have concerns that change should not wait until the new facility that is planned for Cwmbran is available. There needs therefore to be a clear interim plan developed for the Gwent area. The proposals will result in fewer emergency sites. However it needs to be emphasised that the other hospitals will play an equally important role in providing high quality planned care for day case and short stay services. It has long been proposed by the RCS that separating emergency and elective surgical services can provide benefits for both. More important than sites is the quality of the secondary care services and how these relate to community and tertiary services. There are also several areas of surgical practice that need to be configured on regional or all Wales basis. These include Burns and Plastic surgery, pancreatic and hepatobiliary surgery, cleft lip and palate surgery, specialist Paediatric surgery and Neurosurgery on an all Wales basis. Cardio thoracic surgery, Major Trauma surgery and vascular surgery amongst others should be organised on a regional basis. It is also the case that specialist services in other specialties will be regionally provided such as upper GI cancer surgery, Urological cancer surgery, maxillofacial cancer surgery, vitroretinal surgery, cochlear implant surgery and others. What is important here is to establish these services formally as regional services and provide appropriate support in terms of management and administration, data collection and registries. This will require clinicians and managers from across the current Health Boards to collaborate and contribute in terms of personnel and financial resource to make these services work. There should be no impediment to these changes as a consequence of the flow of resources. It is our managerial colleagues’ primary responsibility to ensure that this is so. Similarly it is our responsibility as clinicians to ensure that personal preferences and the maintenance of clinical empires do not impede change. The RCS supports colleagues working more flexibly than has hitherto been the case, particularly in forming teams that support clinical governance. However we are also supportive of the break down of institutional barriers that should allow

83 consultants to work across Health Boards and have different aspects of their practice based on different sites. This is particularly important when designing networked services and specialist support for smaller units. On Behalf of the RCS Professional Affairs Board in Wales Colin Ferguson MB ChB FRCS MCh RCS Director of Professional Affairs Susan Hill RCS Council Member for Wales 17th December 2012

Attachment 1 Public Consultation Response to Betsi Cadwaladr University Health Board Regarding Proposed Configuration of Surgical Services The Royal College of Surgeons (RCS) through its Professional Affairs Board in Wales has been involved in discussions surrounding the configuration of surgical services in Betsi Cadwalladr University Health Board (BCUHB) since the beginning of the process. A visit was conducted in April 2011 during which evidence was taken from a wide range of personnel including consultant surgeons, managers, medical managers, nursing staff and junior doctors. This evidence was supplemented by a survey of opinion taken from the consultant General Surgeons across the Health Board. The Professional Affairs Board brought to the debate the RCS policy documents regarding Emergency Surgery Services, the Association of Surgeons documents regarding configuration of surgical services and the Vascular Society document regarding the Provision of Vascular Surgery Services. A report was written by the members of the visiting team to inform the deliberations taking place. This report is available on the BCUHB website http://www.wales.nhs.uk/sitesplus/861/opendoc/173045&16B41783-E785-D5ED- 3B32FB361B1A33DE The views expressed in this report are based upon the best opinion and evidence available. It weighs the issues under consideration against the Standards being applied elsewhere in Wales and the UK and favoured by the profession. Intrinsic to the RCS report was the statement that the status quo was not in the best interests of patients, staff and the quality of surgical services provided in North Wales. The RCS participated in the Health Board’s Unscheduled General Surgery review process over an extended period. This process has been comprehensive, transparent and inclusive and was at an advanced stage in producing options for consultation. The work of the BCUHB managers has been very impressive and those involved are to be commended. It is our opinion that the outcome of this process, had it been allowed to conclude,

84 would have resulted in the Health Board consulting on this crucial clinical area. The proposal of the Health Board to continue to provide emergency general surgical services on all three sites is fundamentally at odds with the views of the RCS and the PAB. We cannot support these proposals which we believe are unsustainable and not in the interests of surgical standards, staff, training and most importantly patient care. We support the proposal to centralise vascular surgical services onto a single site. On Behalf of the RCS Professional Affairs Board in Wales Colin Ferguson MB ChB FRCS MCh RCS Director of Professional Affairs Susan Hill RCS Council Member for Wales

Attachment 2 Royal College of Surgeons Professional Affairs Board in Wales Response to Hywel Dda Local Health Board Public Consultation on Service Reconfiguration

The RCS Professional Affairs Board supports and endorses Hywel Dda LHB’s proposals to improve the quality of service and integrate services between the various parts of the Health Community. This is undoubtedly the correct approach and we would hope that this is successful. The documentation is however somewhat light in terms of the detail as to how this will be achieved. We would like to point out that the Statutory Professional bodies, like the RCS, who are responsible for setting professional standards have not been formally incorporated into the planning of these proposals or the consultation process. The RCS agrees with the strategy of focusing specialised services in fewer centres. However we are concerned that only a minority of respondents agree with this strategy, and therefore the case needs to be made more clearly with the public if the proposals are to be accepted. We support the proposals regarding emergency and non-emergency transport as this is going to be vitally important in developing safe services in a rural setting. The proposals mention an increased role for primary care in pre-operative assessment, enhanced recovery, diabetes care and developing GPs with a special interest. The RCS supports these suggestions and offer that we can assist in developing plans and offering educational support for this agenda. The proposals for emergency services present two options: a major change with centralisation of services into with nurse led services in the other hospitals, or the status quo with all services on all sites. We do not believe the status quo is sustainable or safe. These options are presented in such a way that

85 the consultation will most likely result in a positive result for the status quo option. We do not believe this can be delivered and therefore we do not support the status quo option. The RCS visited Bronglais hospital recently to discuss the configuration of surgical and other services. We gave approval for the appointment of general surgeons based in Bronglais Hospital with the proviso that commitments were made by the organisation regarding patterns of work and service configuration. It was agreed that we re-visit to evaluate progress on these matters and we suggest a date is set for this. Some of the proposals you have made appear to be independent of the work being undertaken under the auspices of the South Wales Programme. In our opinion the plans to develop some services independently of neighbouring Health Boards in a variety of areas are not cogent. For instance percutaneous coronary intervention for heart attack, vascular surgery and surgical services for patients with stroke are best delivered on a regional basis. It is stated that the proposals being made are dependent on the Health Board’s ability to recruit and maintain sufficient number and calibre of specialist workforce. This can only be achieved by configuring services collaboratively across Health Boards such that modern practice and current standards can be implemented. It is only by doing this that high calibre staff will be attracted to Hywel Dda Health Board. The Health Board should recognise this and draw up plans in collaboration with neighbouring organisations for the benefit of all patients. Colin Ferguson MB ChB FRCS MCh Royal College of Surgeons Wales Director of Professional Affairs Sue Hill Council Member and Chair Welsh Board of the Royal College of Surgeons

Attachment 3 This document will be forwarded once ratified by RCS Council

Attachment 4 (next page)

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18/12/12 Royal College The Royal College of Paediatrics and Child Health, and the Paediatric and Child of Paediatrics Health National Specialty Advisory Group welcome the opportunity to respond to and Child Cwm Taf Health Board engagement document on the South Wales Programme. Health The RCPCH has been in the vanguard in advocating safe and sustainable paediatric services in Wales, and has argued that the twin challenges of the implementation of the working time directive and changes to medical immigration would limit the viability of the current model of care. The implications and potential solutions are

87 outlined in “Modelling the Future 1, 2, and 3”. More recently the RCPCH has published “Facing the Future: Standards for Paediatric Services” which outlines 10 minimum standards for acute, general paediatric care. These standards were agreed by the RCPCH Council and therefore are College endorsed and are intended to support safe and sustainable quality paediatric services for children and young people. Each standard is accompanied by an explanation of what the standard aims to achieve, and how the standard was agreed. We also believe that all infants delivered in consultant led obstetric units should have access to a trained paediatrician for resuscitation. Facing the Future is primarily a standards document, but it is the College’s view that there is a need for configuration of services with concentration of inpatients paediatric services on fewer sites in order to achieve the standards with the paediatric medical workforce that we feel is attainable. Facing the future proposes a largely medical workforce model, and we would accept that for many paediatric services it is important to recognise the multi-professional nature of the workforce, however in our experience it is extremely difficult to replace the experienced middle grade paediatrician with another health professional. Although at the more junior tier this may be possible, at the middle grade tier there are very few examples of non-medical staff having the necessary skills for role substitution.

We understand the complexities of geographical considerations in South Wales and recognise that all inpatient units in South Wales have arguments to support their current existence. However we also recognise that there are insufficient middle grade trainee doctors to deliver the “Facing the Future” standards at all inpatient units Therefore we welcome the consolidation of paediatric high dependency care and neonatal level III care in order to provide a safe and sustainable service to children in South Wales. As such the College would support the SWP scenario 4 proposal of three main 24/7 consultant led units, supported by one other hospital. We are also cognascent that there are unlikely to be sufficient trainees to maintain middle grade support for 3 level III neonatal units, and that there is debate over whether South Wales can sustain 2 or 3 level 3 units. We believe that 2 units are sustainable in the longer term, and that to maintain 3 units will require different working practices probably through consultant delivered services. Any reduction in the number of inpatient units must be offset by improving local urgent and emergency care systems. This must be also be complemented by development of community children's teams integrating different professional groups and organisations. We believe that the reconfiguration of paediatric services should be determined by the needs of the local population and the resources available, and that Cwm Taf Health Board and the South Wales Programme Board are best placed to make these difficult decisions. It is important to recognise the philosophy of paediatric care is that children

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should be treated in their own homes or as an outpatient whenever possible. There are many examples in the where short stay paediatric assessment units have been very successfully developed so that, even when an inpatient paediatric services do not exist on the site, many of the local children can be treated in their local centre. The development of community children nurses is also very helpful in maintaining locally wherever possible. Incumbent in all such schemes are the need for improved transport services, a comprehensive community paediatric nursing service and the availability of local enhanced primary care services. This will have significant financial and political cost. The RCPCH recognises this transformation will have significant costs, resources, and planning, but a whole system approach will be required to develop appropriate services for children and families. Our priority will be to ensure that the services proposed are safe, of the highest quality, and sustainable. We do not believe that standards of care should be diluted to maintain ease of access and that safety and quality must be the priorities. Only through active collaboration driven by a real desire to continually improve will we achieve better health for future generations of children and young people. 19/12/12 NHS staff We write to comment on the proposals relating to configuration of Paediatric and (neonatology) Neonatal Services in South Wales. We are Consultant Neonatologists working in the tertiary neonatal unit at Singleton. We wish to comment specifically on the configuration of neonatal services.

The neonatal service faces many challenges at present. Already there are severe recruitment difficulties and gaps on training rotas caused by unavoidable factors (mainly the European Working Time Directive, maternity leave and less than full time working in a largely female workforce, and restrictions on immigration). These gaps put pressure on the existing trainees and shorten their time available for training outside of their clinical duties. The quality of neonatal training must be maintained, or there will be a further decline in number of trainees wanting to train in Wales, resulting in a worsening cycle of vacancies and poor training. There is general agreement among those involved in training that Wales is also becoming unattractive for doctors as a place to train because of its geography and the large number of small hospitals compared to England and Scotland. Trainees in general benefit from working in large units where they have plenty of high quality training and experience, and are not put under pressure by vacancies on rotas. Furthermore, there are plans to reduce the number of neonatal trainees over the next few years by the Wales deanery in line with Royal College and other workforce planning recommendations.

Safe and sustainable rotas must be maintained in order to ensure that the quality of service to the babies and their families does not fall. If there are insufficient middle grade doctors, alternative approaches of using consultants as resident on- call or using advanced neonatal practitioners (ANNPs) to staff the rotas are possible, but these options are very expensive. ANNPs would have to be

89 developed over several years before they could assume this role. The costs of providing this care would escalate.

In view of all these pressures on the service, a radical change needs to take place in the provision of neonatal services. We are forced to conclude that the only model that can meet the demands on the service in South Wales is a two tertiary neonatal unit option in South Wales as opposed to the current three. This approach would have several advantages:

 Middle grade and training grade numbers could be concentrated in two tertiary units making rotas sustainable.  At present both Swansea and Newport experience significant peaks and troughs. This has been demonstrated in the work undertaken by Dr Drayton, Network Lead in the Neonatal Capacity Review where the number of intensive care, high dependency and special care cots projected to be required for each tertiary unit varies dramatically for each reiteration of the capacity review. Peaks make it difficult to run a safe service and find cots for babies. Troughs are periods of under activity when middle grades and junior neonatologists in training do not have the opportunities they need to develop their skills, and nurses are underemployed. Reducing the number of tertiary units to two would reduce these fluctuations in care, and improve training opportunities and efficiency of the service.  A concentration of neonatal intensive care in two centres as opposed to three would mean that further developments in supporting services could be pursued to enhance the quality of care to the babies. These would include enhanced specialist Perinatal services, radiological cover, better support from Pharmacy for preparation of sterile infusions (CIVA Service), etc.  The concentration of high risk obstetrics into fewer centres would enable consultant obstetric cover to the Labour Ward to be enhanced ie. the number of hours covered to be increased in line with the RCOG recommendations in the tertiary centres. This might reduce adverse obstetric events that result in poor quality outcomes and litigation.

There are approximately 27,000 births per annum in South Wales. It is recommended that each tertiary unit should have at least 10,000 births per annum in their catchment area. Even with two tertiary units the number of other neonatal units needed in South Wales would be few.

Whilst we recognize that the neonatal unit the Royal Gwent hospital has given excellent service and training over the years, it is very close to Cardiff, and the provision of a third tertiary unit so close to Cardiff is simply unnecessary. Cardiff and Swansea represent the logical and reasonable choice of two tertiary units for South Wales.

The enhancement of the units in Swansea and Cardiff would allow reasonable geographical access to the population of South Wales, and would provide high

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quality training in large well equipped and well staffed units. Trainees could rotate between these units easily. Training, as well as service, could be coordinated well between the units. We would propose that just two level 2 units eg. one in Gwent and one in the Mid Glamorgan area would suffice along with a level 1 unit in the Hywel Dda area. We would favour Prince Charles Hospital in Merthyr as being the level 2 unit for the Mid Glamorgan area. This would form a triad of units joined by the A465, the M4 and the A470. Access to Swansea from Merthyr along the A465 is easy so the transfer of babies between Merthyr and Swansea would be straightforward. These could be supported by midwifery led units in other locations if desired.

In order to provide this model, neonatal and labour ward capacity would need to be increased in the two tertiary units. Cardiff is already very busy and does approximately as much intensive care as Newport and Swansea combined. Neonatal capacity could be easily increased in Swansea. Indeed the refurbished neonatal unit when complete would allow for care of 19 critical care babies (intensive care plus high dependency) at any one time. Another ward area would need to be provided for special care and transitional care. It is anticipated that this could be provided relatively easily. Further work needs to be undertaken to increase the obstetric throughput to ensure that all high risk deliveries could be accommodated.

Ultimately the plans to move the neonatal and obstetric services to Morriston in a timescale of approximately 5 years would offer further opportunities for developing the obstetric and neonatal services in Swansea to support the South Wales area. The move to Morriston will also allow co–terminosity with a number of specialist adult services necessary to support the pregnant or newly delivered mother eg cardiology and cardiac surgery, renal, respiratory, intensive care etc to provide the optimal obstetric care alongside excellent neonatal care.

In summary, the further centralisation of neonatal tertiary care is desirable and achievable. If this opportunity is lost, services may become very difficult to sustain in all three existing tertiary neonatal units in South Wales. Quality of training may suffer. Furthermore the quality of care delivered to the babies and their families will also decline as rotas become difficult to staff. Swansea is ideally placed to further develop as a tertiary neonatal unit to support the South Wales population with equity of access. 19/12/12 British Many thanks for the invitation to respond to the South Wales Programme Board Pregnancy engagement process. British Pregnancy Advisory Service (BPAS) is a sexual and Advisory reproductive health charity that provides services, including abortion, Service contraception, STI screening and testing, sterilisation and vasectomy. Last year 96% of our work was commissioned by and carried out on behalf of the NHS. As part of your consideration of the challenges facing obstetric care we suggest that you consider termination of pregnancy services within the scope of the consultation and address how reforming how abortion care is delivered in South Wales might ease the burden and free up resource within obstetric services. Every year BPAS sees approximately 3,000 Welsh women for consultation and

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treatment for termination of pregnancy. Many of these will be at our Cardiff clinic, which this year has seen 1,000 women giving a Welsh address. Our experience as an independent specialist provider of healthcare means we are well placed to address how services like ours might help address the challenges faced by hospital services in South Wales. Improved care for women You note the trend in healthcare for services to be located in convenient places for patients abut also for patients need to the treated by ‘the most experienced healthcare staff’ in that particular field. Commissioning services like BPAS to provide holistic abortion care would in fact address both these concerns, as our staff are experienced experts who have chosen to work in what can sometimes be a highly stigmatised area of care, and yet we also have the capacity to open localised units to provide high-quality care in locations accessible to patients. This is a model BPAS already works to in England and Wales and we are confident that expanding provision of local units for contraception, early medical abortion, and early surgical abortion services would be beneficial in addressing the challenges faced by NHS services in the South Wales region. Improved use of NHS resources Additional benefits to the health system in South Wales if it were to better utilise provision of sexual health services by commissioning third sector providers also include the freeing up of hospital resources, including theatre time. As indicated by the Royal College of Obstetricians and Gynaecologists abortion is a very safe procedure. Women increasingly present requesting an abortion at under 10 weeks gestation and are therefore able to opt for early medical abortion or ‘the abortion pill’ method. Services such as these can be nurse-led, operate out of small units with minimal need for medical equipment and as such can be set up more readily than units requiring surgical facilities. Early medical abortion is increasingly favoured by women, saves the NHS money as it is a more cost-effective service to deliver and has more positive outcomes for women as they are able to be seen and treated earlier in pregnancy. Increasing provision of such units, by commissioning organisations like BPAS to run them, would improve care for patients as well as reducing the burden on hospitals by outsourcing care that does not need to take place in a hospital setting. Fundamental to all NHS care, including that commissioned out to third sector providers, is that patients receive timely access to high quality services that meet their needs. BPAS believes that our charity meets these objectives and that we can support the NHS in South Wales to deliver abortion care. We hope that these comments are of interest and that we might further discuss and feed into the consultation process as it looks at best using current resources to meet the needs of patients in South Wales. Please do not hesitate to get in touch if we can provide any more information 19/12/12 South Wales The SWP paper was published in September 2012 and both sets out a range of Cardiac issues that point to the need to change the way some hospital services are Network organised and also goes on to describe scenarios that concentrate some ‘inpatient’ services (specifically ‘women in pregnancy and childbirth, newborn babies, infants and children, people who are injured in accidents or need specialist medical help in an emergency and people who need emergency ambulance and

92 paramedic services’) in South Wales. The impact of these scenarios on cardiac service delivery does not seem to have been addressed in this paper although it is possible that this will form part of the individual HB responses. In addition, the lack of detail in the current SWP plans hinders speculation and judgement on the implications for cardiac services. Soon after the publication of the document, the SWCN sought to explore the best means of addressing the potential impact on cardiac services. Following discussion between yourself and Sue Wilshere (lead manager SWCN) the lead SWCN clinicians were asked to put together a clinical response to the SWP from a cardiac services perspective. This response has been put together following consultation with lead network clinicians and informal discussions with other clinicians in the network, it does not per se represent the consensus view of clinicians across the network. As SWCN lead clinicians we believe that an opportunity to consult formally with the wider cardiac network with input from the SWP leads in a focused workshop is important if true clinical engagement is required. Given the breadth of the changes described in the SWP, we also wonder whether this would provide an opportunity to consider other scenarios that may be particularly relevant with regards the delivery of equitable, high quality and sustainable specialised cardiac care. The majority of acute cardiac emergencies present to casualty, either via ambulance and paramedic services or as self-presenters. In general, fewer cardiac emergencies present following a GP referral. It follows that all the scenarios described in this paper will create,  hospitals with major A+E centres that will have to take the majority of acute cardiac emergencies, and

 hospitals with minor A+E units that will take fewer cardiac emergencies than they do currently.

The SWP will therefore have major implications on the structure of cardiac services (and acute medicine) in South Wales. The hospitals with major A+E centres will require adequate cardiac staffing and infrastructure to support uplift in demand for acute cardiac care, whilst conversely those centres that will downgrade to have minor A+E units may require less. There will therefore need to be appropriate levels of cardiac staff (medical and allied health professional eg cardiac physiologists, cardiac nurses) in the major A+E hospitals with as a minimum 24/7 Consultant Cardiology availability. However, currently, only 3 hospitals in South Wales provide 24/7 on call cardiology services (UHW, Morriston and Royal Gwent). To expand cardiac services in the hospitals with major A+E will require either expansion within the relevant HB or may involve movement of staff (and equipment) across HB boundaries (potentially moving from hospitals whose A+E will downgrade to receive GP referrals only). The transfer of patients from one hospital to another is a challenging current problem. Creating a small number of major A+E hospitals will place an even greater burden on the ambulance service, with a greater number of patients requiring transfer from the major A+E units to their local hospitals to have further medical care prior to discharge. All the scenarios would need to address the

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increased demand on the ambulance service. To summarise: 1.SWP has major implications for delivery of acute cardiac (and acute medical) services – these are not addressed in the paper. 2.The major A+E units described in the paper will need an uplift in cardiac capacity (this will be more substantial in those centres that currently have no separate cardiac on call services). 3.Ambulance support of the SWP has to be addressed. 4.Given the significant impact that the SWP will have on acute cardiac services (with a knock on effect on elective cardiac services) we would strongly advise that any further discussions relating to the development of the SWP has cardiac involvement. 10/01/13 Royal College The Royal College of Midwives (RCM) is the professional association and trade of Midwives union representing 95% of all practicing midwives in the United Kingdom. The vast majority of midwives work within the NHS, and the RCM is recognised in every Trust that provides a midwifery service.

In responding to this paper, the RCM has consulted widely with its members and seeks to represent their views in commenting on the consultation ‘Matching the best in the world, challenges facing hospital services in South Wales’.

Our response will deal mainly but not exclusively with issues related to maternity care.

The RCM provisionally agrees that having fewer consultant led units (CLUs) is a reasonable idea, provided that the following two conditions are met. Firstly, the lost CLUs must be replaced by midwife led units (MLUs) and secondly the remaining CLUs must achieve a 24/7 consultant presence. However, the achievement of a 24/7 consultant presence could create additional difficulties, as has been seen in England, where, due in part to the cost involved, achieving a 24/7 consultant presence in some units has been unachievable.

The RCM finds the discussion about improving units and creating birth centres positive; however, we believe that there needs to be further analysis into the cost of the suggested upgrades. Due to the anticipated need for extra capacity in the remaining CLUs (in the event of the closure of some units), as well as the necessary creation of MLUs, in those cases where CLUs have been lost, the cost involved in these changes will be an important factor. This lack of analysis makes it difficult to comment on which of the suggested models would be preferable.

The report places a large amount of emphasis on medical intervention rates. Medical interventions are certainly a necessity in some situations; however, it is widely accepted that the number of interventions could, and should, be reduced. This is relevant here as the RCM believes that this reduction could, in part, be achieved by designing and configuring services appropriately, particularly within the obstetrics, but also across the board. The focus throughout the majority of the report appears to be on high risk care, and whilst the RCM fully appreciates that

94 this is an important area for concern, the majority of births are considered low risk, a fact which is later acknowledged within the consultation.

There are currently very high rates of medical intervention across maternity care within Wales, for example, caesarean rates rise as high as 35% in some areas. The benefits of reducing the rates of medical interventions are manifold, including advantages for patients and medical staff, in addition to economic benefits. This is relevant here due to the RCMs belief that this can in part be achieved through reconfiguration of services, and should be taken into consideration when analysing the benefits of each of the suggested models.

The main consideration when considering any change in the structure of patient care should remain the safety of and access for the patient, a fact which the report certainly reflects. This is partly why the RCM highlights the need to create MLUs in place of lost CLUs. Access is also of great importance when considering the provision of high risk care, and this must be examined closely when looking at adopting one of the proposed models.

The preferred model would be one which provides good access for all women whether high or low risk, taking into account all of the issues highlighted above.

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DATE FROM WRITTEN RESPONSE WRITTEN RESPONSES RECEIVED BY CARDIFF AND VALE UNIVERSITY HEALTH BOARD 5/10/12 NHS Staff member If this truly is to be a complete South Wales project then Hywel Dda should also come aboard this project.

All outlining UHBs (compared to the central medical school training UHBs centres in Swansea and Cardiff) are really going to be disadvantaged and some will fail in a few years unless there is a real link up and co-operative process which there seems to be in this SWP plan apart from Hywel Dda.

What could also be considered is peripatic training of junior doctors with training programs controlled by Swansea and Cardiff medical schools but with large period of work placements in outlying UHB hospitals. If this was devised properly with good co-operation and giving really good training to junior doctors (it would make South Wales attractive to come to work for training junior doctors) and also give good service to all UHB hospitals and patients

The one UHB which is outside this project within South Wales- Hywel Dda could have real major staffing problems in next few years which would have a knock on effect for rest of UHBs in SWP as patients from there will still have to be seen and treated.

16/11/12 Third Sector General Comments engagement  There was consensus that people would rather travel to see specialist workshop report doctors, but there are a number of considerations necessary to make this work.  It is difficult to fully comment on options, as they are options only at this stage and options and views expressed elsewhere affect Cardiff and the Vale.  We need a range of genuine options.  Need to emphasise that changes are based on improving quality of services and reassure patients and the public that this is about better services not less or cutbacks.  Need to emphasise that changes relate to specialist services only.  Infrastructure, quality and capacity must be considered.  Perception will be about cut backs. People don’t like the argument that the Health Service haven’t got enough doctors and will see this as a watering down of services. Must ensure that people know it is not about taking things away.  Will this cut down waiting? Needs to be explained to service users.  Need to be less precious and parochial about maintaining local hospitals as we need to focus on quality over quantity  The impact on staff needs to be explored.

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Try to keep what comes out of SW Programme in place for years to have stability.  Perception is that we want things to work efficiently, but we don’t like service change.  Agreement made that high care services would need to be centralised as long as local care remains for less critical care  Clinicians like to be specialists – hyper specialist stuff gets lots of attention whilst other areas don’t.  Community local services need to be available for minor care.  Must explore third sector sector involvement, (example of Crossroads Powys bed saving transferable model). Questions  Why is the Health Board not recruiting enough doctors? Is there anything we can do to attract staff?  Is there evidence that support the 4/5 scenario?  Where is the ‘elsewhere’ where services are delivered? Suggestions  Patient stories – good/bad experiences – use these.  UHB to speak to AMs and local councillors – this is happening.  Need to engage with media and ensure positive examples are highlighted – use good case studies. A&E/Trauma Trauma Centre  Is there a political drive for a Welsh trauma centre and is it based on evidence and best service?  Critical mass means that without a South Wales trauma centre, services in other areas, i.e. , would be negatively affected.  Should there be two trauma centres, in case of a large scale emergency?  How would the UHW trauma service cope with an extra 50 patients per year?  Improve the helicopter service. A & E  There is a lack of clarity around what GPs/minor injuries/A&E actually offer.  Start by making sure that A & E works properly and consider if there should be different types of A & E.  What is the scope in A&E in UHW for times of large emergencies? How will the options listed in the SW Programme affect this?  UHW is very busy and no space – what do you have to move out to make space?  There will be an impact on staff as it might mean people transfer to different areas.  Local services need to work and support centralised services. Primary Care services need to support as well  There is an important role for the third sector in supporting

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community care out of A&E (i.e. on discharge). Go into local communities and unite with the third sector.  It is important to communicate what is best choice as some people will go to the wrong place (i.e. Choose Well). Get signposting sorted out and have social care pathways for people don’t have to go to A & E.  Need to educate on speed and quality over quantity.  There is a lack of trust in the current Health Board and in primary care and this needs to be built up and improved.  Need to explain how services will improve and the impact on service users’ recovery rates.  Put in place culture change to make this specialism more attractive to staff. Obstetrics  Units will need to be funded/expanded to support increased intake: Cardiff takes in from other authorities and transfer fees should follow treatment.  Family visiting is important. Transport, accommodation and financial support may be needed. We need to consider community transport schemes from public and third sectors.  There will be travel issues in terms of time taken to get to hospital, enough ambulances and demands on services. How can we guarantee a better service when often distance to service is an issue for some? Need to take into account times of bad weather. Welsh Ambulance Service plays a vital role  Could volunteers support new mothers?  Has demand reduction been explained?  Need to look wider than South Wales as need to consider extra flows of patients coming into Cardiff and Vale as a result of changes elsewhere, i.e. in England  Are we being over cautious and less tolerant of risk?  Issues regarding women in the Vale – need to be flexible, transport issues.  There is confusion about choice and women’s rights to choose.  Confusion about crossing healthcare boundaries. We need to overcome artificial boundaries.  Reasons for C-Sections may be standardised in this process meaning more comparative service  Is there any feedback about change in Midwifery Led Unit from Llandough to UHW? Use patient stories.  Staff at centres will need a wider knowledge to effectively signpost to support services. Paediatric and Neo-natal  How can Cardiff accommodate more sick children? Will service be overwhelmed?  What links have been made with primary care?

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 Important to get over message that majority of care will still be local.  Assessment Centres need to be included and are very important.  Patients need good communication on what their choices are.  We need to do things differently; stabilise in specialist service and discharge to care at home if safe/appropriate. Why don’t we do this anyway?  Need to address issues around patient transport including communication between hospitals and the ambulance service and transport between services; local to specialist and back. Also third sector community transport schemes will be important.  Out of area parents will need support at the site, e.g. accommodation and access to support services.  Will there be issues on patient flow – additional numbers?  Bed availability will need to be explained.  Need to ensure the first contact is also well skilled i.e. GP out of hour, public health has a large role to play in educating parents.  Whole system approach needed; what services is the third sector involved in and what can the third sector become involved in?  Paediatrics A&E and A&E work very closely together  Need to stress this really is a small percentage of services and this is about ensuring some people are going to the most appropriate service straight away.

15/12/12 Local councillor Please would you take on board my concerns as Councillor for the Heath Ward which includes the University Hospital of Wales.

I have read with interest the information on the South Wales Programme. Whilst I appreciate that it is merely an outline and suggestions are welcomed, it is so vague that it is puzzling what exactly the general public can offer in terms of any such suggestions.

Firstly the public will not have the first hand inside knowledge to make an informed judgement but would just be able to speculate on if, what, when and how much would any service cost. Again I appreciate that cost would not be the operative word but in this era of austerity it must be a consideration. There are no specific potential local service changes so it is difficult to respond without proposals of substance.

There has no focus on what services would have to move out to accommodate any changes and to where they would be moved. However, while more services are going into the hospital, not a lot is coming out. The infrastructure around the hospital cannot take added pressure of more traffic and specifically more parking. Responsibility must be taken to ensure that parking should be sufficient to allow patients, visitors and staff to park if not easily then at least short term without resorting to parking around the perimeter in the streets that do not have the benefit of residents-only parking. One of the main topics of 99

concern for the residents of Heath is parking and I am continually asked that hospital staff should be discouraged from parking indiscriminately. I really sympathise with staff that are faced with either getting to work very early in order to get a parking space or parking so far away that some resort to folding bicycles in the boot of the car to finish their journey. The local park and ride scheme at Pentwyn is too distant, too intermittent for shift work and too inconvenient a service to ensure staff are punctual.

I agree that trained specialist centres should be available 24/7 and larger hospitals will most certainly attract specialists who can continue that level of specialisation, and I have no objection to any specialist services being provided by UHW. However, I would hope that any non-urgent services could be provided elsewhere. I have attended several clinics with my family that could be accommodated outside of the hospital. Maybe it is a case of reviving the CRI and putting services where they are easily accessed and yet still near city centre travel routes.

One thing I feel that hasn’t been taken into consideration is the Local Development Plan which as a Councillor I have been involved in. This plan (Option B) if it goes ahead will see almost 46,000 houses being built in Cardiff which could put a huge strain on the resources, services and infrastructure of the City. Option C which was the preferred strategy of almost every consultation meeting that the public attended envisaged 36,000 houses to be built, but that option was withdrawn. The Plan has not yet progressed but certainly there will be a plan in place next year that will see a great deal more development for the City of Cardiff, which will in turn have a great impact on all its services.

In conclusion, before any services are considered for major investment in UHW can the UHB inform the public of how and where the local, elective or routine services will be delivered as I feel it is of vital importance when considering the bigger picture. 19/12/12 Local councillor 1. As a local councillor on the Vale of Glamorgan Council and Barry Town Council I am pleased to have been consulted as part of the engagement on three occasions and would like to thank the staff who have attended these consultations and given explanations on the purpose of the engagement. This has allowed me to draw my own conclusions regarding the engagement exercise.

2. It appears to me that the timetable for engagement, consultation and implementation of any changes is very tight and that comprehensive impact assessments will not have been carried out to everybody’s satisfaction. These include financial impacts and impacts on health inequalities. This is a serious failure in the engagement exercise.

3. In the engagement process it was said that the intention was to agree to the principles of centralisation before further details were discussed,

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but the published documents and presentations both suggested that continuation at three sites were effectively being rubber-stamped and asking respondents to choose which of the remaining sites should see their facilities removed. It therefore appears very much that respondents are being led to a specific position through this engagement – pitting them in favour or against the closure of facilities in particular locations. This does not appear an open and fair discussion.

4. Although I welcomed the opportunity to discuss the issue on multiple occasions, I do not believe that the case for change has been effectively made and I am not convinced that these proposed changes will produce clear benefits for patients.

5. I remain concerned at the apparent lack of consultation with the Ambulance Trusts regarding the impact of these changes. Increased travel times to hospitals will be a concern especially given that cuts are also likely to be made to ambulance services. This could have very serious consequences and these changes should not be taken lightly.

6. It remains unclear what work has been carried out regarding workforce planning and staff retention and what possible alternatives exist regarding clinical networking.

7. I am pleased that there are no plans to remove facilities from Barry Hospital, although I would also like to see an increase of services in one of Wales’ largest towns.

8. I hope that any future documents published on this topic will contain substantially more detail to allow a wider debate to take place. 19/12/12 Cardiff and Vale The MAG has considered the potential options in the local engagement Medical Advisory document and proposes that the four unit model is a safe combination. Group The MAG fully recognises the historical problems with the doctor training structure in Wales that have led us to this point. It is a great concern that we have such problems attracting doctors to Wales to train and keeping trainee doctors in Wales. The core issues must now be addressed. Whilst agreeing with the drivers for change, we acknowledge the GP community’s concerns about enhanced services activity being capped at this time, when the reconfiguration brings the prospect of GPs doing more routine hospital work in the community (e.g. if elective rheumatology is moved from UHW), which the Health Boards must fund through the appropriate budgets. For better patient engagement and communication, hospitals must modernise and enable patients to use new technologies to manage appointments. Travelling times for patients to hospitals have already increased following the reorganisations of some local hospital services and these proposals will compound them, so the proposals will have to be skilfully presented

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to the public. It is a concern that a major element in the reconfiguration plans is the Gwent SCCC, which is not even built yet. There needs to be more equity of access into UHW from all directions – currently it is better from the East and South than from the North and West. 19/12/12 GP Surgery I am writing to express our concerns in respect of the proposals contained in the South Wales Programme. As a practice which is located in three sites; Llantwit Major, St Athan and Rhoose, our patients can currently access services from different hospitals depending on the proxmity to their home and whether the boundary enables them to access the services depending on their postcode. The proposal to limit the paediatric services, and also to reduce the obstetric provision from Princess of Wales would undoubtedly have an impact on our patients and would deter them from attending Princess of Wales, forcing them to attend hospitals that are at an even greater distance.

We are particularly concerned by the proposal to reduce the A&E provision at Princess of Wales. Patients need to access A&E services in a timely manner, and given the paucity of public transport in areas covered by our practice, the much greater distance required to travel (20 miles instead of 10), and the pressures already on ambulance services in the area, we cannot envisage that this proposal will provide a safe option to patients in this area. This proposal would particularly impact on the most vulnerable groups, for example, where would an asthmatic child go at 10.00pm to access emergency services quickly, and the same would apply to elderly patients with a fractured hip. It is highly likely that patients would attend A&E in Princess of Wales and then find that the service available is too limited to deal with their condition, resulting in un- necessary time delays whilst patients travel elsewhere.

We require further documentation to demonstrate safe and timely pathways for patients to follow before we can offer any support to the proposed changes.

21/12/12 Community While recognising the need to review the provision of specialist hospital Council based services, the Council wishes to express its extreme concern at the proposal that the Accident and Emergency Department at the Princess of Wales Hospital in Bridgend might be closed as part of the reorganisation. For residents of the Western Vale, Bridgend provides a vital service, particularly when Accident and Emergency services are required. Taking our own village as a prime example, Colwinston is 21 miles from the University Hospital in Cardiff and 28.5miles from Morriston Hospital in Swansea, compared with 5 miles from Bridgend. We have 25% of the population over 60 years of age (2011 Census), with the concentration of the older people in villages like Colwinston. Nearly 20% of the population do not won cars and public transport links are limited. It is possible to go

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by bus to Bridgend. According to Traveline Cymru, the bus and train journey to Morriston would take just over 3 hours. To get to the UHW, it would take 1 hour 24 minutes.

The suggestion that there might be a new Critical Care Centre built in Cwmbran would do nothing to provide an effective replacement for the closure of A&E facilities in Bridgend for residents of this part of the Vale of Glamorgan. In view of recently reported health financial date from the Wales Audit Office, we are baffled as to how Assembly officials can contemplate the further major expense that the CCC would require. If services are to be rationalised then there will be spare capacity in existing hospital accommodation which could be used.

We understand the benefits of the centralisation of specialist services and expertise but feel strongly that, in emergency situations, these would be outweighed by the additional travelling time to Cardiff, Swansea or Cwmbran. In many emergency cases, early treatment is the most critical factor. As you will know, there are already concerns about the provision of Ambulance Services in the Vale and we have little confidence that these are adequate to meet current needs, let alone fulfil an increased demand for longer journeys. 18/01/13 Cardiff and Vale The Cardiff and Vale of Glamorgan Community Health Council (CHC) was Community Health pleased to participate in the above process and would like to offer its Council comments as follows: • The CHC are of the opinion that the twelve week period of engagement was successful. It was considered as being sufficient and was undertaken in a professional and meaningful manner. • The process conformed fully to the guidelines on Engagement and Consultation as laid down by the Welsh Government document of April 2011. • It is recognised that, at this stage, no concrete proposals have been devised and that the engagement exercise could only consider the future, across the South Wales area, of the following specialist services: Accident, emergency and trauma Specialist maternity provision Specialist inpatient provision for children and very premature babies, i.e. paediatric and neonatal services. • The University Health Board made a concerted attempt to engage as many patients, carers and members of the public, along with relevant organisations, as possible during the time allocated. • Although there was a limited attendance at the arranged meetings this was not due to a lack of advertisement of the events but general public apathy. • The CHC is satisfied that all the questions posed at the meetings, along with the responses given, were recorded. This information, along with any written submissions, will be used in the construction of any future

103 consultation documents. • The CHC also support the proposed round of public consultation that will be based, in part, on the findings of the engagement process. • However the CHC feel that there was a lack of clarity, throughout the engagement process, on what local services may need to relocate from the Cardiff and Vale UHB area to other health board areas. Similarly, there was limited clarity over the impact on demand on local services of services being relocated to Cardiff and Vale from elsewhere. While we appreciate there was considerable uncertainty over these issues and no firm proposals were being put forward, it would have assisted the engagement process if an option appraisal and likely or possible impact assessment could have been developed as suggested by the CHC. It feels that this concern can, and should, be rectified by implementing a further period of engagement on these services, prior to the proposed consultation exercise commencing in the spring of 2013. The Cardiff and Vale of Glamorgan CHC would therefore submit the above points and look forward to supporting and being fully involved in the proposed future engagement on services and subsequent consultation process on the South Wales Plan.

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DATE FROM WRITTEN RESPONSE WRITTEN RESPONSES RECEIVED BY ANEURIN BEVAN HEALTH BOARD 23/10/2012 Member of Public Hospital services for the Caerphilly Basin area CURRENT SITUATION At present all hospital services for the population of the Caerphilly basin are provided by the Aneurin Bevan health board. Some minor treatment is carried out at Ystrad Fawr hospital but Most of the treatment is carried out at the royal Gwent hospital at Newport. A limited amount of treatment is carried out at the Heath Hospital in Cardiff but I have been led to believe this will cease completely from next month as The Aneurin Bevan trust will not pay for the treatment. Approx. 10years ago all the treatment that is now carried out at Newport was carried out at the heath in Cardiff and East Glam hospital. So ten years ago I would have been treated at my nearest Hospital which was only 5 miles away from home. Now I have to get treatment at a Hospital 15miles away. The nearest hospital is still providing the services but I am not allowed to use them. I recently had an outpatient appointment at the Royal Gwent Hospital for 0930.I had to leave Home at) 730 to catch buses to make the appointment time. (I could have caught a bus at 0800 at the risk of missing a bus connection and the appointment. This was annoying as a similar appointment time at the Heath in Cardiff would mean me not leaving home until 0850 as opposed to 0730 or o800 if I risked being 30min late for the appointment. Also the heath Hospital is close enough to home for taxis to be a viable option as a one way fare is approx. £13 one way as opposed to £30 TO Newport. I have also been led to believe that more treatment is likely to be carried out at Neville Hall in Abergavenny.If the royal Gwent is busy, patients will then be referred to Neville hall instead of the Heath, even in an emergency Situation. More and more people from the Caerphilly basin are being treated in Neville Hall. Apparently women in labour are being now taken from Caerphilly to Abergavenny. Access to abergavenny from Caerphilly is a problem. Even if a car is available then it the journey time of 50min is required. Public transport users need to allow at least 3hrs for the journey. And 4hrs if allowing for missed connections (I recently travelled by bus from Caerphilly to abergavenny via Pontypridd usually I leave my house at 0800 to arrive in Abergavenny at 1030 however the bus was 4min late arriving at Pontypridd so I missed the connection. Rather than wait 1 hour for the next bus and get there at 1130 I used another service to Abergavenny changing buses at Brecon to arrive at 1045.) This illustrates that if I had an appointment in Neville Hall at 1100 then the quickest way for me to attend would be by catching a bus via

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Pontypridd and BRECON People living in the centre of Swansea are able to access Neville hall easier than the people of the Caerphilly basin. My situation is not unique it applies to most people in the Caerphilly basin and the . A population of approx. 50,000 who are not living in an isolated rural area but in a continuous built up area from to Cardiff and westward to Bridgend yet The welsh Assembly have not configured their services to provide treatment at reasonably accessible sites even when they exist within 5/6 miles. It is rumoured also’ that instead of using the mental health services at whit church hospital (20min bus ride) Caerphilly people will be treated at Caerleon(hours away by bus). The present situation is unacceptable and is entirely in the control of the welsh assembly. From a public point of view I cannot see any excuse for not providing all the treatment required by the people of the Caerphilly basin at the Heath in Cardiff. The hHeath is even as near as the NEW YSBYTY YSTRAD FAWR. It appears that the health budget for the population of the Caerphilly basin has been allocated to The Aneurin Bevan health trust (for no logical reason except to make the numbers up in the old Gwent area).From a users point of view it would only be a minor administrative change to re-allocate that budget to the trust operating the Heath hospital .likewise, the budget of other areas which are more accessible to The Heath than The royal Gwent. If it was necessary to increase the numbers using the Royal Gwent perhaps it would be better to look at communities which are as near to the Royal Gwent as the heath. Areas such as eastern Cardiff where the Heath and The royal Gwent are equidistant and have far superior transport access to the royal Gwent than does the Caerphilly Basin. I cannot see how’ for example it is more expedient for the Caerphilly basin to be served by the Royal Gwent rather than the St.mellons and llanrumney area of Cardiff. I can only assume that County boundaries have something to do with it. I cannot see why local authority boundaries should have any bearing on the provision of health services. Health services are provided by the Welsh assembly and should be provided with accessibility of the patients in mind. Many of the local authority boundaries are false divisions and groupings .they do not reflect the natural traffic movements of the communities they serve. e.g. Caerphilly county covers 3 parallel valleys with poor transport links between them. The eastern part of the County (, newbridge area has excellent public and road transport links with the hospitals at Newport with bus frequencies of every 5-15 min and journey times of 1`5-30 to Newport. Thus the accessibility to the new ysbyty Ystrad Fawr is far inferior to the Newport Hospitals with no direct bus routes. Therefore the new hospital, although it is within the same county, is much less accessible than the Newport hospitals for perhaps 30,000 people living in the ebbw valley of Caerphilly. In the Sirhowy

106 valley of Caerphilly public transport to Newport again is far superior than that to Ystrad farther lower reaches of the Sirhowy valley have no direct bus services to Ystrad but a 2buses per hour link to Newport. Upper Sirhowy valley has 8 buses per hour to Newport as opposed to 4 to ystrad.Although the journey time to Ystrad is much shorter. On balance there is very little benefit as far as accessibility for the Sirhowy valley people to use Ystrad Fawr instead of the Newport hospitals. Population approx. 30,000. The Rhymney valley can be divided into 3 1 The Aber Valley and The Caerphilly basin (except the Bed was , area) has far superior transport links to the Heath Hospital rather than to Newport and is 1/3 the distance.approx half the population work in Cardiff. 2. trethomas and Machen have transport links to Newport which are about the same as that to the Heath. 3.The upper part of the Rhymney Valley(bargoed-rhymney have a different public transport profile again. Probably Prince Charles hospital(part of a different health authority)l in Merthyr Tydfil is more accessible to this area than either the Newport hospitals or The heath .IT is much closer via car and by bus is at least 20 minute quicker. AS I have shown there are at least 5 distinct areas within the County OF Caerphilly with totally different patterns of public transport accessibility profiles with regards to accessing hospitals. The whole county should not be treated the same when allocating which hospital should serve which community it is not necessary and is causing a lot of inconvenience and could be damaging people’s health. There is no reason why each community could not have its budget allocated to it’s most accessible hospital. In fact why not merge the hospital trusts and allocate resources according to the customer demand for each hospital after directing patients to the most accessible hospital. All resources should be shared. FUTURE RE-ORGANISATION MEDIA REPORTS INDICATE THAT SPECIALIST SERVICES WILL BE CONCENTRATED IN A SMALL NUMBER OF HOSPITALS.I have no comment to make on this principle .I accept it may be necessary.However,wherever the specialist sites are located I would think it is essential that patients are directed to their nearest centre irrespective of which county they live. It has been suggested that all specialist services for the Aneurin Bevan Trust Area will be provided at a new hospital at Llanfrechfa. However bad the accessibility is at present for people from the Caerphilly basin it will be much worse if patients are required to travel 20miles to Llanfrechfa it would make it impossible for people without private transport to visit sick relatives in the evening. Patients will be required to attend a centre 20miles away when one exists only 5 miles away and another 10 miles away(royal Glamorgan if that becomes a centre ) or Prince Charles 18miles away. The resources

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of these centres should be pooled together even if the resources of the other parts of the trusts are not are not. MANY PEOPLE AT PRESENT IN THE CAERPHILLY BASIN NEED TO ACTUALLY CATCH THE BUS TO THE HEATH HOSPITAL BEFORE CATCHING THE BUS TO NEWPORT AS THIS IS THE quiCKEST WAY TO THE ROYAL GWENT How ridiculous is this situation e.g. It takes the people of the Watford area only 45min to get to Newport by bus via the Heath hospital and is the only route available before 0900.any other route takes at least 10min longer. I question whether or not it is necessary at all to provide the specialist services at Llanfrechfa would it not be better to expand The Heath There is an excellent bus service between Caerphilly and The Heath 3 per hour and the journey time is only 20min. Unknown Member of public I am offering these comments as a midwife and midwife teacher with 30 years’ experience in South Wales

 I have read the published documents on the South Wales Programme and have these comments:  I understand the wisdom in reducing the number of larger maternity units across South Wales.  Despite possible lack of engagement early in the process of change there is likely to be public resistance as the changes are implemented.  It is essential that women in Wales have the realistic chance to opt for home birth, birth centre birth or birth in an obstetric centre.  It is absolutely essential that student midwives in Wales have access to all types of maternity services – in order to become fully rounded and effective professionals that seek work throughout Wales and the rest of the world.  To ensure that the proposed larger obstetric units are used effectively I would recommend:  That the numbers of potential births in the whole of South Wales are calculated very thoroughly in order to achieve the right number of units in the right locations.  That traditional patterns of travel to maternity units and traditional alliances are considered very carefully.  MOST IMPORTANTLY - That alongside birth centres are set up close to ALL of the larger units – these must be designed by midwives and service users.  Midwives must be supported to run these effectively with as few transfers to the obstetric units as possible, within safe parameters.  The alongside birth centres must be run by appropriately prepared staff who are supported to also run a homebirth and modified ‘domino’ service from the centres.

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 Ambulance services MUST be considered in some depth & breadth in order to ensure appropriate and rapid transfer to the obstetric units from all over Wales. 14/11/2012 We understand that services have to be sustainable whilst still Optical Committee affordable and as an organisation we are interested in how to make this possible in particular regard to the eyecare pathways. We are concerned that because of the current overstretching of Ophthalmology resources and services that there is a risk to patients and in some cases sight is being lost as a result, e.g. the AMD and diabetic treatment times are slipping because of capacity issues. Although it is important to have specialist and emergency care in fewer centres to make better use of resources, we notice as an organisation that emergency eye care is already much reduced at a weekend and in particular retinal detachment care is unavailable at weekends with patients having to travel to Bristol or London for care. In Aneurin Bevan emergency eye care is currently only available at the Royal Gwent but patients are unaware of this. It would be much better for patients to be directed to primary eye care services in order to triage to the appropriate service so valuable resources and patient time are not wasted. This depends on where the specialist team are. There are examples already of this occurring within eye care, e.g. All tumours are referred to Liverpool, all retinal detachments are referred to Cardiff. This only becomes a problem if Opthalmologists then deskill – where does the definition of routine end and specialist begin? We as an organisation would like to see the proposals as to where the divide is. Emergency eye care is already limited within the Aneurin Bevan area to the Royal Gwent. However some emergency eye problems are seen at Nevill Hall by non specialist medics. Better signposting to emergency services both in primary and secondary care would be beneficial both financially and clinically for the patient. 18/12/12 Neonatology I am writing on behalf of all my neonatal colleagues and the nursing directorate team and as a representative of the Neonatal Directorate of the Aneurin (Aneurin Bevan Bevan Heath Board regarding some aspects of the South Wales Health Board)s Programme. As you know, the ongoing consultation as a part of the South Wales Programme regarding the reconfiguration of neonatal services has as one its options to reduce the number of level 3 neonatal units from 3 to 2. Lack of middle grade availability, quality of care and outcome and the quality of training are some of the drivers for this change. An option which seems to be emerging is to change the status of the neonatal service in the Royal Gwent Hospital from a level 3 to a level 2 unit thus leaving only 2 Level 3 units in S Wales. We shall present a reasoned, evidence based argument showing that this is a poor option in terms of all major outcome parameters – patient safety, quality of care, patient convenience plus the standard and availability of specialised neonatal training in Wales. It is also highly unlikely to achieve the desired option of improving middle grade

109 availability, merely shifting the problem elsewhere. While we recognise that the “reconfiguration” of both service and training is a major and important piece of work which needs undertaking and the current status quo across Wales cannot remain, we have concerns over how the issues regarding neonatal services appear to be emerging. Neonatal services are highly specialised services and currently the three level 3 neonatal units in South Wales function together as a close interconnected networked service with the level 2 units in Wales. The volume of work in each of the 3 level 3 units entirely justifies the existence of the units on these sites. The implications of consolidating into 2 units instead of the current 3 have not been thought through, understood or discussed and we would like to take this opportunity to highlight the services provided by the Neonatal Units of the Aneurin Bevan Health Boards and point out the effects of downgrading the Level 3 unit at the Royal Gwent to a Level 2 unit.

Background The in-patient Neonatal Service in the Aneurin Bevan Health Board comprises two units, a Level 3 unit at the Royal Gwent Hospital (RGH) and a Level 2 unit at Nevill Hall Hospital (NHH), both of which combine to provide integrated care for sick and premature newborn babies. The two units function as one unit on two sites. The service caters for approximately 6200 annual deliveries across the Gwent region. The service also takes in babies from other neighbouring regions depending on the need. The Neonatal Intensive Care Unit (NICU) at the RGH unit provides a full range of intensive care services including high frequency ventilation, Nitric Oxide therapy and therapeutic cooling. Neonatal surgery and cardiology services are provided by the University Hospital of Wales, Cardiff. The level 3 unit at the RGH is staffed by Consultant Neonatologists. We have a highly motivated and skilled nursing team that has chosen to work for this Health Board. Nurse staffing levels have incrementally increased over the years and great efforts have been made to make the service very close to being compliant with the All Wales Neonatal Standards. The Special Care Baby Unit (SCBU) at the Nevill Hall hospital provides stabilizing intensive care, high dependency and special care and is serviced during the day by the Neonatologists who undertake ward rounds three times a week with out-of-hours cover provided by the general paediatricians based at the Hospital. Some babies are transferred out of the RGH Unit to NHH for their follow up care to create capacity and repatriate babies to their place of birth.

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Birth rates and Preterm birth rates Number of births in Wales 2007-2011 Registerable births 2007- Average birth/year 2011 Abertawe Bro Morgannwg 32814 6563 UHB Aneurin Bevan HB 31214 6242 Betsi Cadwaladr UHB 36421 7284 Cardiff and Vale UHB 31433 6286 Cwm Taf HB 21552 4310 Hywel Dda HB 17818 3564 Powys Teaching HB 1478 296 From All Wales Perinatal Survey 2011 The numbers of registerable births in the Health Boards of Wales over the 5 year period 2007-2011 is shown in the table. It is clear that the births are very evenly distributed in the 3 major areas of S Wales, and ABMB, ABHB and C &V have virtually similar numbers of births averaged out over a 5 year period. Preterm births by Health Board of residence in Wales 2002-2006 and 2007-2011* 2002-2006 2007-2011 <28 weeks 28-32 weeks <28 weeks 28-32 weeks Abertawe Bro 168 388 169 412 Morgannwg UHB Aneurin Bevan HB 205 511 179 461 Cardiff and Vale UHB 139 339 163 363 *AWPS Annual Report 2011 Over the periods 2002-2006 and 2007-2011, the ABHB had the highest number of extreme preterm births (<28 weeks gestation) of the current 3 level 3 units in S Wales, all of whom would have needed intensive care. It also had the highest number of babies born between 28-32 weeks gestation most of whom would have needed intensive care. This high numbers of preterm births is possibly related to the high levels of deprivation seen in the ABHB region (AWPS Annual Report 2011)

Activity and occupancy Royal Gwent Hospital activity and occupancy over 6 years** Year IC HD IC+ IC + HD SC SC Total % HD Occupancy Days occupancy (IT+HD+SC) Occupancy ‡ Φ 2006 1522 2064 3585 140 2394 50‡ 5991 82 2007 1240 1995 3235 127 2739 58‡ 5981 82 2008 1352 2097 3449 73 2517 115Φ 5977 82 2009 1566 1773 3339 70 2559 117Φ 5898 80 2010 1573 2213 3786 80 2705 124Φ 6491 93 2011 1351 1948 3299 70 3094 141 Φ 6393 92 2012* 1537 2252 3789 80 2862 131 6651 96 ‡ Based on historically funded cots (7 IC and HD cots and 13 SC cots) Φ Based on notionally available cot spaces (6+1 IC, 7 HD and 6 SC cots) (IC= intensive care, HDU= high dependency care, SC= special care) * Projected **From the Annual Report 2011 of the Neonatal Units of the Aneurin Bevan Health Board

The unit activity at the RGH has been on average 1448 days of Intensive care, 2048 days of HD Care and 2695 days of Special Care annually. It

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shows that the Neonatal Unit is running at 96% overall occupancy and 80% occupancy at Intensive Care and High Dependency levels. These levels are much higher than the recommended safe occupancy rate of 70% suggested by the British Association of Perinatal Medicine (BAPM 2001).

Very Low Birth Weight (VLBW) throughput The median number of babies <1500g in the 850 level 3 NICU units worldwide of the Vermont Oxford Network is 55 (table from VON). The figure for the Royal Gwent for this is 65. This means, in terms of size for treating VLBW babies, the RGH NICU is larger than average size. The Vermont Oxford Network is a voluntary network of 850 neonatal units (90% level 3 units) from across the world, mainly from the USA but includes 30 level 3 units from the UK.

Unit closures: The neonatal unit has on occasion needed to close to admissions as below: 2010: 65 occasions 2011: 44 occasions Jan – October 2012: 72 occasions

In-utero transfer: Every time the RGH unit is closed, it results in transfer of pregnant Gwent mothers to other obstetric units across Wales and England. Extrapolating data from Jan-Sep 2012, it is estimated that during 2012, 63 such in-utero transfers will have taken place due to lack of capacity in the neonatal units of Gwent. 16 such in-utero transfers have been to England. This clearly is greatly inconvenient (and potentially dangerous) to Gwent mothers who have to travel great distances to deliver.

(continues below)

Nevill Hall Hospital activity and occupancy over 6 years** Year IC HDU IC+HDU SC days Total days % Occupancy (12 cots) 2006 104 709 813 2143 2956 67 2007 147 746 893 2028 2921 67 2008 140 907 1047 2162 3329 73 2009 145 712 857 1821 2680 61 2010 136 746 882 1991 2873 66 2011 150 760 910 1999 2909 66 2012 (projected) 130 856 868 1873 2741 75* * Based on a total of 10 cots **From the Annual Report 2011 of the Neonatal Units of the Aneurin Bevan Health Board The neonatal unit at NHH has 136 days of IC, 776 days of HD Care, 2002 days of SC on average annually over a period of 6 years. The average occupancy for 2012 will be 75% against a recommended occupancy of 70%. Combined: The average combined activity and occupancy (over a period of 6 years) in the two units of ABHB is as below:

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RGH + NHH Occupancy Intensive Care 1584 72% High Dependency Care 2825 77% Special Care 4698 107% Based on 6+1 Intensive Care cots, 10 High Dependency cots and 12 Special Care cots This gives an average occupancy of 89% overall which is still much higher than the recommended 70% occupancy. The figures presented above show that the activity of the neonatal units in the Gwent is high, and needs an upgrade in capacity rather than a downgrading in capability.

Outcomes:

AWPS Annual Report 2011

This funnel plot shows the still-birth rate (number of still-births/1000 live births) for each hospital in Wales, plotted against the number of births in that hospital over a 5 year period. The average still-birth rate is indicated by the solid horizontal line. The curved lines represent limits within which 95% of hospitals' results should lie if the average rate across Wales applied to all hospitals. Hospitals above or below these dashed lines have a still-birth rate that is significantly different from the average rate. Higher still-birth rates are expected in the obstetric units where level 3 neonatal units are co-located, where the highest risk mothers are delivered. Of all the high risk S Wales obstetric units with a level 3 neonatal unit attached on site, the Royal Gwent Hospital has the lowest stillbirth

113 rate.

AWPS Annual Report 2011

This funnel plot shows the neonatal mortality rate for each hospital in Wales over a period of 5 years, plotted against the number of births in that hospital. The average mortality rate is indicated by the solid horizontal line. The curved lines represent limits within which 95% of hospitals' results should lie if the average rate across Wales applied to all hospitals. Hospitals above or below these dashed lines have a mortality rate that is significantly different from the average rate. Higher mortality rates are expected in the level 3 units where the sickest babies are cared for. This graph shows that the neonatal mortality rates at the Royal Gwent Hospital, Newport, are the lowest of all the level 3 units of Wales over this period of observation. In a like for like comparison of similar sized units with similar birth rates and activity the Neonatal Mortality Rates (number of deaths/1000 live births) in the Royal Gwent has been 2.9/1000 live births compared to Singleton Hospital 4.3/1000 live births over the last 5 years. Put another way, there have been 27 fewer neonatal deaths in RGH compared to Singleton Hospital during the 5 year period.

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Vermont Oxford data of key performance measures of babies < 1500 g RGH (2011) versus all other NICUs in the UK (2010) and in the Network (2010) RGH (2011) UK (2010) Network (2010) Measure Cases N % N % N % Q1 Q3 Mortality (including Labour room deaths) 5 65 7.7 1678 17.3 56916 15.4 10 19.4 The Vermont Oxford Network is a voluntary network of 850 neonatal units (90% level 3 units) from across the world, mainly from the USA but includes 30 level 3 units from the UK. At the RGH, mortality for babies <1500 g was 7.7% against a UK mean of 17.3% (30 level 3 neonatal units) and a mean mortality of 15.4% for the Vermont Oxford Network (850 Neonatal units). When compared to international standards of the Vermont Oxford Network the mortality rates stand out as outstanding – in the 10th centile of the entire group. Training The 2012 National Training Survey report from the GMC is presented below*

Indicators

ational ational

Trust / Board / Trust

PostSpecialty

Overall Satisfaction Overall Supervision Clinical Handover Induction Undermining Experience Adequate WorkLoad Educational Supervision Educ to Access Resources Feedback Teaching Local Teaching Regional StudyLeave

Abertawe Bro

Morgannwg

University LHB

WHITE PINK WHITE WHITE PINK WHITE WHITE WHITE WHITE PINK WHITE WHITE WHITE

Aneurin Bevan

LHB

HITE

Green WHITE WHITE Green WHITE W WHITE WHITE WHITE WHITE WHITE WHITE WHITE

Betsi

Cadwaladr

University LHB

Neonatal MedicineNeonatal

WHITE WHITE WHITE WHITE PINK WHITE WHITE WHITE WHITE GREY WHITE WHITE WHITE

Cardiff & Vale

TE TE

University LHB

RED WHITE Green WHITE PINK WHITE WHITE WHITE PINK WHITE RED RED WHI

The neonatal training at the Royal Gwent has received the highest degree of satisfaction and only 8 other units out of 82 in the UK have a “green” for overall satisfaction. Overall satisfaction of trainees at the Aneurin Bevan Health Board (GMC Survey 2011)

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Within the Health Board, as can be seen from the GMC Trainees’ Survey of 2011, the trainees’ satisfaction levels were at the highest for Neonatal Medicine. Parental satisfaction The neonatal unit at the RGH has regularly received high levels of praise and surveys carried out internally (A survey of patient satisfaction 2010, V Patel, H Murch, J Lewis, T Kollamparambil) showed that 98% of parents rated the unit excellent or very good. A repeat of this audit in 2012 showed similar results. Anecdotally, most doctors and nurses regularly receive letters of thanks and gratitude from parents.

Summary of work done by the Neonatal Units In summary then, the neonatal unit at the RGH is a high functioning, high throughput unit with best-in-class outcomes for survival of babies. It is highly regarded for its teaching and training and has a high reputation amongst parents whose babies are admitted here. Consequences of downgrading the Level 3 neonatal unit to a Level 2 unit at the Royal Gwent Hospital 1. One of the consequences of downgrading the level 3 to a level 2 service will be a combined medical staffing for neonatal services and general paediatric services with a single middle and possibly senior tier rota.

2. Most of the 1500 intensive care days currently provided in the Royal Gwent Hospital will have to be transferred to the two remaining level 3 neonatal intensive care units. For all practical purposes, this will be to Cardiff. Cardiff

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at its current state would not be able to accommodate this activity (which is an additional 75% increase on their current intensive care activity). Cardiff would then need a massive increase (a 75% increase) in their current intensive care capacity. This would require a major reconstruction and capital expenditure. This cannot be achieved in the short term.

3. This will result in a “mega” NICU in Cardiff which would require an additional layer of middle-grade doctors or an alternative staffing structure e.g. ANNPs or resident consultants to manage. This nullifies the very purpose of the proposed reconfiguration.

4. Cardiff would also require an added number of trained neonatal nurses. This in theory could be from nurses at the RGH but in practice may prove to be very difficult.

5. Obstetric units of the ABHB currently deliver 6200 babies annually. With the re-designation to a Level 2 unit, only a limited number of low and medium risk deliveries can be undertaken. The residual combined delivery rate in Gwent would therefore be substantially less than 6200 deliveries, but the actual number is unknown depending on how patient flows change.

One means of estimating the number of deliveries with which the Gwent could then cope is that of a typical Level 2 unit without a separate middle- grade staffing. Such a unit could only manage approximately 300-350 neonatal admissions per annum which would translate to approximately 3000-3500 deliveries per annum. This would necessitate moving 2700-3200 mothers from Gwent to Cardiff and other regions. This would defeat the purpose of developing the SCCC. Each transfer is a lengthy process and involves contacting the neonatal and obstetric units, arranging an ambulance, paper work for the transfer and arranging to have an accompanying midwife. The average time spent on arranging a transfer is 2 – 6 hrs with the additional time of travel. It would not only be tedious, it would put mothers and babies at risk. 6. The maternity facilities of Cardiff would need an increase in capacity by 50%. This cannot be achieved without major reconstruction.

7. The level 2 neonatal service at the Gwent would then provide only short term intensive care and ongoing lower end high dependency and special care; this would still require considerable medical input. This level 2 unit would look after approximately 300-350 neonatal admissions and possibly provide a volume of service somewhere between that currently provided by the RGH and NHH. The workload would be mainly in the lower end High Dependency and Special Care spectrum. This would be a in a unit without a dedicated middle grade cover.

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8. With natural attrition the current neonatologist numbers would gradually dwindle and the level 2 unit would essentially be staffed by a couple of the remaining current neonatologists and general paediatricians. There would be a shared team of middle grade doctors covering both the general paediatrics and a level 2 neonatal unit.

The activity in unscheduled care in General Paediatrics at the RGH had made this impossible to deliver by a single set of middle grade doctors more than a decade ago and at a time when training grade doctors were considerably more experienced than now. The continued increase in unscheduled care activity together with the reduced experience of junior medical staff (now often FP1 and FP2 doctors) has meant that an on-site consultant paediatric support for the Childrens’ Assessment Unit at the RGH has already been necessary in the evenings during the winter period. It is therefore unlikely that a single middle grade doctor would be able to allocate any meaningful time to the neonatal service, particularly out-of-hours. Consequently a very significant burden of the out-of-hours middle grade duties in the Level 2 neonatal unit would fall to consultant staff. This might be derived in part from the limited notional resource from the NHH consultant staff; from resource liberated by departing neonatal consultant staff reinvested in additional consultants (but who are willing to work effectively as middle-grade doctors); and from existing consultants at the expense of their existing scheduled care work. In practice all three may be necessary. This plan would need to proceed on the presumption that most if not all consultant paediatricians would be willing to provide combined general paediatric and neonatal services including a great deal of work at middle grade level, in a unit which would have one of the busiest children’s assessment units in Wales. They may well not be. The general paediatricians at the RGH have not delivered neonatal services for almost 10 years - they do not have the skills to deliver this combined role or have a willingness to reacquire them. Consultant paediatric posts within Gwent could become be exceptionally unpopular among the existing team, some of whom could seek employment elsewhere. 9. The Nursing team which consist of highly skilled and motivated nurses has been nurtured and built over the years, would break up and disintegrate. There would be a great deal of unhappiness and loss of morale amongst them.

10. The maternity unit in the Royal Gwent Hospital is the only unit in Wales meeting the RCOG standards for providing the recommended hours of consultant presence in the labour wards in keeping with the delivery rate. This has been built up over the years, and we provide a high quality maternity service and cater to a high risk population and the results are there to see. The proposed reconfiguration would have major implications and great challenges to quality of care of the maternity services. 118

11. All three level 3 neonatal units in Wales are accredited for higher specialist training and National Grid Training in Wales. Neonatology is one of the few subspecialties in Paediatrics that can be completed entirely within Wales. Decommissioning one of these units may jeopardise this training status. This would mean that neonatal Grid Training could no longer be completed within Wales and neonatal trainees would have to leave Wales to complete this. This would further reduce the numbers of the middle-grade work-force.

Summary 1. The ABHB region has a high rate of delivery and a higher number of preterm births than the other regions of S Wales. There is a high level of deprivation in this region.

2. The current neonatal service provided within the Gwent is a best-in-class service with outstanding outcomes for survival and top of the grade training reports. It is a service highly valued by the patient population.

3. Decommissioning the level 3 service to a level 2 service will result in an inferior service for the mothers and babies of Gwent. Safety of mothers and babies would be compromised.

4. As it stands, Cardiff has neither the capacity nor the manpower to accommodate the spill-over of maternity and neonatal workload from the Gwent.

5. It would require substantial capital investment in terms of building capacity in Cardiff to be able to handle the mothers and babies from the Gwent.

6. General Paediatric and the residual neonatal services would have to be staffed by a single set of middle-grade doctors. This would result in diminution of both services resulting in their becoming unsafe and dysfunctional and training quality would be compromised.

7. It would jeopardise the stated objective and the viability of the Specialist and Critical Care Centre and become unaligned to the original plan.

8. It would result in a significant displacement and dissatisfaction amongst the nursing and midwifery teams.

9. This plan has a significant effect on the job plans of both the consultant paediatricians and neonatologists and the nursing and midwifery teams. It is universally opposed by the consultant, nursing and midwifery bodies of all 3 aligned specialties, the neonatal, paediatric and the maternity teams.

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I hope these facts and figures are taken into consideration when firm plans on reconfiguration are made.

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DATE FROM WRITTEN RESPONSE WRITTEN RESPONSES RECEIVED BY POWYS TEACHING HEALTH BOARD 04/12/12 Member of Although I enjoyed the evening and it gave people a chance to “whinge about public issues in the NHS” , I remain baffled by the choices I am being consulted on. It appears that a 4 or 5 hospital solution are the only options. Cwmbran(although not built), Cardiff and Swansea are broadly fixed. In a 4 hospital solution I am being asked to show a preference between Llantrisant and Merthyr. Now you might find a handful of selfless souls in South Powys concerned over the well being of the good people of Llantrisant, but frankly not many will vote for a hospital 30 miles away over one 10 miles away. There is really no choice at all and therefore I’m baffled what the value of the consultation is. Also the hospital strategy was being described in isolation of the means of getting sick people to the hospital. The 3 specialities being described were  Obstetrics

 Paediatrics

 A&E

Referring to A&E there used to be a “golden hour” where people needed to get to treatment but this is a decades old rule. Nothing was explained about the latest medical reasoning which will drive the hospital locations or the delivery systems. If you fix the delivery time at say 45 mins I would have expected options like 1. 6 hospitals, 100 ambulances, 1 helicopter

2. 5 hospitals, 120 ambulances 3 helicopters

3. 4 hospitals, 130 ambulances 4 helicopters.

Clearly the numbers are notional but the cheapest solution must involve the delivery system and location not just location. Without this you could end up with a Sir Humphrey solution. Picture the scene- Sir Humprey proudly showing the Minister the new Cwmbran hospital with the latest scanners and world class consultants and the Minister saying –“yes Humprey, its very impressive but all the patients are “Dead on Arrival” It would be indeed be a scientific coincidence if the optimum delivery time to hospital for acute conditions was precisely the same for A&E, paediatrics and Obstetrics and therefore the integrated solution may need to be different for A&E than Obstetrics/Paediatrics(which need to be together). It may be that Consultant led emergency stabilisation units may be needed at say Nevill Hall before transferring to Cwmbran, to meet the optimum time for the best outcomes. None of this was explained and for me therefore, it is difficult to feel realistically engaged in the process. Can I suggest if a consultation is being proposed for next spring then a more meaningful presentation of the facts and the strategic options is set out including

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hospital locations and delivery systems. If not then I can confidently say that the majority South Powys residents will vote for Merthyr 10 miles away over Llantrisant 30 miles away and I’m equally sure the good people of Llantrisant will vote for their local hospital. I struggle to see any value in consulting over this limited choice. Brecknock 1. I refer to the period of public engagement concerning the South Wales and Radnor Programme which closes on 19th December 2012. You will be aware that in Community conjunction with Powys Teaching Health Board, Brecknock and Radnor Community Health Health Council has participated actively in the programme of public engagement Council events held in the principal towns in Brecknock and Radnor.

2. Members of the Community Health Council received a presentation concerning the South Wales Programme at the CHC meeting held on 19th November 2012.

This presented an opportunity for Members to make their views known directly to the Interim Director of Planning, Mr Bruce Whitear. Members of the Community Health Council have chaired the public engagement events and have heard at first hand the comments and observations that members of the public and CHC members made at these events. I set out below a summary of the comments and observations heard and these form the response of the Community Health Council to the engagement concerning the South Wales Programme. The Community Health Council trusts that both Powys Teaching Health Board and the South Wales Programme Board will recognise the benefit of having regard to and take the Community Health Council’s comments and observations into account as the Programme Board reflects on the public engagement in its crafting of the formal public consultation document concerning proposed health service changes in South Wales.

3. The Community Health Council’s responses including those garnered from public engagement events are set out below:

3.1 Document Title The first point heard by the CHC concerns the title of the programme. You will be aware that very little of the area of Brecknock and Radnor can be regarded as geographically part of South Wales. In fact it is probably true to say that only the Ystradgynlais area would be deemed in South Wales. The remainder of the Brecknock and Radnor area sits within Mid Wales and the title of the document “South Wales Programme” may have led members of the public to consider that the proposed changes in South Wales did not apply to this area. The views gained from public engagement events held at Knighton and indicated that the “South Wales Programme” needs to bear a revised title, when it comes to public consultation, to indicate that it is not merely South Wales (as perceived as the former industrial areas of Wales) but it embraces a far larger geographical area than may be defined as South Wales.

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3.2 Formal Links to England NHS Services In the light of observations and comments gained at engagement events in Knighton, Rhayader, Llandrindod Wells and Builth Wells, the CHC is of the view that the public consultation must make a much more formal link to the plans being developed for specialist hospital services in the West Midlands and in particular for such services based in , Worcester, Cheltenham and Gloucester. Members of the public in much of Radnorshire look to the West Midlands for their specialist hospital services.

3.3 Access to A&E and Trauma Services The CHC is concerned that the South Wales Programme, as drafted currently, does not indicate how patients requiring urgent and rapid access to accident and emergency including trauma services, paediatrics, and obstetrics and neonatal services would be conveyed to more distant specialist centres in South Wales. Extensive concern was expressed about the limitations of the road network in mid Wales and thus the ability of the Welsh Ambulance Service Trust to convey patients at speed to specialist centres within the prescribed clinical timescales. Moreover in expressing these concerns the CHC endorses further views expressed about the Wales Air Ambulance Service. Whilst recognising the importance of the Wales Air Ambulance Service, the CHC recommends that within the public consultation document there are clear proposals that demonstrate how the Wales Air Ambulance Service would be expanded in terms of aircraft numbers, 24/7 flying time and sustainable finance to ensure that patients are able to access distant specialist centres. There is concern that the continued charitable funding of the Wales Air Ambulance Service may constrain its ability to meet all needs into the future. The long term funding support of the service should be examined and resolved at the highest level.

3.4 Relatives’ Accommodation Provision In relation to patients receiving specialist care at more distant locations, the CHC shares the views of members of the public that appropriate and inexpensive provision needs to be made so that relatives, who are naturally worried about their loved ones, can afford to stay overnight, possibly several days, in close proximity to the specialist hospital service treating a member or members of their family.

3.5 Supporting Evidence The CHC recognises much of the detailed work supporting the public engagement document may be found in the publications issued by Professor Marcus Longley earlier in 2012. This led to a number of questions at all events around issues such as the numbers of patients likely to be affected by the proposed changes, the capital and revenue costs of the changes, and a healthy questioning of the views and opinions that must have been expressed to Professor Marcus Longley by the Wales Deanery, the Royal Colleges and the cohorts of specialist clinicians who came together at clinical summits. The CHC recommends that evidence to support the proposals must be demonstrated clearly and understandably in any public consultation document.

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3.6 Locations of Specialist Services The CHC supports the provision of specialist accident and emergency including trauma services, paediatrics, and obstetrics and neonatal services at the following hospitals: o Morriston Hospital, Swansea o Prince Charles Hospital, Merthyr o The proposed Specialist Critical Care Centre at Llanfrechfa Grange near Cwmbran o University Hospital of Wales, Cardiff.

3.7 Prince Charles Hospital, Merthyr Tydfil In relation to the four hospitals indicated above the Community Health Council impresses upon Powys Teaching Health Board and the South Wales Programme Board the increasing importance of Prince Charles Hospital, Merthyr in serving the southern area of Brecknock and Radnor. Access to Merthyr from the Brecon area via the A470 across Storey Arms has improved over the years. In supporting Prince Charles Hospital, Merthyr as one of the four hospitals, the Community Health Council believes that the South Wales Health Boards must impress upon the highways agencies the urgent need to gain further safety improvements to the A470 road between Brecon and Merthyr. Safety improvements should be aimed at reducing the number of events annually where the road is closed because of road traffic accidents. In addition the announcement made about the completion of the conversion of the Heads of the Valley Road, the A465 into dual carriageway will make access to Prince Charles Hospital, Merthyr and beyond to Morriston Hospital, Swansea attractive to people living in the and Usk Valley area. In fact it is probably true to say that following the completion of the duelling of the A465 journey times along that road to Prince Charles Hospital, Merthyr would be significantly better than access to the proposed Specialist Critical Care Centre (SCCC) to be built at Llanfrechfa, Cwmbran.

3.8 Sustainability of Current DGH Services In setting out its support to the four hospitals indicated above, the CHC for itself and on behalf of the public and patients believes that the forthcoming public consultation document must demonstrate assurances around the future role of other current district general hospitals such as Nevill Hall Hospital, Abergavenny. For example the provision of specialist services at the SCCC will require appropriate diagnostic and therapeutic services to be concentrated at the new hospital. This will include the concentration of anaesthetic services. Most of the public and the Community Health Council are anxious to avoid the situation developing where the concentration of anaesthetic services at the SCCC leads to a diminution of anaesthetic services at Nevill Hall Hospital. There is a risk that this would compromise the ability of that hospital to continue to provide surgical and related services.

3.9 Development of Minor Injury Services In connection with the point made immediately above, the CHC considers that the

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consultation document needs to address concerns expressed about those current district general hospitals, such as Nevill Hall Hospital, that will not feature as one of the four specialist hospitals and consequently might become less attractive places in which to work. The CHC does not wish to see a situation where medical, nursing and paramedical recruitment falters at these hospitals since that could lead to a reduction in the services provided by those hospitals. This further risks hospital services being concentrated along the M4 corridor. If this were to happen people living in mid Wales, who already have long distances to travel to access hospital services, would find longer journeys making access to distant hospital services extremely difficult. The public consultation document would be wise in giving assurances to the public about the roles and range of services that hospitals such as Nevill Hall Hospital would continue to provide into the future. In relation to the proposals signalling that accident and emergency services would be located at four or five major hospital sites in South Wales, there will be merit if the public consultation document explored in some detail the nature of lower level emergency services. These services should/could be provided at hospitals such as Nevill Hall Hospital, and in the context of Powys, at Breconshire War Memorial Hospital. Ystradgynlais Community Hospital and at Llandrindod Wells Hospital. Clearly it would be unwise and impracticable to concentrate all accident and emergency attendances at four or five major departments. There is a need to begin a process of identifying a middle range of “accident and emergency services” that can be developed to meet patient need for interventions requiring a greater input than can be provided at a minor injury unit. In relation to the hospitals at Brecon. Ystradgynlais and Llandrindod Wells, the Community Health Council heard members of the public indicate their support for both hospitals to provide an enhanced range of services on an inpatient, outpatient and diagnostic and therapeutic basis. Views expressed and endorsed by the Community Health Council are founded on the basis that enhancing services at these hospitals would make a contribution to reducing the amount of travel out of county which patients face currently.

3.10 Networking Major Trauma Services The engagement document indicated that the proposed major trauma centre for South Wales should be provided on a network basis between Morriston Hospital, Swansea and the University Hospital of Wales in Cardiff. Views expressed at some of the engagement meetings questioned whether a networked solution for the major trauma service was the most appropriate arrangement. The South Wales Programme Board may wish to discuss again with the appropriate specialist clinicians to establish whether the more preferable solution would be for a major trauma centre to be provided at one of the hospitals only.

4. I trust that the comments summarised and offered by the Community Health Council to both Powys Teaching Health Board and the South Wales Programme Board will assist in moving the process from engagement toward formal public consultation. 19/12/12 Member of I would like to express extreme concern at the proposal to move some specialist public services, including critical A&E, to a new location even further and more difficult to

125 reach from Powys than are Nevill Hall and Prince Charles Hospitals. The new location is, I understand, at Llanfrechfa, to which there is no readily accessible public transport from Brecon for relatives or patients. Also the prospect of transfer to such a place can be very alarming, as I found in 2011 when I was suddenly and unexpectedly taken to the Royal Gwent, whose location I did not even know then, in the dark, in an ambulance, and with a supposed stroke. It was much worse for my wife, following in a car on unfamiliar roads. Furthermore, I got no treatment when I got there. I would not wish that kind of experience on anyone. Please resist this proposal to move even more of our services even further away.

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DATE FROM WRITTEN RESPONSE WRITTEN RESPONSES RECEIVED BY ABERTAWE BRO MORGANNWG UNIVERSITY HEALTH BOARD During the engagement process, ABM UHB discussed the South Wales Programme ideas and its Changing for the Better programme about local issues and service change - this is reflected in the comments received. September Comments from 1 Distance to travel if Princess of Wales (POW) downgrades; short- to members of the sightedness of NHS regarding staff shortages. Have you yet made December public recommendations? Should not this been patient-led not staff? Changing for 2012 received by ABM the better don't agree; can you imagine having to travel 50 miles north of UHB at its Bridgend to Merthyr Tydfil in winter conditions? Misleading statement’: Changing for the "you may have to travel to a nearby hospital. Thanks for the consultation Better public please note points raised are important please listen. information drop- in days 2 If either myself or someone in the family needed to go to A&E then this should be accessible and near. It is not good enough to either go to Cardiff, Swansea, Llantrisant, Merthyr, how would we get there? The time delay? Cost too much? Would cost lives. I realise there is a shortage of doctors but this isn't the real issue. It is the cost of keeping all the A&E open in all the hospitals. We have a good NHS but it is being eroded. Lack of beds, etc. Community care has increased but we still need hospitals and beds. Not everyone can be nursed, cared for in the community.

3 Concerns over Swansea voluntary organisation (specific identifying information has been withheld)

4 Paid £37 for taxi to Singleton following ambulance not turning up. Received paperwork for reclaim but Ophthalmology patient and papers that are large print.

5 Please look at the centre of the map, and Bridgend is the most central hospital in South Wales. Train, bus or air. There's more money spent on homeless down and out people in Bridgend. Years ago Bridgend was a mental town, now it’s the down and outs. This Welsh Office wants to update its staff.

6 I have had cause to be a patient at Bridgend and Llandough hospital since February 2012. Whilst I have no complaint with any hospital staff in either hospital - on the contrary everyone has been wonderful - my problem has been with the system which requires constant consultation with other hospitals. Meetings which only occur monthly which delayed decisions on who would take on my care and where that care and ultimately my

127 operation would take place. This meant worry, from mid February until 28th June before entering hospital.

7 Concern - care in the community - not enough personal care time is allocated to each client. Call times often do not suit the client. Often no choice in when calls are made - clients not getting up early enough or put to bed too early. Where possible there should be one dedicated carer.

8 Second class NHS system in Wales for children. "Paediatrics" is under funded. 18 weeks wait re-occurring despite being consultant to consultant. Free prescription charges need treatment after diagnosis LHB do not give funding for treatment or delay giving consent. Equality of care for all children conditions. Wales has got a terrible NHS I didn't realise.

9 The most common issue raised by my constituents is providing a home visit, I am aware of medical nurses being used for this purpose which is good but as the population gets increasingly older I believe and many others also believe that the home visit will be increasingly more important.

10 It appears that ambulance drivers are no longer as "local" or as familiar to their "patch" as maybe they once were. Specifically key locations such as residential homes/sheltered housing, etc.

11 Future of Tonna Hospital - need a response on future of the hospital.

12 Concerns raised regarding provision of equipment (crutches, etc) from various ABMU departments. Concern that there are insufficient control measures in place to have equipment returned. This leads to "waste" of financial resources to replace this equipment. Finance that could be better targeted. Workforce management would be identified medic shortages. Why has this been allowed to hit a critical point and not resolved earlier?

13 I have had multiple sclerosis for 15 years had no support from my consultant. I do not even know who this is. I only have a number for an MS nurse at Morriston Hospital, this number is not manned and can sometimes take days to have a response from a message. It is only through my own positive and self manageable attitude that I have remained so well.

14 I am a third year counselling and psychotherapy student at Swansea University. My GP informs me that there is currently a two-year waiting list for psychotherapy on the NHS. Also I recently had a client who was released from ward F at Port Talbot Hospital with no support, no therapy just drugs. Why don't the NHS use current counselling students to ease the pressure on the NHS? At least then some therapy in a controlled environment is better than no therapy and potential suicide!

15 Recently diagnosed with a large breast lump by GP who wrote letter to

128 hospital on day of consultation 9th November 2012. Today is 19th November 2012. I have heard nothing from the hospital. This is not acceptable being this could be a potentially life-threatening condition.

16 I think it is vitally important that when decisions are being made about the provision of health services, great attention should be paid to the transport infrastructure particularly public transport, so that people can easily access the medical centres where the provision is made.

17 I facilitate the Swansea Disability Forum. At the last meeting of the Forum I gave out copies of the Changing for the Better booklet and people were concerned that this series of meetings encompassed the whole of the consultation. It doesn't appear clear for the public the difference between engagement and consultation.

18 Fractured communication between A&E, GP and paediatric consultants about patients' history. Why are patients records still not digital and accessible e.g. at A&E. Son had anaphylaxis - several episodes require A&E but not admission, but A&E didn't have record of his previous episodes - why not? Son has eczema. Consultant dermatologist will prescribe medicine that GP reluctant to add to son's repeat prescription, why? Extremely inefficient the number of repeat items on repeat prescription - regularly mis-prescribing by GP - silly things - strength of ointment, ointment vs. cream, etc. Means calling at pharmacy, then GP, then requiring correct prescription, then return to GP wasting an hour of time. Why isn't it being used better? If other organisations can keep a big database why can't NHS?

19 Acute eye clinic Singleton. Access via referral from GP very good - but why are appointments currently made when the actual waiting time (for wife) was four hours. No admin support after 5pm - clinic being run by two doctors who were continually being interrupted by calls from A&E on to book patients manually into a diary - doubling the duration of each session. Surely you can employ admin staff after 5 pm at Singleton?

20 Access to local GP fantastic. Can see doctor same day if required. Well done Primary Care Centre.

21 Free prescriptions. As lifelong asthmatic this is great for me long may it

129 continue. I am glad to be Welsh just for that.

22 Need to accentuate the importance of Neath Port Talbot Hospital and its additional issues - to maintain local services.

23 Hadn't heard about drop in sessions. Heard via church word of mouth.

24 Many illnesses are self-induced by a voluntary lifestyle i.e. drugs, alcohol, smoking, obesity. Surely patients should not receive full medical benefits unless these basic causes are faced. An alternative would be to make these people pay for their treatment as it is self inflicted.

25 Concern at lack of chiropody clinic, GP clinic and communication.

26 Obvious declaration on pge 16 of the booklet; states that shortages of middle grade rank doctors. Then offer a bursary of £750,000 to encourage doctors to commit at "least" five years obligation to Wales and with any other help they require remember it "can" be done, with a little application.

27 Believe there should be a token charge for prescriptions - a great deal of wastage at present. How can we balance out budgets in Wales when in England, patients pay over £7 per item. I believe there should be a token charge for car parking again, abuse of "free" system. During the recent scare over breast implants the NHS in Wales just widely offered free replacements for all, instead of stating that the private medical services who had not the initial operations should be responsible. When provided with crutches at A &E after a fall no mention was made of returning them to the hospital. I believe a form should be signed so that a record could be kept of when he was given them and when they were returned. When having a number of blood tests and scans after each stage recalled to the hospital and seen by a registrar. The attention was excellent but so much time was wasted. The consultation was extremely lengthy and not at all time efficient. GPs have 10 minutes but each consultation last approximately 25 minutes with very little feedback given. Attended hospital to have a "magic eye" the nursing/technical person present at the outset was very disrespectful to the doctor before the procedure and when he went out of the room she was very critical of him. The staff rota was badly planned there was a delay of at least one hour due to the fact that there weren't sufficient nurses present. Time wastage. (personal information withheld)

28 I am naturally concerned that monies are wisely spent in providing the best possible service and I am convinced that much inefficiency and waste still exists e.g. surely token parking fees and prescriptions would prevent the many abuses that are currently occurring. I can see that rationalisation of our major hub hospital services will be vital and this may initial consequent closure of some minor centres. However, the creation of regional primary

130 care centres (which of course may re-use some of the previously mentioned centres) I believe vital - within any facilities e.g. minor x-rays, phlebotomy services and possibly, social services also would be a great asset to a community. (personal information withheld)

29 Please finish this plan looking at bereavement for both adults and children. Responsibility needs to be taken for children not eligible to go to CAMHS. Third Sector organisations can provide the support but please make sure money is given to them to provide this care. Life is a circle - good bereavement support completes that circle. Good support in the early days saves money by having more complex issues later on.

30 From residents living in large council estates e.g. Townhill, Mayhill and Manselton areas, disappointment that ABMUHB not holding these events nearer to their homes e.g. why has Phoenix Centre not been used. Many of these residents do not have access to cars etc and find difficulty and cost of travel into town where event held at Grand Hotel. Please consider this issue for future events.

31 When information will be available to allow patients to have an informed new of the quality/mortality rates of different hospitals, and of different consultants. One ought to be able to look up a consultant and see his/her qualifications, career path, experience, and (carefully presented) surgical success.

32 How to respond to questions 3, 4, 5, 8 and 9 was not understood. Very confusing and help sought actually gave varying opinions and more confusion. I don't feel that these questions will help with accurate feedback.

33 The all important consideration is the continuation of the NHS within Wales. In England the service is gradually being privatised - breaking the sacred bond which Aneurin Bevan set up. A political yes but it affects us all.

34 Yoga for Healthy Backs teachers deliver the most recent (and largest) researched, beneficial and cost effective programme for back care (research carried out with York University and funded by Arthritis research UK. Findings published in 2011 in the "Annuals of Medicine and Spine"). The specialised programme of 12 weekly, 75 minute group classes is being delivered throughout the country - with 12 teachers now delivering courses for NHS in Cornwall as AQP (any qualified provider). The programme is being used internationally and more details can be found on websites. The programme would contribute to the care in the community and have huge savings for the health board.

35 Expanded use of GPs to provide a more extensive community service linked more strongly with community hospitals. (The system years ago was good but lacked consultant intervention and support). This would take

131 pressure off regional hospitals and in particular A&E (latter tends to be a nerve shattering wait). Highly specialised centres of expertise will be fantastic and productive however patients require support from family for basic, practical and emotional sustenance. Widowers, etc require family or friends to supply support to obtain peace of mind which assists recovery.

36 Ambulance service response times. The ambulance service is in difficulty. Will making emergency centres, fewer and further apart improve this problem or will it tie up vehicles even longer? Surgery hours - surgeries now keep office hours with no doctors available at weekends or evenings. Patients prefer doctors they know. I hope the Maesteg Community Hospital can provide an evening and weekend service for minor accidents and reassuring advice and consultation if required.

37 With the planned changes, I would like to be assured that good quality care remains intact. I witnessed the change for delivering education from special units/classes to the later model of delivering education in the main stream The belief of integrating "special needs" pupils I firmly believed in but specialist teachers, resources, back up services did not reach the mainstream situation to the level required. Good ideas transfer into good practice only if resources/requirements are available. Moving medical services into the community is a positive attitude but it will only work if the required resources and skilled staff follow. (personal information withheld)

38 Concerns raised over continual cancelling of family member's surgery. (personal information withheld)

39 Concern raised regarding transport to Princess of Wales Hospital. (personal information withheld)

40 People didn't know about the event. Called Neath Port Talbot Council and Neath Town Council and they didn't know about it. Advised to contact the library who also didn't know about it. Concerned that others wouldn't know about it and wouldn't have the opportunity to have their say. Found out about it through a friend and had called to confirm whether the information she had was correct.

41 To allow the "Changes for the Better" to succeed in Porthcawl we consider it essential that immediate steps are taken to provide a new health centre. The provision within the "Regeneration" plans have made no progress. 21% of Porthcawl population are over 65. A primary healthcare centre will ensure Porthcawl residents can accept the changes being proposed.

42 Urgent action needed towards the provision of a local primary care resource centre.

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43 Need to urgently clarify position regarding development of new health centre in Porthcawl. Need to include community in developing solutions and being clear what barriers are. Must identify list of problems and priorities. The community is suffering because progress isn't being made. Porthcawl needs to be a priority for primary care development.

44 Swansea Medical School - What was/is the cost; How many doctors have we trained; How many have stayed in Swansea/ABMU/Wales?

45 We in this valley are very concerned about how we are going to get to these new hospitals. Not everyone has got a car and if anyone is seriously ill by the time we get out of this valley a lot of people will be dead. The ambulance service is not to blame for late times turning up, because of the difficulty getting to people. It’s easy to say that family doctors are taking more on, but you cannot get them out, out of hours.

46 Transport - previously found difficulty in travelling to and from Neath Port Talbot Hospital. We do not have our own transport and have to rely on public transport. While we can at the moment get to appointment in PoW Hospital, going further afield, especially in emergency, would cause serious problems both in expense and transport. To get to Merthyr would mean hours on the bus plus time waiting for connections. (personal details withheld)

47 Transport to Morriston, Singleton, Merthyr are very difficult to get to fro Maesteg There are no buses to Swansea on Sunday and bank holidays. If you got to the University Hospital in Cardiff it is very difficult to park now as it is in all the hospitals. In emergencies I think Princess of Wales is far enough to travel especially pregnant women and people with heart attacks and stokes. It would be a matter of life or death. Perhaps we could sack some of the chiefs and get more staff on the wards.

48 These issues have been raised by public at recent event. Transport - people having to travel outside of Swansea, e.g. Bridgend Hospital eye clinic. Six visits, how can they afford to pay. Bridgend Hospital - to claim back from Welsh Government it is aimed at mostly younger people, who are on benefits. Older people are disadvantaged. Suggestion - can details of how people claim back monies be added to onto the appointment letters, which will ensure people are aware. (personal information withheld)

49 Concern raised about future of Princess of Wales Hospital. Good idea would be to have children's nurses to visit children at home instead of all

133 being hospital based. (personal information withheld)

50 Issues raised regarding loss of paediatric services from Princess of Wales Hospital. Transport times are too long. Is ambulance service being reorganised? Issue regarding A&E department. How is it going to cope with more patients?

51 Poor publicity regarding event; Informed by Church notices; concerns regarding transport for visits to access health services.

52 Tried to ring Morriston A&E to change physio appointment time, series of options, cut out after 4.5 minutes. Why continue to have physio at Morriston and not other sites.? Physiotherapy in community networks would be more appropriate/accessible. Felt that events not publicised enough, GP surgeries, libraries.

53 With the proposed changes I feel very concerned about the potential for further travel and less access to more local acute services (A&E). The cost of travel for relatives would be prohibitive and this could lead to lack of visitors, increased stress for patients coupled with a concern about travelling time by ambulance in an emergency e.g. stroke, heart attack etc. The reliance on GPs and the voluntary sector being potentially increased is also very worrying as the current GP services have poorer access than before the last changes were made. I had hoped that with the apparent large spend on the Princess of Wales Hospital over recent years that this hospital would serve as a major asset of the NHS Wales including acute A&E and other services.

54 Public are not aware of all in implications of "Changing for the Better". Better informed such as a copy should be sent to each household. Worried about the effect on ambulance services. Has enough been done to recruit doctors to work locally. We know the changes to recruiting doctors from outside the EU and the change to doctors working hours but what about UK trained doctors? A&E cannot cope at the moment - albeit long numbers using A&E inappropriately. Starts at primary care and patients not being treated by their GP.

55 Regarding the suggested closure of Bridgend casualty unit - this unit I have known over 40 years. The service has always been excellent when I have taken friends and relatives there on quite a number of occasions. It's proximity to the M4 is one of it's assets. (Not everyone has transport especially the elderly and infirm).

56 A&E facilities - Port Talbot, Morriston or Royal Glamorgan, Llantrisant would be too far to travel if an emergency took place. Bridgend is closer to Pyle, Porthcawl and should be left open. (personal information

134 withheld)

57 I am against the downgrading of the Princess of Wales Hospital in Bridgend. It is already geared up to cope with major incidents on the M4. Also I believe it is a centre for excellence for certain specialities. A lot of money has been spent setting up these services, which will have been a waste of money if the hospital is downgraded. Services in community are not working together for the benefit of the community now - different factions fighting against each other for their individual share of "the pot". There is already a lack of communication between hospital doctors and GPs, regarding test results and further treatment the patient ends up telling the GP. The Wales Air Ambulance Service is funded by donations and volunteer- led fundraising. How can Welsh Assembly fund this - some other service will suffer. Why are agency doctors and nurses paid for more than regular hospital staff? Why are members of health boards paid more than staff working at the "sharp end"? Treatment of in-patients cannot be run as a business different people take longer to heal and may have to spend more time in hospital than others.

58 Possible closure of A&E Princess of Wales Hospital, Bridgend will be devastating to the valley communities in and around the area. If people cannot drive it will take them four buses to get to Morriston and lets be honest if you need A&E you need to get to the nearest hospital asap. I have used A&E a few times and would have found it almost impossible to travel further than Bridgeway Port Talbot as I have no transport to get there. Let's be honest here, it's all about keeping the cities and consultants sweet and hang the rest of the working class communities. Get rid of some of the office staff and there'll be plenty more money in the pot. (personal information withheld)

59 Why are valley people being made to suffer fro the indignity of waiting for emergency healthcare, over half an hour drive to Swansea from Maesteg. Fifty people in Princess of Wales casualty today waiting for beds in Princess of Wales Hospital. It is full to the brim how are Swansea Hospital going to cope when Morriston Hospital cannot cope at the present time with planning their emergency patient's in beds. It will be changing for the worse as far as valley people are concerned. should be ashamed of closing departments in the Princess of Wales Hospital when he should be looking after the people who voted for him and getting rid of too any middle managers who are sucking the health service dry. The publicity for Maesteg people to attend this roadshow today has been very poor. I work in the health service and have watched the decline in services over the past few years. Doctors tell me that if applying for a job in Bridgend, from Asian countries they cannot get a visa to enter the UK as eastern countries are being given priority over the Asian doctors.

60 Distances with the increasing amount of traffic, its accidents, breakdowns

135 and repairs/maintenance issues guarantees on "times of arrival" are impossible to predict. Therefore, if a suspected heart failure happened in Maesteg or other life-threatening events, the ambulance staff, paramedics, although skilled would not be able to provide the necessary support to ensure the patients chances. A local A& E service is essential for the wellbeing of communities. Shortages of doctors. Because of the shortage of doctors in A&E and paediatrics such areas must be made more attractive - this could be done by reducing hours decreasing stress and anxiety; offering incentives to young doctors by offering the opportunities after a level of service in A&E in other chosen areas of medicine; increase support both administrative, physical by using skilled nurses to identify and treat minor cases to take pressure off.

61 Ambulance Service - the workers (WAST) do not feel fully engaged. Needs investment at grass roots - not just money but in informing and training the staff. Joint training of paramedics and emergency care practitioners, emergency nurses and doctors and inform the public. More communication needed about what currently available e.g. MIU at Neath Port Talbot Hospital. Transport is a major issue for the elderly and a new mum with small toddler/sick baby there would be charities to engage e.g. third sector/volunteers. Where is the local authority in Changing for the Better? We the public need to know that partnership/engagement is going on. Using volunteers in a structured way to raise awareness of developing problems e.g elderly on their own at home need support and how are we going to hear their voice?

62 Extra travelling time getting to hospital further away from home when time is so important e.g. heart attack or stroke. Extra stress for people travelling or visiting family. Hospitals being able to cope with older pressures. (personal information withheld)

63 Are the two programmes - Changing for the Better and the South Wales Programme details in the booklet as on the boards? Are these two programmes. Where the review started? Does the NHS funding for Wales come only from the Assembly? How do we keep informed from now on? Would the anticipated changes actually increased doctor numbers for training?

64 Finance - a recent television programme showed how severe the fraud took place when people came into our UK for medical attention. My family have worked all our lives contributing to National Insurance and when travelling on holiday abroad find it necessary to be covered by insurance which refers to that particular country. (Perhaps or) we should adopt the same rules, started from the ground staff. Our education system should encourage a career as doctors in the medical profession. Why is this? Is there difficulty in recruiting; salary; working conditions? Whatever it is these items/issues need to be addressed early. When choosing GCSE/A-

136 level subjects and career planning, good marketing techniques with the population growth. Within Bridgend County Borough Council and planned housing development I believe it is essential that Princess of Wales Hospital is made a regional centre.

65 The issues I am raising concerns the way elderly people might be nursed and treated in the future, if all community based hospitals are closed, the personal and community spirit of being admitted to a homely cottage style hospital will be lost forever, elderly people will miss the link of having their care to rehabilitate them to return to their "normal" way of life has been returned to the from the care of the nursing team at Gellinudd Hospital, what a waste of a good facility if this hospital is to close.

66 Why is there no afternoon visiting in Neath Port Talbot Hospital? Issues around evening transport if you don't drive. Afternoon visiting is important. Fully support the closure of Gellinedd due to the standards of nursing care there. Poor standard of food. Why are nurses using disabled parking spaces at weekends? Unable to park because of this. Nursing support staff need to be taught how to talk and communicate with patients. (personal information with held).

67 Having spoken to the staff here today about the issue of Gellinudd closing. I feel Mr Byron Adams has no idea how the staff feel about the closure telling the staff as far as he was aware are happy! The patient care at Gellinudd Hospital as is their support to families of the patients. Never in any other hospital have I ever received this open door policy. Do not close Gellinudd Hospital.

68 If they close Gellinudd and wards in other hospital, is the community ready, have extra carers and nurses been employed and trained in preparation for this. I'm very concerned about the ambulance service has their budget been increased with their extra workload, and have more people been employed? Is Gellinudd only closing because the land is prime for development?

69 Staff feel they have been kept in the dark over proposed closure. They think it was a viable hospital until staffing and services were out over the last year. This is when it stopped being a rehab hospital. They understand that £360k will be invested in the community - what will happen to the other £500k - it should be made clear how this will be used - honesty is required. There needs to be up front investment into community services before these beds shut.

70 The issue I wish to raise is that I do not agree with these future plans. I am against the plans to close Gellinudd. Gellinudd is a major part of this community

137 and has helped so many members recover also their families. I also think that it is scandalous behaviour to state that not all 30 beds are being used in Gellinudd when the hospital are not sending them forward causing hold up and bed shortage in main hospitals making your points seem valid but in reality you are causing this problem by not allowing patients to use these beds. DO NOT CLOSE GELLINUDD!! Allow Gellinudd to help your project by caring for the patients that may want to be cared for at home but health wise are not able to fulfil this. Gellinudd are a brilliant team and make a huge impact in this community team day to day.

71 The figures used in the C4B (Changing for the Better) presentations are only a “snapshot” (with regard to Gellinudd Hospital). Until recently, Gellinudd rarely had an empty bed and many of our patients are actually from the Swansea area (even as far as ). Our length of stay has improved following a small investment in staff. I feel that with further investment, patients would improve sufficiently to remain out of hospital for longer periods. When patients are discharged too soon, they often end up re-admitted to hospital within a short space of time.

72 Gellinudd Hospital – Uncertainty of its future in the community; major concern that the number of patients being referred is being reduced by the “system”. Thereby giving the IMPRESSION that the hospital is being underutilised. This is adding to the bed blocking in local hospitals – the patient care and family support is not being acknowledged – Impression being given by a member of the community council that staff in Gellinudd are happy with the situation is absolute twaddle – We need clear concise information, so we can make informed choices – rumours that Gellinudd is being closed to sell off the land, short term solution!

73 If Gellinudd Hospital closes, will there be adequate services to cover the patients who are sent home? Everything must be put in place for visits by

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the proper district nurses as well as just “carers”. Some elderly people would find it really hard if they weren’t looked after consistently and would miss the company and the regular attention of nursing staff.

74 Having read all the statements on your boards, you do not mention much about elderly care, if we do not have places like Gellinudd Hospital to help people get back to their own honest hen they would have to remain in the mainline hospitals and therefore bed blocking until packages can be arranged. I think the elderly deserve better and a great deal of soul searching should be done before you decide losing this much needed facility because this is not an old out of date building.

75 Very concerned about the proposed closure of Gellinudd Hospital. Feel that many elderly patients in the early stages of recovery require more support than could be offered in their own homes. Staff at Gellinudd Hospital are dedicated, trained and give 100% support 24 hours a day. Many patients suffer from early stages of dementia and leave patients very confused and vulnerable – who will support these patients 24/7 at home?

76 So sad to see Gellinudd going. A lovely hospital. Everybody friendly, great place to work for and excellent care given to every patient. I think too is very frightening to see if there is the way we are going forward. (personal information withheld)

77 Don’t support the closure of the hospital. Very concerned about the level of communication with the staff at Gellinudd. Staff feel very unsupported. Gellinudd is an integral part of the community and patients feel supported. This element of care will be lost. (personal information withheld).

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78 Feel patients are discharged too early often with complications and the aftercare is very poor. Supports Gellinudd remaining open. (personal information withheld).

79 I find this situation very worrying. Closing all our smaller hospitals, where are all these patients going to go? You say about care in the community, well I don’t think that’s going to happen even with extra money being pumped into it. What’s going to happen when they are bed blocking in bigger hospitals because nursing homes not available? It could be any one of us or a member of our family stuck in a queue in an ambulance outside!

80 Comments form completed to support the retention of Gellinudd Hospital.

81 The skills of the staff of Gellinudd Hospital have developed to be offer a excellent support, and care to patients. Many patients’ relatives would find it difficulty in travelling to other hospitals to visit regularly.

82 Proposal of closure of Gellinudd Hospital. This hospital has served the community well and is a big support in the area. Many of the patients are local and families are able to visit. The skills of the staff at Gellinudd have developed to be able to offer an excellent standard of care to patients suffering from dementia The focus on the patient’s individual needs and discharge planning ensure that they are on the road to returning to their home environment. It would be a great loss to the community should it close.

83 Firstly Gellinudd Hospital has always been full (30 beds) only now they are moving patients out. Most of the patients need a lot of care. So you think by putting them back into their homes they would have better care. I don’t think so. At the moment the community staff go in for about half an hour in the morning and a couple of times a day for the same amount of time. Some got family others haven’t got anybody. Yes, they got a nappy on that collects so much urine

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but I don’t think it’s the way to go. Lonely and left too long on their own. Not fair on them. There’s not enough community staff out there now. Just hope you do know just what you are closing. Gellinudd and other community hospitals are needed. The care is very good and they do recover a lot of patients to go home but they do need a stop hospital to get the treatment they need. Leave these’s patients in their homes and they will end up falling and back in hospital where there are no beds anyway. I say keep Gellinudd open.

84 Closure or proposed closure of Gellinudd Hospital. Acute complex patients need 24 hour care. Building at Gellinudd lends itself to be used as there are no hills around and within the grounds. Patients can be wheeled around easily. STRATEGIES – between social services and medical care are not fully in place so that patients can be fully cared for should they be sent home. Bed blocking at general hospitals will increase. Elderly people deserve care and respect. The League of Hospital Friends has seen good care and practice utilized over 30 years and more. With the new building opening in 1995 huge sums of money was spent making the wards ideal for elderly patients six bedded and 24 individual rooms for privacy of care and dignity at their time of life. Press release rather late for public consultation even though staff were aware last August and before of possible change. Uncertainty of job positions of staff possibly sometimes leading recently to certain tragic events. Please inform us of further public discussions on this matter. (personal information withheld).

85 From my own working and family experience, I know that for so many elderly people, the level of support they need goes far beyond the support, which a family can offer. Plus the family may feel vulnerable and inexperienced to deal

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with their relative. The need for individual skills and experience at a crucial point in a person’s illness is paramount. Community care should remain exactly what it says, in the community, the family are so important and their need for respite support should not be ignored.

86 Question – which wards at Morriston do the swab before the operation takes place?

87 Technician coming from Bristol to Phillips Parade every Monday – all orthopaedics should be under one roof for Paediatrics. The CDC should be at Morriston not Singleton. Not enough social work/support being organised before leave hospital. Shortage of doctors – we should pay the same incentives as other countries. Shortage of nurses – more healthcare support workers not qualified. Endoscope medicine (Neath Port Talbot Hospital) broken for six months and this was disgraceful. Nurses should change their uniforms before they leave the hospital.

88 Can someone check on the Princess of Wales and maybe other hospitals, car parking for blue badge holders within the regulated parking areas. The reason I ask is that a few weeks ago I can into the Princess of Wales at 8.15 am and found that two of the bays were completely full to my amazement. Can this be sorted out?

89 A&E doctors. A combination of such solutions should produce pressure and stress on A&E doctors to create a more manageable environment. The future of Maesteg Hospital. You tell us it is secure. However, you do no tell us what its future usage will be, surely Maesteg Hospital could and should be sued as a short- term convalescent respite for patients recovering from major surgery. Also, the hospital should be expanded as a “medical centre” to provide checks on heart conditions, annual medical/physical check-ups. Colon, breast, testicular and other cancers. Also, local GPs should be encouraged to carry out local low key surgical and medical practices at the hospital. Preventative and holistic medical

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practice should also be encouraged at the hospital.

90 Too much focus on Merthyr what about Llynfi Valley, this valley is deprived as well, more deprived. Transport – takes too long to get to Merthyr not good enough for people, heart attack who need urgent. No feedback re- Nantyfyllon Surgery, GP left today. Maesteg Community Hospital needs to stay open for local people.

91 Care of older people. While in hospital that hospital should be as near to their home as possible so that their (probably elderly) spouses and friends could visit. Visitors are important to their mental state and quicker recovery. Large hospitals are inconvenient for the elderly – the distance from car park/bus stop seems immense as do the long corridors. On discharge, staying at home is most desirable BUT the services provided are woefully inadequate and unsatisfactory. It was much better when run by the local authority when less rules and regulations enabled carers to provide what was actually needed. Closing the small local hospitals is not the answer. Patients get better personal care and recover sooner. Emergencies could be quickly transferred to the acute hospitals if necessary. The nurses do not all need to be degree standard. Bring back the auxiliary nurses who are more lightly to be more caring and help patients who need feeding and washing, etc i.e. have the right personality.

92 A&E services and ambulances. Closing centres and sending everyone to Morriston has increased their workload to an unmanageable level. The resultant backlog of ambulances is a disgrace – patients cold die in the ambulance and others die while waiting for one which is tied up. Personally, if I had an emergency I do not want a long drive followed by a long wait in A&E; I want to go to the nearest one. Ambulance staff would use discretion if it was care in the specialist units required.

93 Doctors/GPs coming out at night – so important. Epileptic and seizures happen

143 during the night but doctors don’t come out. (personal information withheld).

94 Cwmavon – workload for the GPS too high in this area. How many patients on their list and how is the workload split. One GP seems to have a excessive workload at list. Likely to have a knock on effect on A&E admissions. Better access to GP required and GPs to do many more home visits.

95 Welcome centres of excellence, must ensure “bed availability”. This should ensure no mixed wards, but tests, etc should be done locally. Non- emergency WAST, needs to be tight to allow people to be transported throughout all the system to support the whole system including the “centres of excellence”. Experienced phlebotomy cancelled – having only one person to undertake certain tasks will lead disruptions and this may lead to other delays. NHS Direct – concerns that this not responsive access to doctors. That access out of hours to GP for home visit is so poor that 999 used to go to A&E instead. Food in Morriston Hospital is awful, this will have to improve. (personal information withheld).

96 Transport – community – Could you please look at transport community services. Public transport, community transport, private paid transport. Length of time, availability, cost. Communication with community. Community services – could you look at transport community services. Lack of services in the community. Availability of professional, overtime change of staff. Communication to community. Infrastructure – make sure these teams of multi professional are available. That the way the tears are structure would be correct for the individual areas. Not for these changes to be money led but service let. Do not put into place any changes unless the new format is in place and working. Important please listen to what is being said, not what the engagement thinks is being said. Realise that all areas in the country require different style structure. The saying each area must have their own way forward. Do not forget communication does not mean a drop in day. But today has been a huge step forward for us in

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the valley. The thoughts of people must change, but you must understand that bad experiences are long memories.

97 Requirement for meeting in Glyncorrwg due to poor public transport links to Croeserw. Rumours of demise of district nursing services.

98 Brought along prepared response and thoughts including newspaper cuttings to reinforce concerns about – transport, the experience of Morriston Hospital. Fears of attending this site. Concern that patients are already being sent to Princess of Wales and Morriston for services that are provided in Neath Port Talbot Hospital (e.g. INR) and worried that this will get worse. Prepared response reads: Care in the community/Changing for the Better – a term brandished lightly by Bro Morgannwg Health board HA!! But where? Certainly at Neath/Port Talbot – high standard of cleanliness/staff who care and are conscientious, parking excellent and within easy access as is bus service. BUT three other hospitals no thought by planners etc to be better!! These people reside outside area, are younger than 60, have little health problems. For 60-80+ - Outside this designated domain some of us still drive at the moment. Can we part on arriving? Near to entrance? Mobility problems on arriving. (Press cuttings attached). Public transport to three areas – 2 buses = 1 to 1.5 hours duration if changes are on time. Taxi service approximately £1000 both ways (going and returning)!! Visiting hours – in-patients, public transport – no evening services. ? flexible visiting times. I wonder? No other family in circumstances. Shortage of funding WASTED FUNDS by paper pushers and so called administrators who are not familiar with ON SITE. SITUATIONS – Choice of care for us and many others is NEATH/PORT TALBOT. Easy parking always available. Public transport every 15 minutes to most parts. CLEAN/STAFF REALLY CARE AND TREATMENT IS FIRST CLASS. If your policy is to reduce population re 60-80+ by using this scheme. People myself included fear at the thought of hospital with this method in mind. Neath/Port Talbot was supposed to be for our area. The so called caring planners will reach this situation one day. ANEURIN BEVAN’s policy health care from cradle to grave – think on! We can either increase medication to fatal ends or buy a pistol. How is your conscience? Does it prick? Don’t you all care? September Comments 1 Until there are definite proposals there is no point. Too many "mays" to received from difficult to get a clear idea of what the new changes will mean in practice. December members of the Booklet is not value for money in what information it contains. public at engagement 2 Until proposals are more definite and not hedged with "may be" there events run by seems little point. Expenditure on this booklet must have been enormous,

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ABM UHB judging from the numbers available both here and in Morriston Hospital alone. There was little information to justify this cost.

3 I think you should have open access clinics where you walk in for treatments for back, heart, orthopaedic, neurology, etc to replace the current referral system.

4 I fear, bearing in mind the past 20 years the money of services in Cardiff, e.g. neurology. In particular my current concern revolves around the proposed "South Wales serious accident unit". I have severe concerns that no matter the relative pros and cons it will be based in Cardiff to the possible detriment of other parts of South Wales. I also believe this comment is a waste of my time - Page 56 refers.

5 Issue with access to orthotic services.

6 I fully support the centralisation of some specialist centres. Increase staff competencies etc. However, we should look at the fuller potential of all professionals in the workforce, e.g. look at the contribution of paramedic services, nurse practitioners, etc, for example how we practice. we should accelerate the evolution of all services.

7 Needs to get much publicity to get more people through the doors.

8 An extension of PR in smaller outlets.

9 Look at recruiting more doctors and nurses. This is where money should be spent. Spend money on training and employing more.

10 They will cost lives. The engagement process is a farce as the people this is going to effect the most have not been consulted.

11 Issues relating to ophthalmology department

12 Nothing will change until after period of consultation is over. Information given tonight enlightening. Very concerned at prospect of losing A& E in Bridgend considering growth of area and heavy traffic on M4 leading to many accidents. Can see sense of "centres of excellence" for dealing with serious illness e.g. head trauma, burns, paediatric and obstetrics.

13 I have concerns over initial assessment being increasingly reliant onto the paramedics, so that they go to the correct hospital for treatment if there are more we of "care in the community" we need to ensure that it is properly funded and staffed correctly.

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14 As long as quality services are available within the trust then I believe the general public would understand the need for rationalisation.

15 Transport for OPD as many services are possible for health at as any centres as possible but only within budget and at highest standard. Remember everyone cannot live forever, self-help important.

16 I’m particularly concerned about emergency calls (999) how for people will have to travel to get quick treatment. Will there be enough beds for these patients when they arrive at the centre of excellence?

17 We need more time to think and digest what we have seen.

18 Er fy mod un deall y rhesymau dros angen newidiadau, mae lloliad gwasanaethau yn gofid. Hefyd mae'n bwysig bod trafnidiaeth wedi cynllunio ac, ar gael i scrhau bod pawb yn medru curraedd gwasanaethau. (Even though I understand the reasons behind the need for change I am concerned about the location of services. In addition it is important that transport is designed and accessible for everyone to reach the services.)

19 I agree strongly with the plan to improve/modernise services by concentrating key services in (what I hope will be) centres of excellence. Obviously, I would like to see local hospital (Princess of Wales) as one of the proposed regional centres.

20 Didn't know where ARC Centre in Bridgend (helpful to have further information regarding address of venue.

21 Although informed that no decisions had been made yet regarding changes to services, resulting in the downsize of services provided, working on the frontline, I am fully aware of changes already and not necessarily for the better all staff or importantly patients.

22 Bridgend is a very central and fairly newly built it seems strange that it might be downgraded.

23 Obviously monies need to be available in order to set up an excellent structure for care etc to take pressure off hospital facilities. Start at the bottom eventually save monies at the top.

24 I think the ideas are sensible and practical. It is vital that there is adequate support regarding transport when patients have further to travel to hospital (or back home upon discharge). A long bus journey would be very uncomfortable for someone who is not feeling well. Also parents of sick children may need help with transport when travelling further afield.

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25 Just simply the geographical position of the Princess of Wales Hospital is in an ideal position off the M4 corridor covering all points of the compass.

26 Put patients lives at risk, by downgrading Bridgend is not the answer, regional centres are fine for certain things, heart ops etc, but everyday things like midwifery, A& E and children are bordering on the ridiculous.

27 Main concern - losing local facilities and care, specifically Princess of Wales as a complete hospital. Travelling, time factors would be affected by moving health care further from our locality.

28 Too many comments to outline here.

29 More information, people need to know about these meetings, not everyone has access to PC, poor advertising, I didn't receive any information through the door (major issue).

30 Time will tell!! Are to too late to make a difference.

31 More investment must be made in community care if this proposal is to work.

32 The main worry for this area is the proposed closure of the Princess of Wales Hospital. This has excellent facilities which would be denied if various parts closed. Also the locality is important as all other hospitals are too far away.

33 Mae angen gwasanaeth ambiwlans da. System i ddiogelu pawb - mae angen ysbytai yn agosach at Gwmnedd. Ystyried fod nifer o bobl. There is a need for a good ambulance service. A safe system for everyone - there is a need for hospitals closer to Glynneath. Consider the amount of people. 34 Ambulance service is very poor and to get through to the doctor can take up to 20 minutes on phone.

35 To save the health services, centralise the health boards, so that patients can go to the nearest hospital which will be better for the patient and relatives.

36 Changing our Health Board that we are nearer to an A&E - make Neath Hospital and A&E unit to alleviate Morriston and Bridgend to specialize.

37 One of the most important problems the future of the health service. Absenteeism in the services is another. Can’t own-grown doctors and

148 nurses be employed?

38 This booklet should be sent to all the residents who live in the ABMU health area, because of the serious changes that will take place.

39 It would be good to have an event on a weekend in each area. I would like to have had a leaflet through my door and book telling me about everything. Not happy with some of the changes, happy with others.

40 Keep Neath Port Talbot Hospital and Prince Charles Hospital for local people i.e. Glynneath, Banwen, Cwmgwrach, Resolven, etc.

41 Ambulance service? What is happening? Don't expand Singleton Hospital.

42 Would like more information as I feel we in the Upper Dulais Valley are - have not been thought about when making any decisions regarding our health services.

43 "Regional centres" are OK, but not for people who live far away. Concerns about A&E. Would this improve at Morriston/PoW Hospitals Upper Neath and Dulais Valley furthest away from hospitals. Transport problems for elderly people. More care "close to home" is a good idea. Neath Port Talbot Hospital can this run on a "smaller basis" would it close all together?

44 The concept of regional centres of excellence is a good one, however there needs to be a first class community facility and a proper integrated transport system to support this. No one wants to be in hospital so treatment locally or at home is the way forward.

45 Sort out the ambulance waiting outside A&E taking the ambulance out of service.

46 We in Glynneath are far away from the hospitals. The information on the boards do not address this issue. The "golden hour" will not apply to us.

47 Glynneath (Pontwalby) is 12 miles from Neath, 35 miles from Bridgend - I'm not certain where A&E is at present. 48 I will provide detailed comments in due course.

49 Disagree with all aspects.

50 Too much information not enough facts. Most people unable to read/didn't know about this event. Why are you moving services further away from people who need it most ? (Most deprived areas). Why does

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Wales always suffer? Less money for education, health service, etc, etc. Ambulance service to suffer.

51 Never was a title so ill conceived. It’s not Better but then "Completely Bonkers Changes" wouldn't go down well would it?

52 Totally disagree with proposed changes because the Dulais and Neath Valleys are furthest away from essential services in region. Major issues regarding transport Morriston and Bridgend on M4 corridor, Singleton across a city centre. Ambulance service in crisis putting us more at risk. Not enough capacity in Morriston or community to deal with extra influx of patients.

53 Concentrating too many resources in too few locations. What would happen if one or two of these sites were made operationally defunct? Need a greater spread of hospitals with adequate services not fewer. The fewer the number of A&E units then the longer the waiting times at these hospitals. What is the use of getting to a hospital and spending hours waiting to be processed through the system. The selection of hospitals should make allowance for the topography of South Wales. Health board divisions appear to be somewhat impractical and poorly thought out. Room for improvement here. Time the Welsh Assembly sorted out how Wales is divided up on a number of issues - one of them seem to be co-ordinated, e.g. divisions for health, fire and rescue services, regional waste, water, gas, electricity, railways, etc. I think that the assembly should go back to the drawing board and get, not only health right, but everything else as well.

54 Looks good on paper. In practice maybe not.

55 The Princess of Wales serves my area – if certain services are moved to other hospitals, how do patients without cars get there? The public transport system to the main hospitals listed is nonexistent from Bridgend, e.g. I have to attend an appointment at the Neath Port Talbot Hospital. I don’t drive. I am going to have to catch three buses and in the evening there are no buses from Port Talbot to Bridgend.

56 I believe any extra travel for me would be a danger too far. I frequently visit Bridgend A&E and receive great care. It should stay efficient and caring (personal information removed).

57 Video presentation in wrong place as the sound was overpowered by excessive background noise. All sounds good on paper but hadn’t really addressed the issue of costing. I fear the public are being told what they think we want to know. 58 SHORT TERM SOLUTIONS. If there are less middle grade doctors in a few years there will be less consultants. Initiate a better route for doctors. What happens in bad weather when unable to travel to hospital?

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59 The stoma unit in Bridgend is closed. The health service should be spending more money on doctors to train them more qualified nurses in Neath Port Talbot. NPT hospital gave me brilliant treatment – great.

60 Need time to absorb the ramifications of the proposals.

61 I recognise the need for change and centralising services seems sensible provided that extra travelling time will not adversely affect patients. Better community care is to be welcomed to keep elderly people in own homes – but all treatment must be undertaken with the dignity of the patient paramount. Worry regarding A&E facilities. How many venues?

62 Transport problems in getting from Tonna to Princess of Wales. (Personal information provided).

63 NHS needs extra funding in Wales – lobby Welsh Assembly for more funds – do not cut costs! (or reduce services) As the worst performing trust in Wales – a sticking plaster solution won’t work.

64 How much have these all cost? Could the money have been better spent on patient care?

65 It all sounds very good and does make sense let’s hope it works.

66 Minor hospitals need to keep their out patients clinics so that patients have less travelling and waiting list could be kept down. Major hospitals as centres of excellence.

67 I better understand it since this visit and feel it’s all inevitable unless there is a vast increase in doctors and or budgets.

68 Yes, but I need to find out more before I do that.

69 How long will the new ideas be brought in?

70 We need to know what is happening where. OP clinics kept locally. With population increase all areas need a “centre of excellence”. You will not have trained staff coming along if there are no training facilities available. The downgrading of Neath Port Talbot has resulted because there were no prospects for staff there.

71 I have gathered a great deal of information from websites and this visit. In general I understand; 1. Changes have to be made to the NHS; 2. These proposed changes are well reasoned; 3. Good public consultation has been done.

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72 Care in the community – paramount specialist care ok in specialist centres. Funding should fundamentally change i.e. separate taxation = ring fence

73 It is well needed as there don’t seem to be much going for the area.

74 I understand the need for specialist centres but, after having first had experience of the children’s ward at Bridgend hope the ward does not suffer as a result. They provide a fantastic service just as it is.

75 My concern is if I need A&E where will I need to go – as I don’t have my own transport.

76 Transport – logistics regarding patient movement, timing and weather conditions. Shortage of doctors, why? Trained in UK, work in UK for prescribed time. Misconceptions of Wales. Trust titles not helpful for non- Welsh.

77 We would like more information and definite time and dates of when these changes are going to happen.

78 More detailed information needed. Better promotion of publicity in community area. More input from people who have practical solutions to entrenched problems.

79 It’s all cut and dried anyway. These meetings are poorly advertised and a complete waste of time.

80 I was unaware of this event. This maybe me!! Has it been adequately advertised??

81 I have been reassured on my visit and am satisfied to hear of your “Changes for the Better” (although I don’t much like change at my age!)

82 Will all the proposed changes cut waiting lists? I think one should have treatment when needed at the time. It is available if one pays, not everyone can do it.

83 To “change for the better” and the cost savings incurred seems on the surface a good reason to look closely at the proposals.

84 The U/M is only for use once further “new” information is available.

85 Yes, discussed and action to supply to ABMU agreed.

86 Very informative, the suggestions given seem on the whole good, but will read the booklet for more information.

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87 What we have read and seen at the venue is informative but would like to read booklet before commenting further.

88 What we have seen so far at the venue suggests improvement.

89 With such an important issue it’s very gratifying to see that so much thought has gone into planning such a series of events to inform the public and members of the community.

90 What was on show appears to be very informative and makes sense for the future – but will read booklet first.

91 My belief is that Changing for the Better is anything but. Why can’t the trusts look at ways to recruit more doctors – make the job more attractive. People have not got the same confidence in the GPs as the trusts have. Day to day problems in getting appointments etc are worse.

92 More advance notice and clarity on information.

93 Too much information to read and digest. Worried about impact on ambulance services. Every household should be given a copy.

94 I am taking the forms home to truly reflect my views. This is a serious subject which requires thought and deliberations. My opinions are measured but “framed” in history and protection.

95 I guess these make sense in the 2000s.

96 (Need time to think about it). It’s all down to finance provided for all these changes.

97 Haven’t fully read changes yet.

98 I feel our many issues regarding hospital stays etc, have not been taken on board. (Personal information not included)

99 No literature received in CF36 5NH.

100 The staff were well informed and extremely helpful. We discussed transport from Porthcawl to Morriston, etc. The need for a health centre. (Personal information not included).

101 I think you have made up your mind already. Millions spent on Morriston – you must have decided years ago! Only found out on the day that this event was taking place. Poorly advertised.

102 Medical training at Swansea – is it a cost effective course. How many

153 have qualified, how many practising in Swansea? How much has it cost in total? Swansea building, etc.

103 Hospital should be kept as pathology for local areas. I find this convenient. Bring back hospital cook and staff. Bring back NHS employed cleaners, as contracted cleaners are slipshod and no pride in their ward and incur extortionate payment.

104 Seems like a good idea, but staff levels would have to be adequate. Need to consider travel arrangements for both patients and family to/from centres of excellence. Also need sufficient (free) parking for visitors at hospitals.

105 Is the population factor – pertinent to hospital location a major factor in eventual decision? Accessibility must also be relevant, e.g. Porthcawl to Morriston.

106 Difficulties for communities such as Maesteg to access services if moved from POW – public transport issues. Problems for ambulances to respond. Already having problems.

107 Transport requires to be reassessed when travelling long distances. I’ve written comments on a separate sheet and I’ve handed it in.

108 Old people do not have transport to get long distances.

109 The transport implications for patients need to be described when available.

110 More appreciation that there are different needs of patients and all need to be catered for. It would be a change for the better if for instance disabled patients were catered for better.

111 Prince of Wales Hospital is geographically the best of the choice.

112 I have submitted my comments on a pink form.

113 I don’t think the NHS has thought the whole thing through leaving themselves wide open for compensation claims.

114 I feel that a public meeting would be of more benefit, so that members of the public have the opportunity to consider points raised by other members of the public.

115 All these leaflets are about the change as you see it, not what is going to happen to the people it is supposed to serve. It is all going to happen anyway.

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116 Finance - My family have contributed to National Insurance and taxes for decades. If it’s not possible for everyone to do this, then a system of insurance to cover medical care should apply just as it applies when UK residents visit other countries. Education – schools should promote a career in medicine using good marketing techniques to raise recruitment figures.

117 Yn angenrehidiol I gael ysbyty I ddelio a damwainiau yn agos. It is vital to have a hospital to deal with accidents nearby.

118 I would not like to travel too far to get to hospital in an emergency.

119 I understand the need for change as I have two daughters working within the NHS. My concerns would be that people would not have to travel too far distances for general hospital services, i.e. elderly people.

120 I would like more information on the accident and emergency departments, where they will be based, what function each A&E department will be responsible for. How will A&E be divided? No one has considered non-motorists – as we do not have a good connecting public transport system.

121 I was told this was to help keep A&E Bridgend open.

122 Need for increase in ambulance service. More medical staff – less managers. Improvement of GP service so people can get appointments before minor conditions become serious. Why not just employ all these temporary doctors.

123 Having worked in the NHS for the past 22 years I have seen the changes that have occurred. I understand the concept of the proposals but feel that we need to be more proactive in public health and prevention and utilising the services we have effectively and not abusing them i.e. A&E, use of ambulances.

124 There has been a lack of information available I feel, we heard about this event via a church news letter. The venue I feel would have been better suited based within the town centre, more accessible to all ages.

125 Main concern being distance to A&E; Transport service for visiting; and issues in obtaining appointments with local general practitioners. (personal information not added).

126 Would need more information regarding the provision of A&E services in the Bridgend area.

127 More deaths if A&E closes.

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128 Would not like to see the A&E close at Bridgend.

129 Lack of information on dates of flu jab because of the cost of postage letters no longer being sent to patients perhaps these dates could be advertised in local supermarkets, etc. 130 Well presented, but counter arguments not put forward.

131 Taken into account age, geographic position of home in relation to hospital when making appointments. Consideration for children with diabetes.

132 We would be relieved to hear there will still be an A&E in Bridgend, which seems likely. We would also appreciate transport to Neath/Port Talbot and Morriston if necessary.

133 I appreciate these are difficult times and finance drives the decisions. I trust the extremely large population of older people in Porthcawl is taken into account when considering the future of PoW Hospital, Bridgend.

134 I have received information here and can get more on the internet if required.

135 Money should stay in this country not go abroad.

136 It would be useful to have a clearer view of where and how vulnerable elderly who do not attend a GP surgery or hospital will be identified before a crisis occurs. Will acute medical beds in the POW be affected? Having spoken to a ABM representative I understand community services will be upgraded to include IV antibiotic treatment, etc in patients’ home and social services care at weekends will be improved. Greater integration between the two services is needed plus a great deal of money before this can be provided. As the trust is already trying to save money, where will this come from?? I feel that more detail needs to be available at the open days, as without the opportunity to discuss this personally I would have been none the wiser.

137 Is a Change for the Better it doesn’t seem so. More people need to this information. How can people from Porthcawl be sent to Cardiff or Morriston – time spent getting there will lose lives in lots of cases not save them! The Princess of Wales should be available to us living here.

138 Biggest concern as we get older is will there be an ambulance available to take us to the specialist hospital and how long the journey would take. (Heart attack in mind).

139 Please keep initial visit to Princess of Wales.

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140 Concerns regarding travelling time and availability of an ambulance to even get to these speciality doctors. A local A&E (Bridgend) could refer after diagnosis. Elderly concerns i.e. heart attack.

141 I should like to know more about the ambulance service - will it be increased? Obviously I should like accident and emergency facilities to stay at Bridgend Hospital.

142 I think that unless Bridgend – Princess of Wales Hospital is made the regional centre there will be great difficulties in travelling for appointments, for visiting in patients, etc. Whichever centre is chosen good, frequent bus services will be essential. Public services to/from and within Bridgend are good.

143 I cannot understand why Princess of Wales A&E should be considered for closure, as it is on the M4 corridor, unlike Royal Glamorgan and worse still Prince Charles Hospital. Lives will be lost.

144 There are too few doctors at the hospitals as it is waiting times in some hospitals are up to 4/5 hours in emergency departments.

145 It is vital that Princess of Wales Hospital, Bridgend is given regional centre status. It is ideally situated centrally between the Heath and Morriston Hospital and easily accessible to the M4.

146 More thought given to genuine patients needing treatment. Hard enough for people to travel now without closing Princess of Wales, Bridgend.

147 Not changing for the better if possible patient no longer drives and lives alone (precluding lifts) to access out of the way new facilities.

148 More statistical information, more locally focused.

149 I am glad to hear there is a stroke unit at Princess of Wales Hospital.

150 While accepting the need for change I would be very concerned if there was to be any downgrading of the facilities at Princess of Wales Hospital bearing in mind its proximity to the motorway and the large population locally.

151 The ideas are good in theory but not in practice at least four and more hours in waiting time at present in a day and up to ten at night. We need more A&E at home. (personal information not included)

152 I’m sorry you have to make these decisions, I hope that every service

157 you need to make this work, will all pull together, and I can hope Princes of Wales Hospital will be picked to keep it’s A&E department.

153 Having been told that the A&E department in the Princess of Wales Hospital is under threat of closure. This is so frightening for people who may suffer from accidents or serious illnesses (strokes or heart attacks).

154 I will be interested to see how the plans develop as I have concerns about the accident and emergency treatment centres; if you develop new centres of excellence how will you recruit the right calibre of staff; missed wards just have to go in the new format.

155 Obviously living in Porthcawl I would wish the POW to be a regional centre. A consultation with 300 NHS doesn’t seem a lot.

156 Transport access to centres of excellence. Concerns of A&E departments. Necessary to have better information for the sessions.

157 This session has been very informative but it would have been better if it had been widely advertised. A&E is the first port of call in an emergency and for any patient to travel long distances will mean loss of lives. Bridgend serves a very wide area.

158 Go back to the drawing board, all hospitals should be specialist.

159 Before now I was firmly against any cuts to Princess of Wales facilities. I now have a better understanding and would be interested to learn the actual proposal.

160 I don’t want to sound negative but am opposed to any change for the worst, which some of the proposals are. Only fix the things that are broke, don’t change the whole system.

161 Good idea to involve public opinion, but don’t believe that any notice will be taken of public opinion. This exercise is driven by lack of funds. There isn’t any financial help forthcoming.

162 I would be interested as a retired physiotherapist to know what arrangements would be in place for physio, OT, speech therapy, etc.

163 Wrote on forms and spoke to doctors about shortage of doctors and new medical centre and English exam. What about learning disabilities and mental health futures?

164 I see no mention of either mental health or cancer provision – the latter needs to be improved as Wales lags behind England.

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165 All seems to be part of a logical necessary plan.

166 My husband and I might one day need the services of our local senior citizens hospital if not for our convenience but our family too. What a loss it would be to our community if Gellinudd was to close. (personal information not included)

167 Closure of Gellinudd causing much anxiety.

168 Byddai colli Ysbyty Gellinudd yn golled enfawr I’r gymuned lleol. Lle bydd y ceifion yn cael eu adleoli? Beth oedd angen gwario’r holl arian ar yr ysbyty yn ddiweddar. Losing Gellinudd Hospital would be major loss to the local community. Where would the patients be transferred? What was the point of spending all that money on the hospital recently?

169 Yes, keep all community hospitals open for the elderly to be looked after and cared for the way they should . It will be our turn next.

170 Concern at closure of Gellinudd. (personal information not included)

171 Require more time to consider details.

172 We agree the patient should have first priority before visitors.

173 No, perhaps we need more time to give it more thought.

174 Good, providing all sections of the NHS are prepared to pull together with the common aim of improving the service.

175 Get younger people involved, perhaps seminars at work/school/college.

176 Not at the moment, after reading the booklet I will have a better idea.

177 Not at the moment because I would like to have more time to read the booklet and consider it.

178 Very informative with some good ideas.

179 “ENGAGEMENT”

180 I feel the consultation is very comprehensive and is exploring all the options.

181 I have made comments on line but feel these sessions are excellent for us to understand the reason for change.

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182 I understand the need to work ……… and ……… but not as a loss to a local hospital wards.

183 Need to keep centre at PoW. Princess of Wales is at the centre of an expanding area. It’s an ideal site for regional centre. Two minutes off motorway. We need to sell the area for new doctors. Two minutes from M4; 6 minutes from sea and half way between Cardiff and Swansea.

184 I would like the Princess of Wales Hospital to remain the major hospital in this area. I look forward to further discussions to maintain this.

185 We would like to keep the Princess of Wales Hospital as our major hospital.

186 If PoW closed transport to other hospitals will be hard for some people, more doctors needed.

187 I have commented fully on the Issues form but I have very much appreciated the session and the discussion with the officers attending.

188 We are very much in sympathy with the objectives – but are just concerned that people will be apathetic about the new proposals and just critical of change.

189 Concerned about closure of A&E at PoW, Bridgend. Concerned regarding NHS Direct waiting call back up to four hours. Also the call comes from the Midlands.

190 Bridgend Hospital is one mile off a major M4 road link. Bridgend is growing day by day. Please consider this when you look to the future. This area needs most services (don’t kill us off).

191 We need more trained staff to stay here. We need our own ER department, not travelling for miles with seriously ill people.

192 How would Princess of Wales cope covering a wider area and more work?

193 More awareness for information to patients.

194 Helpful members of staff.

195 Concern of transport times if PoW has to change to a minor hospital. NB to help finance within the NHS prescription changes should not have been abolished and drink and drive-related illnesses should be paid for by the patient involved.

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196 I don’t think what you are proposing is for the better.

197 I don’t think what you are proposing is for the better.

198 Mae’r video yn syniad day n y sesiwn and roedd yr un Penybwl yn gwneud a bron yn ymhosib I darllen y posteri gydaf holl swn.

199 We are well informed as to the coming changes. (personal information not included).

200 Community networks are the mechanism for shift into community but they’re DEAD! Wound care and mental health needs addressing in Penderi Neath but not being supported locally.

201 There has been a lot of effort put into the presentations. Publicity regarding presentations has been very good.

202 If it involves mental health issues, how the area will accommodate this area of illness? 203 Issues relating to waiting times within Morriston A&E. (Personal information not included)

204 I see the point of “centres of excellence” but I ‘m concerned about the distance that some may have to travel in some emergency situations (e.g. stroke). There is also the concern of top heavy management and the finances that will therefore not be used for medical/clinical purposes.

205 It is sad to hear that the services of doctors are in short supply. One would think that should be right at the top of ABMU priorities. “Changing for the Better” suggests a first step of an improvement programme – people of ABMU communities need health support and care – the few main hospitals would fare better with the primary care being community based.

206 Will be interested in final outcome for the benefit of patients within regional hospitals and of course within the community.

207 Very concerned that the A&E department in Bridgend is insecure. Would be very concerned about a closure of this service. A&E medic -led services should be no more than 30 minutes drive away. Suggest we use actual costs of services to demonstrate why we are making choices about health service design. Avoid using % alone.

208 No. Everything is clear – all issues presented and hopefully will work for us all in this area.

209 With respect to finance I would like consideration given to a charge of £11.00 per prescription no matter how many items are listed.

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210 I will have to study the booklet before I can comment.

211 I am very interested in the preventative side of health and would like a campaign on healthy lifestyles. Many worry at idea of fewer, bigger hospitals, both for accessing care and visiting friends/relations, especially for children.

212 Concerns about travel to outlying hospitals – particularly when elderly patients, relatives, friends are involved. After care needs a lot more planning and staff to make the aftercare work for the benefit of the patients – needing much more time with each patient.

213 It would be beneficial to have some availability of medical advice within GP surgery for longer periods of time, i.e. Saturday and Sunday morning.

214 The “TV” presentations highlighted “lifestyle” problems but I did not notice any initiatives proposed to meet this situation. The activities carried out to date do not seem to be “converting” offenders more “preaching to the converted”. The chart showing average spend per annum per person against age was a revelation (to me). It also highlights total/actual costs on a per capita basis. Much more significant than “global” figures normally reported. Refer Page 32 of Booklet – “Not use illegal drugs” is too restrictive. Something like “Not misuse drugs and similar substances) would be better??

215 When I have read and digested the content of the booklet I will comment. However there are main areas of concern for me. Poor doctor diagnosis/lack of concern; lack of information whilst in hospital; poor after care service after discharge. (Personal information not included)

216 Having had it explained to me by the GP and medical director, there seems to be huge demographic and costings to take into account. It looks as if these changes are needed asap.

217 Mental health – care and support for OCD and no progress/moving forward. Under 16’s lack of community services. Disgusted regarding lack of support. NSPCC. STORM – no contact details. Very difficult to get referred through GP/GMHT/Group work.

218 An “open” house somewhere central for sharing ideas, feedback, untangling facts and reality from political spin.

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219 Computer-generated appointment letters are confusing and sometimes duplicate other letters. Some of the letters say urgent appointment is coming but they don’t say when in the computer-generated letter – BAD! Appointment booking lines are horrendous and can’t get through.

220 How will this impact on carers?

221 Information of the events only received through the Church.

222 Event not publicised only know by word of mouth.

223 Transport issues – bus routes.

224 Used seaside news for publicising information – banners outside library/PO – publicity. Ability of doctors and nurses to communicate effectively in English. Transport to Singleton when from other areas. Visiting hours at Princess of Wales Hospital problem not all day, in week, long day. CISS team wonderful. Unnamed people are calling/who to contact.

225 Concerns regarding transport from Porthcawl to Morriston. There is no bus route and costs £48 for taxi journey. Getting to hospital within the “Golden Hour”.

226 How long will I have to wait for an ambulance – if there are fewer hospitals?

227 Event wasn’t publicised nor was any information put through the post. It was only by chance two families were aware.

228 CF36 3HS – no information or leaflets at our address or at CF35 6BY. Member of public On hearing the so called rumour that A&E is closing in Bridgend, I felt I should comment by letting the stakeholders involved and the media know exactly what is going on and how we feel, hence the mailing list. The fact is that while Bridgend is growing in both size and population the health authority in its profound wisdom is thinking about closing the accident and emergency at the princess of Wales’s hospital and I am outraged. The reason for my anger is that over the last fortnight I have had need to use the A&E on numerous occasions due to my father’s illness. On all these occasions he had been kept waiting for on average four and half hours. The waiting room has on all occasions been full to the brim as my photo will testify(see above) this is at differing times of the day and night. The staff are

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not only having to deal with sick patients but also very disgruntled users of the department. The staff in the A&E endeavour to see people as soon as humanly possible yet many restraints are put on them. With all the issues they have to deal with they still manage to serve the patients professionally and compassionately. I cannot believe that the Heath authority are even contemplating closure of this much needed department and this is a serious failing on their part. I feel by making seriously Ill people travel to Morrison or further afield will only result in an increase in avoidable deaths. Where will this centralisation of services end? hospitals only in major cities or even just London! Bridgend area with regards population is growing all the time yet our services are being constantly eroded. I call on the health authority , the local MPs and AMs to do something to avert what I feel will be a great disservice to this constituency and halt the closure of the A&E or the consultation of closures in Bridgend immediately. My family and I would like to thank the staff at the accident and emergency for all the help and assistance they have given us during our visits there. This email has been composed while I am waiting once again facing a long four hour wait. If this department was not being used I could understand its closure yet a four hour wait tells me this service and department is required and kept exactly where it is Please help our NHS and the people who work therein continue to treat people locally and where it is needed in Bridgend .Thanks for reading this and hoping action is taken by those who are in a position to do so and the word is passed on by those who aren't . Petition Petition of around 700 signatures objecting against any downgrading of the POW Hospital, particularly A&E services. NHS staff member I have just attended the staff forum at Morriston which was useful and informative. It seems clear that the Morriston site is going to have significant changes with services needing to be moved onto site and that existing services will need to consider whether they need to be on site. We are just about to move into the new specialist rehabilitation centre (also known as combined services development) in January so it is not the right time to consider whether our services should be on site or not. The business case considered other options such as new builds or re-use of community sites but it was decided to proceed with a new build on site. I am not against moving into this new build but I am aware we could deliver our services from a community based setting and perhaps this should be considered over the longer term of the changing for the better programme. It may not be economically viable as the best option financially may still be to stay on site but it may also be that other services could be moved in and would fit better with the vision for Morriston in the future. If we were to move off site in the longer term it could be a golden opportunity to consider creating an integrated wheelchair and seating service. At present the wheelchair service provides the majority of wheelchairs and associated clinical assessments to Hywel Dda and ABMU from its Cardiff-based depot. So their appointments to assess patients are often done in inadequate facilities without equipment or workshop facilities

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to support this work. We provide the complex special seating service but if we took on the wheelchair service provision as well we could create an integrated service provided from a centre with appropriate facilities. The wheelchair service is commissioned via WHSSC so Hywel Dda and ABMU could opt to take this approach to providing what is a mainly community orientated service. I would be more than willing to discuss with the C4B team in more detail at an appropriate point. NHS staff member I have visited your web site and find it extremely unweilding and user unfriendly. Individuals in my workplace are baffled by all the reams of pages to navigate in order to give any feedback. In addition, it is not very clear that you do not need to register to give any feedback. I cannot see that the vast majority of people will persevere to go through the registration process..... indeed the individuals in my workplace were instantly ‘switched off’.... I can only assume that this is NOT the intention. Maternity ‘Changing for the Better’ document discussed with key highlights relevant to Services Liaison maternity and newborn explored. Committee Suggestions and Issues raised by MSLC • Are paramedics prepared/trained for longer journeys when women with intrpartum complications require transfer in? • 6,000 births size units are not positive places for women’s experiences and there needs to be a balance from the conveyor belt process of you’re a “breech birth” to a women going though the experience of birth whose baby happens to be in the breech position. • Concern that the home birth-rate may drop if women are concerned on transfer times to the nearest consultant led unit • Positive messages on public health particularly breast feeding • Women must have local access to antenatal care if they are low risk and high risk as its expensive for some families on low income to travel daily to hospitals for monitoring of their baby or themselves…cheaper for them to be admitted it will then put pressure on beds. • Need for midwife led environments of care and a choice within the HB Other noted issues The community drop in sessions are not well placed to attract pregnant women There needs to be much more clarity on the other HB plans as they impact so significantly on models of care and flows….they all felt there were to many unanswered questions to be able to come up with any plan for services. Partnership Changing for the Better/ South Wales Programme Forum The chief executive and the Director of Clinical Strategy attended the meeting to give a presentation on Changing for the Better and the South Wales Plan. The engagement document had been accepted by the Health Board at its meeting on 26th September and there was now a period of public engagement (between 26th September and 19th December 2012) when staff and the public are able to read and comment on the document. Staff Side enquired about why a significant sum of money was being spent

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invested in the Neonatal facilities when a decision about the future of such services was pending. PS confirmed that between £2 and £3 million was being invested in these facilities. This was felt to be unavoidable expenditure in order to have adequate facilities for the next 4 to 5 years before any plans emerging from this engagement process are implemented. Much of the equipment will be transferable if it needs to be relocated elsewhere in the future. Staff side expressed concern about the difficulties being experienced at attracting Medical Staff. BF pointed out that the Education Framework in Wales did not support the career progression of doctors in Wales as well as those in England. Consequently it was difficult to attract doctors to Wales and more work is needed to develop the Educational Framework to allow Wales to be competitive in attracting and retaining Medical staff. The South Wales Plan proposes large hospital networks which will allow for better training and clearer career progression. It was agreed that the Health Board needs to make much more of its University links. The Chief Executive stressed the importance of staff and the public having the time to read the document and to comment on it. He emphasised the importance of submitting measured arguments so that they could be properly evaluated. HL encouraged staff to send their comments in electronically via You Tell Us, which is a website hosted by the University. He also encouraged staff to register so that although all individuals would remain anonymous, their views could be sought on any future changes. He pointed out that staff were also able to comment in writing if they preferred. Socialist Health On behalf of the Socialist Health Association (Wales) I would be grateful if Association Wales you would supply the following information in respect of the above so that the SHA might understand more fully the changes that you are advocating. At this stage I am especially interested in:a) detail of the inpatient capacity that you are planning (for a future date of your choosing) in a number of key specialties, by selected hospital site,b) a comparison of your planned in patient capacity with that which existed as at 1 June 2011c) a comparison of that capacity and historic and forecast demand.d) any assumptions about changes in ambulance travelling times and distances (including air ambulance) that you have made. Hospital dataCould you please supply data for the following hospitals: Morriston Singleton Baglan Hill House Cimla Princess of Wales for all surgical and medical specialties and for obstetrics. Please show ITU, CCU, HDU or similar separately. Would you please show for each specialty, by hospital:

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1) total available beds - both historic and planned 2) average lengths of stay - both historic and planned 3) turnover intervals - both historic and planned. 4) discharges and deaths Finally, where your planned changes relate to services in neighbouring Boards - for example if it is planned to import work from Llanelli or Carmarthen - please identify the workload and capacity changes involved. Ambulance data Please let me have your assessed impact upon journey times for both road and air cover. NHS staff member I work in Pathology and we have already lost members of staff to Singleton hospital with cut backs. More of us will be following in January. We have been warned that a lot more cut backs will follow shortly. Our department was always such a happy hardworking place to come too, now everyone has long faces and continually worried as to what is going to happen next.

To hear now that A&E could also possibly close will be the nail in the coffin for Pathology!!! It is one long drive to Merthyr, surely many lives will be at risk here. A person having say a major heart attack, where every minute counts, would not make a 45 minute drive to Prince Charles Hospital in Merthyr. I just hope it will not be a member of my own family that it could well happen too. How about our elderly parents having to make such a long journey like that!! My friends Mum was bought in as an emergency last Thursday as she couldn't breathe, had she have had to travel to Merthyr she would have probably died. We must not allow our A&E to close. It is an extremely busy department and we all need it. Member of public Having read about your plans to move Singleton Maternity Department back to Morriston Hospital, may I point out that maternity is a purpose built unit of just 20 years existence. I would suggest that greater urgency be given to a larger purpose built department for Intensive Coronary Care. The patients and staff are enduring the most cramped and overcrowded conditions that I have witnessed in over 40 years of nursing!! I am sure Health and Safety would be appalled!! Pyle and Kenfig On behalf of the Pyle and Kenfig Hill Labour Party branch, I would like to Hill Labour Party convey our dismay at the possible downgrading of services at the Princess of Wales Hospital, Bridgend. We believe that paediatric, obstetric, neonatal and accident and emergency care are not specialist services, and merging these services would not serve the interests of the people living in the Bridgend area. On the contrary, we believe that downgrading these services could cost lives. These changes would also disproportionately affect the least fortunate. Patients that rely on public transport, such as the elderly or low income families, will need to use taxis when needing to use the services when public transport is unreliable (such as night or on Sundays and bank holidays). Additionally, it will be the most sick that will need to travel to use these services (and would be at most risk).

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Member of public After reading the article in the Glamorgan Gazette Thursday September 27th, I believe that downgrading the A&E facilities at the Bridgend Princess of Wales Hospital is quite literally a life endangering action. In the case of an already overstretched Ambulance service having to transport emergency patients to alternative hospitals, journey times from the centre of Bridgend are likely to be increased substantially. For example 35 minutes to Morriston or 26 minutes to the Royal Gwent hospital and that is assuming light traffic. There are many times when getting to Morriston would be the best part of an hour. For critically ill patients that really is not good enough. With ambulances having to travel further distances, then it follows that at any one time there will be less ambulances available to respond to an emergency call, the only remedy for this being more ambulances incurring greater costs. Quite a proportion of the population of Bridgend county are elderly and do not necessarily have access to a car. Taxis to get to these hospitals would be prohibitively expensive In most cases ambulances would not be available to transport patients or anyone accompanying them back home after the visit. Bus journeys would seem to be the answer to this but the journey times back to the centre of Bridgend are between one hour from the Royal Glamorgan Hospital and just over 3 hours from Morriston. Pity help them if they need to go further afield in Bridgend County Borough as this is going to stretch their journey time even further. Should we really be subjecting a 70 year old pensioner to this in a high stress situation. This does not really fit in with a caring society providing basic health care to the community. Using figures from the 2001 census, 21% of the population of Bridgend County Borough were aged 60 or over. We are told repeatedly that Wales will be suffering an increasingly older population size. We are also told in the case of heart or strokes that getting the initial treatment within a very short time period is the key to preserving the person’s health. Since older people are more susceptible to these problems, surely moving the healthcare facilities further from them is not the way we should be going. PT4L (NPT) Questions asked by the GP audience : relating to C4B 1. Investing in primary and community services has been talked about but where is the pump priming to develop services? It is hard to see how this can be achieved within the current financial environment. 2. What is the mechanism for the shift in resources from secondary care to primary care? What is the mechanism for increasing the number of primary care doctors? 3. What % of ABMU’s salary budget is spent on administrative staff as opposed to front line staff? 4. Enhanced services – there is concern that this will be raided to fund the shift of resources from secondary care to primary care. Can you confirm that this is not the case?

Member of public I have just found this e-mail address on the Abertawe Bro Morgannwg website and thought I would write to provide feedback on my experience. I am currently under this health board and am supposed to have regular

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colonoscopies due to having the genetic condition HNPCC. This genetic condition is present in a large number of my family members who are also under this health board and they also have to have regular colonoscopies. We are all due to have checkups over the next few months, however we have just found out that there is an issue in the endoscopy unit in Neath Port Talbot hospital which means the department is currently running a year behind with its clinics. Having contacted the department concerned, I have been advised that the only way I can have my check up this year (in line with the check up schedule recommended by my genetics consultant) is to contact the hospital via the raising a concern process. Having been told by the genetics team in Cardiff that I should be having checkups at a minimum of every two years I am appalled that I have to go down this route in order to have this important check, and now that I know they are running a year behind at present, I am concerned that this situation is only going to worsen over the next few years and that I am going to have to keep using this process every time my checks are due. Member of public Your leaflet “The challenges facing our local NHS” “Unequal Health” “A Growing Population” “Poor Lifestyle” “Long Term Illness” “Staffing and Funding”. Apart from “Staffing and Funding” all the foregoing are not peculiar to the “local NHS” the same situation applies in England and Scotland. What are they doing about it. As regards the possible removal of “Accident and Emergency Services” from Bridgend, it is a fairly new building opened by the late Princess Diana and since then has had considerable additional building work done, event quite recently. The Hospital in Quarella Road, Bridgend was demolished and houses built on the site. This was a mistake. 1. Prior to being demolished a considerable amount had been spent on redecoration. 2. If for no other purpose all the bed space could have been used for overflow from the Princess of Wales as at times ambulances have to queue to offload emergency cases. You are also no doubt aware that the Bridgend Hospital is at the base of a triangle. Merthyr Swansea Bridgend. To travel from Bridgend to Merthyr can be a hazard in Winter due to Ice and Snow at the Head of the Valleys even before you reach the A470 main road. The journey to Swansea even in good conditions can take up to 1 hour. The route to the other hospital at the Heath in Cardiff is a slow journey during commute times. This could also take up to 1 hour. Instead of moving existing services around to no good purpose, build another “emergency centre” suitably cited. No doubt business and the public would contribute towards the cost. Remember Better is not always Better. Regarding the serious shortage of some Doctors maybe the existing number could be used to better advantage if they were paid “the difference” to deal with NHS patients during the times they would have spent dealing with Private Patients.I trust that the Princess of Wales Hospital in Bridgend will not be affected by any changes. Member of public Thank you for your letter with the information I requested regarding a Donation to the Princess of Wales Hospital, Bridgend. I enclose a cheque for the sum of ***, so that it can be applied to the area of

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greatest need. So many Departments of the hospital have helped me and my sister in the last weeks and months, and I can only reiterate my highest praise for the treatment that we have received there. I have heard of rumours in the Newspapers of possible future reorganisation of the Health Service. I would strongly object to any downgrading of the princess of Wales Hospital, which covers Llynfi, Garw and Ogmore Valleys, Porthcawl, Pyle and Kenfig Hill, as well as the area around the town of Bridgend. Should sections be removed to Merthyr Tydfil or Llantrisant it would man longer journeys for the Ambulance Service, when time would be of the essence when life threatening illness occur. The first words I hear when I telephone my Doctor’s Surgery are if it is urgent to immediately ring 999. I hope that sense will prevail and that the services provided at the Princess of Wales Hospital will be enhanced and not downgraded in any way. Member of public Proposed closure of children’s ward Princess of Wales hospital Bridgend Firstly I would like this opportunity to say a very big thank you to everyone on the children’s ward for their professionalism, dedications and unwavering support to Mike and I during Rosie’s very difficult illness. Without the support of people like you I don’t know how we would have made it thought those very stressful and anxious times looking after our daughter. Secondly I have written to the Children’s Commissioner, First Minister for Wales, Madeleine Moon and Huw Irranca-Davies regarding the proposed closure. I cannot believe that some person somewhere thinks it’s ok to close or downgrade our children’s ward to save a few bucks! I’m all for changing for the better but, closing our ward when it is so desperately needed by the community beggar’s belief! I hope that whoever has come up with this preposterous idea does not need the assistance of a children’s ward in a dire emergency like we have on several occasions and find themselves having to travel miles with a very poorly child in the back of a car! When we have brought (our child) on to the ward as an emergency we have made the journey in less than 10 minutes, something that we could not have achieved if we had to travel to either Swansea or Cardiff. The Princess of Wales is our local hospital and as such the children’s ward HAS to stay. We lost our little girl this year due to her illness and I know had it not been for the wonderfully dedicated staff on the ward we may have lost her sooner. Please find a copy of one of the letter I sent attached to this, I don’t know if anyone will take any notice but I had to try something. I hope the closure or downgrading does not happen and I wish you all the luck in the World. Please let me know if there is anything I can do in the future. Local councillor I am contacting you following concerns raised with me by constituents worried about the future of Tonna Hospital under the Changing For The Better document currently under consultation. Tonna Hospital provides a vital service not only for the village but to the wider community providing specialist care for those suffering with Alzheimer's and other mental health problems. It also provides much needed rest bite for those caring for people with mental health problems and is a vital employer in the area.

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Having read the Changing For The Better, plain English document online, it makes no mention of Tonna Hospital which is only adding to the concern felt by residents and those who use the facilities.

I would be grateful if you could let me know what the implications for Tonna Hospital are under the a Changing For The Better Document. Member of public Evidence-based healthcare dominates hospital system development worldwide. Some developments discussed in the ‘Changing for the Better’ are overdue in South Wales - the regional trauma centre model, systematic management of chronic disease, the concentration of some specialised care. However, the document neglects important balancing evidence which is relevant to any judgement about what is best for the Bridgend area - patient-focused care, equitable access to centralised services, the increased use day and ambulatory care regimes, mobile teams and technologies providing specialised hospital services close to communities. Some evidence is misapplied - suggesting that stroke units should be centralised. Other ‘evidence’ used is irrelevant - comparing Wales and England bed numbers and outcomes. No serious analysis would suggest a connection between bed numbers and outcomes. (Paradoxically, within England, London has high bed numbers and better outcomes than other English regions). The document gives four main reasons for change - a fifty year old blueprint, money, doctor shortages and quality. The basic NHS blueprint is regarded internationally as sound. It is constantly evolving. Many countries still strive to achieve, or in the case of Scandinavian countries, sustain an NHS model achieving effective outcomes. UK has significantly fewer doctors than most European neighbours. Staffing ‘crises’ have been predictable for many years, well before the implementation in 2004 of European Working Time Directive, which reduced junior medical staff numbers for 24 hour cover. Although a UK issue there has been little initiative to establish a consultant-lead service in Wales. Quality and safety is a major issue. There are evidential links between quality and safety and the concentration of some services. However, there are many other aspects to improved quality and safety in hospitals including culture change, human resource development and systems developments. On money, it is impossible to comment meaningfully. Changing for the Better includes no economic analyses that would normally sit alongside an ‘evidence-driven’ analysis and no financial analysis. Emphasis is rightly promised on health promotion but this will have little short term impact on the disease burden. There are promises of increased community care without any assessment of future needs or resources – some community care models are more expensive than institutional models. Community care is more than a health system issue. Social services, NGOs and social welfare systems are important partners, at a time when local government budgets are being squeezed and welfare benefits are under fire. Joined up thinking? It is disingenuous to suggest that concentrating hospital services in

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Moriston and Singleton Hospitals and downgrading Princess of Wales Hospital, whose catchment harbours a significant burden and legacy of chronic disease, is ‘Changing for the Better’. And, to suggest patients, carers and families may travel ‘a little further for your services’ to relatively inaccessible Swansea hospitals, against a background of ambulance service resource and response time pressures. It is misleading to suggest that under the downgrading option, Princess of Wales Hospital would continue to provide ‘most of the services it now has for the people in Bridgend and surrounding areas’. It appears that it will cease to deal with increasingly common medical emergencies - cardiac and neurological events, common surgical emergencies, consultant supervised deliveries, inpatient paediatrics and other emergency conditions in all specialties. Since ABMU was created increasing numbers of patients are travelling to access transferred services (without any consultation) to Swansea Hospitals, in some cases for minor causes. Changing for the Better is in effect a finance-driven document, selectively using clinical evidence to justify the transfer of Princess of Wales Hospital resources to sustain an excess of hospital service capacity in the western catchment. Local council Changing for the Better Programme Following the recent Drop-in Session held at Maesteg Sports Centre, Members considered and discussed information received on the above. I was directed by the Council to stress how the Maesteg Community Hospital is valued within our community, and state that is it essential that the current service provision is maintained locally and that the Princess of Wales Hospital at Bridgend be given Regional status during the re-evaluation process. Swansea Deaf Questions asked by Swansea Deaf Club: Club Q1 – Will Accident and Emergency at Singleton and Morriston change. Q2 – Government regularly doing changes of locations of services/lots of cuts, moving to new buildings etc, should be thinking of people. Changes on financial side will affect people and their lives. Q3 – NHS started by Labour Government, Tories reduced and cuts 50 years later and cuts again. Q4 – See in papers in Merthyr bad car accident basic treatment and had to transfer to UHW, because no room in Morriston. Badly injured patients should not be transferred. Q5 – Focus on aftercare can be problematic and person gets worse because not supported at home. Information for patient in BSL should be required. Older people – numbers increasing so greater challenge to look after – accept this. But Expert Patient Programme is excellent at helping you look after yourself, should be more widely available. Q6 – In hospital for three weeks, Dr and interpreter booked in advance so knew what was going on throughout. However different advice received from Doctor and Nurse which was confusing. Q7 – Mother is 98 years old never been to hospital and still going strong. Q8 – Fell ill, ambulance wonderful, went to Morriston queue of 6

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ambulances, had to wait over one hour in an ambulance to be admitted. Q9 – Lived in Cardigan and had pneumonia, wife drove 27 miles to Carmarthen and beds full, on trolley for hours. Q10 – Accident and Emergency do they have emergency access to other services as required as well? Q11 – Fell down stairs, could not breathe, went to Accident and Emergency, what would happen in future. Older Persons’ Providing sustainable Health Services – We question the level and standard Council, Neath of care proposed especially in respect of care within the home. In relation to Port Talbot ensuring adequate visits for medication and personal care that could adequate to 4 daily visits. ABMU and care providers cannot do that at present, with out increased number of patients/ clients in future. In respect of the questionnaire it is very difficult not to disagree with the characteristics to be considered to make sure health services are sustainable. However, we are concerned if services are not sustainable now, how is it intended to sustain future services? For these proposals to be truly sustainable it is necessary to overcome the access to services and transport issues. Not clear how ABMU intends to prioritise all of these proposals. No clear proposals for recruitment and retention. Great reliance on the other agencies not within their direct control namely Welsh Govt, Ambulance Trust, Local Authority, for both care packages and transport subsidies, and not forgetting family and friends as carers. Concern on how this be delivered / financially supported and sustained. ABMU should be applauded for putting on extra engagement events, however, as it may be difficult for people to access and travel to health facilities so it may be difficult, especially from valley areas to access these events. We question are there enough staff to service outreach facilities with the community, i.e. District Nurses, Stoma Nurses, Doctors in the Croeserw area. Staying Healthy and Reducing the Risk of Becoming Ill – Within Neath Port Talbot there have been many examples of how such preventative initiatives have had a big impact upon, particularly older peoples’ health and wellbeing i.e. Assisted Shopping projects and healthy eating programmes. For these suggestions to be truly effective, they will require substantial investment as even voluntary organisations require core funding. Promotion of good health and a healthy living style is something that should be a priority for everyone, but a healthy diet that contributes to this is not something that everyone can afford when faced with individual choices when on a low income. Also we are concerned at how it will be defined where does the responsibility of the health service begin and end. GP and Community Services – A suggestion to also promote good health and a healthy lifestyle which the health service could support is for GP practices to do more regarding annual health checks for those over 50 to identify a wider range of conditions that affect older people. Although these are being considered by Welsh Gov, it is something that GPs could do as part of every consultation with older people. It is felt that GPs are these days less vocational, and service is more on a 9 to 5 basis, with no, or extremely rare home visits, with no weekend service. Some areas have no GP come whatsoever, i.e. Croeserw. There have been recent improvement

173 in Community Services, but lack of staff may compromise the situation which may worsen. A big issue is that services in the home or community are not feasible or sustainable without organisations working together, better collaboration needed between Health and Social Care services, need to improve communication between them. It is also felt that, provided that the services remains accessible to all, that provision of services in the home and community are better and more localised, but there is a need to develop cluster practices in some areas and most importantly have some uniform standard of services in such practices. Transportation again can be a problem especially if there is no regular public transport link, or if not easily accessible adjoining valley communities are clustered. There also needs to be more flexibility in the timing of services i.e. community health teams stopping at 5pm on a Friday for the weekend! If community hospital services are to be retained, then it is vital that there is adequate night time cover for care. Community beds should not be totally dispensed with, possibly reduced when plans for the early discharge of particular older people can be supported by ABMU and their partner agencies. Long Term Conditions – We are concerned that there is no allowance for the projected increase in demand upon services, especially in relation to the impact upon mental health and dementia from current and past substance misuse. Would favour specialist staff based in local communities and for local people with long term conditions to be supported to look after their own health. Frail Older People – For this proposal to work effectively it is important for both health and social care to collaborate more effectively in relation to: Discharge, Communications between services, Multi Disciplinary Working and Home Discharge. It is felt that at present discharge from hospital is arranged too soon, before adequate community support and care packages are in place, such care packages should immediately include, if appropriate, support for carers and respite services. Hopefully these proposals will not worsen this situation. Will ABMU be making any contributions to Local Authority Social Services budgets to facilitate discharge care packages, especially as the possible reduction in hospital beds could place greater demand upon social care? Future Pattern of Hospital Services – Low incidence and complex conditions should be dealt with at specialist centres. However, concerns regarding cost of transport for family and friends for these centres. Local access to outpatients departments for many conditions will require further travel that at present, again there are concerns regarding the cost and availability of transport. Whilst it is acknowledged that this engagement process is offering transparency and communication to a certain respect, we ask that this be a prime consideration throughout this process, and in future deliberations. The recent experience within Neath Port Talbot, whilst appreciative of the need for urgency on this occasion, was not a good experience of communication and transparency of decisions. Also concerned at the time span involved if critical/ acute care patients have to be transferred from one hospital to another, and back again when out of the critical/ acute stage, by ambulance services, and time of day that the transfer will be carried out. Specialist Services – Promotion for good health

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and a healthy living style is something that should be a priority for everyone, but a healthy diet that contributes to this is not something that everyone can afford when faced with individual choices when on a low income. Member of public Emergency Care – Great concerns regarding fewer A&E Departments. Paramedic response times linked to further travel time could be the difference between life and death. Capacity in fewer centres needs to be addressed and better publicity as to what types of emergencies should be directed to the non major emergency hospital sites as this could reduce waiting times at the major emergency centres. There appears to be no mention as to how the ABMU ideas will impact upon their contribution to the Major Incident Plan. Identified a possible need to raise awareness amongst GPs, hence reduce the incidence of people having to phone 999 after a negative response from a GP surgery. Other Comments – We feel that ABMU/ Health Service should reconsider the issue of car parking charges. It is felt that those using public transport/ taxis incur a substantial charge, and the cost per mile to travel to a hospital for a care user is much lower. It is also important that car security is an important consideration and gives peace of mind for patients and visitors has to impact service provision. However, it if vitally important that those with long term conditions or long stay patients, are given and made fully aware of concessions. Carwyn Jones AM As important discussions continue across the Borough through the for Bridgend ‘Changing for the Better’ engagement process, I have been encouraged by the level of meaningful response by those who have contributed the drop-in sessions and online. I won’t be able to be at the meeting on the 8th of November because of a longstanding commitment in London but I wanted to share some views with you about the engagement process on hospital services in South Wales. The first point to make is that is no “downgrading” of any hospital is proposed. The intention is to work out how to deliver safe and sustainable services in the future. It doesn’t mean that people will have to travel to Merthyr or A&E services. That certainly won’t happen. Secondly, service changes are being driven by doctors themselves, not by managers or politicians. Doctors themselves know that in the future Wales has to be seen as an attractive place to rain and work. There are four things to bear in mind when thinking about any changes; • The body that trains doctors wants them to get enough experience in their training. This has led to doctors increasingly wanting to train in hospitals when they get enough cases to deal with, preferably in centres of excellence. If we don’t reconfigure services in Wales then we’ll struggle to recruit in the future. • Services have to be safe. Yes, everybody wants a short journey to hospital but people also want to be treated by suitably qualified staff when they get there. At the moment this happens, but in order for a hospital to provide most services then it needs a team that can cover that service 24 hours a day, 365 days a year. • It isn’t about money. The money is there to employ staff but there are vacancies. It isn’t unknown for hospitals to advertise for senior doctors and

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for nobody to apply. We need to make the NHS in Wales attractive as a place to work in the future and having more specialised hospitals is one way of doing this.

Inevitably, I want the Princess of Wales to be a Regional Centre of excellence with full A&E cover. I was brought up in this town and I live here still. There has to be change, I know that full well, but I want that change to be for the better, and over the coming weeks I will of course be making the case for Bridgend during this consultation process. That means safe services and the continuations of 24 hour emergency cover. Bridgend stroke Stroke group – Bridgend group Questions arising from Changing for the Better Engagement: 1. Where does the Ambulance service fit into these proposals? 2. This is driven by finance and shortage of staff. 7-8 years ago a member of the stroke group sat on a panel and was being told exactly the same thing, that the working time directorate and subsequent shortage of doctors would cause problems in the future. Why wasn’t this acted upon? 3. What are the proposals in relation to stroke services in Princess of Wales Hospital? Does a regional centre include a stroke centre of excellence? Would like to see the documentation before consultation. 4. Money should be spent on stroke prevention – for every 10 deaths from Stroke we could save 4 people if the monitoring of blood pressure was done routinely through health MOT’s. 5. What help will people have with transport if services are to be moved around? 6. Why has the Health Board assumed that everyone can access computers? The very people who need to be engaged with are the disabled, vulnerable and elderly. Out of 40 people at the meeting only 4 or 5 had computer access and due to their disability, some cannot access libraries etc. 7. If patients are admitted to Morriston Hospital from the Bridgend area, it is important that they receive visitors to help with their recovery, it is very difficult to visit from such a distance, taking 2 hrs in the daytime and probably even longer in the evening, that is if there is a bus service during the evening. Also, if there is only evening visiting, this could mean some visitors not getting home until after 10pm and do buses run to Bridgend at this time? 8. What would happen with the A&E department at Princess of Wales if it doesn’t become a regional centre, would it still continue to be open 24/7, or will it become a 9-5, Monday to Friday, service? 9. Would the ABM area lose ambulance cover if A&E at Princess of Wales is downgraded? 10. If downgrading Princess of Wales hospital what will happen to the specialised equipment that has been bought especially for that hospital? Further to recent correspondence and the meeting of Llwchwr Community Community Network on 8th November, I am pleased to provide details of the planned Network response to the above consultation exercise. Practices in Llwchwr Community Network are: Talybont Surgery,

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Pontarddulais, Ty’r Felin Surgery, Gorseinon, Princess Street Surgery, Gorseinon, Penybryn Surgery, Gorseinon, Gowerton Medical Centre, Penclawdd Medical Centre The comments below relate to the specific queries raised through the official consultation questionnaire included within the mail “Changing for the Better” document circulated and available online. “Sustainable health services have a number of characteristics that need to be considered together. The Health Board believes that sustainability should mean that services: Keep people safe; Follow guidance; etc, as per questionnaire.” RESPONSE • Agreement to points as raised with the addition of ensuring that services are also accessible – both geographically and in terms of affordability and timeliness for patients and public having to travel – to this end we suggest that providers of local public transport are included within the planning process. • Adequate appropriate information must always be provided to patients/public to raise the level of understanding as to why they may have to travel to specialist centres • In providing services “within the community” better usage can be made of Gorseinon Hospital with a range of clinics. “At the moment the Health Board focus is on treating the consequences of poor health & lifestyle they think they should invest for the long term in improving people’s health & wellbeing, even if some benefits may not be seen for a number of years.” RESPONSE: • Agreement in principle – needs to be done in collaboration with local authority in developing leisure centres and activities – and in raising awareness through schools and colleges working with the NHS to educate the population from an early stage to encourage responsibility for their own health & wellbeing. • There should be a range of initiatives showing partnership working with the NHS/National Public Health/ Local Authorities and the Voluntary Sector and more effective engagement with these partners. • Healthy City Programme is a good example of how this works in practice. “The Health Board believes it is better to invest in services provided in patients’ own homes and elsewhere in the community (for example at GP practices) than in community hospital beds. How would you prioritise between the opinions of (a) improving services provided at home/community and (b) relying on community hospital beds” RESPONSE: There was a great deal of concern that GP practices were, once again, to be put under pressure to provide additional services and higher demand/ expectation when already working at full capacity. It was stressed that any initiatives to transfer work from hospital settings MUST be properly resourced and supported and that this should not simply be seen as a way of saving money! Development of new services to be delivered by the Community Nursing Teams should not be regarded as a simple way of

177 closing smaller health centres and reducing community beds. Careful consideration needs to be given to the needs of individual patients and their carers – and whether Daycase/Ambulatory services are adequate and appropriate in all circumstances. Again we raised the possibility of expanding services provided at Gorseinon Hospital as a way of bringing services closer to the Community. Greatest concern is ensuring properly resourced and supported services and acknowledging the strain that GP practices are already under. “At the moment many people with long term conditions regularly receive treatment from specialist staff at hospitals. The Health Board wants to help people look after their own health...same specialist staff in the local community (eg at GP practices) RESPONSE: Again there was general agreement to the principles stated – but concern once more that there is a possibility of increasing demand and workload within practices. It was acknowledged that there are a number of excellent initiatives in place already, eg CCM team; Expert Patient Programme – although maybe not enough use is made of these and they could be reviewed/expanded. Other local initiatives relating to Heart Failure and COPD developments are encouraging; and many patients are already being seen by the Nurse Specialists. There should not be any shift in responsibility to GPs in this regard, and those present at the meeting found it difficult to see how the proposals would reduce hospital beds as patients with chronic long term conditions will still need to be admitted if they experience an acute episode. “In principle do you agree or disagree that healthcare services should be designed to support frail older people to live at home and avoid them needing to go to hospital as far as possible?” RESPONSE: • Agreement in principle – however must be adequate support systems in place to ensure that frail older people are not isolated and forgotten. • This initiative will undoubtedly increase the pressure and demand within the community District Nursing team, as well as increase pressure for Social Service colleagues. • Intermediary Care service – excellent initiative locally but at full capacity so needs further investment • Important that funding is seen to follow patients so if to be cared for at home – how is this to be resourced? • Concern that there is not a uniform approach across the ABM area at present – with Neath Port Talbot believed to be providing better services in this regard. “Professional advice to the Health Board has recommended keeping good local access to outpatient and assessment services as people have it now, with specialist and emergency care concentrated in fewer centres so that better care can be provided 24/7” RESPONSE: • Plans and proposals include significant shifts of services between Morriston and Singleton – in general these were considered appropriate.

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• It was felt that the shift should also include movement of the GP unit to Morriston as it made no sense to retain this at Singleton • Accessibility (as per first question) transportation etc., should be considered • 24 hour access to diagnostic resources must be considered as essential part of the “24/7” service • Improvement/ expansion of services at Gorseinon could again be included as a consideration NB for Talybont Surgery there is a further consideration/concern: there does not seem to have been any consideration given in the proposals and statistics to the planned changes to emergency/ A&E service at Prince Phillip by Hywel Dda Health Board – the patients living in the East of Camarthen/Llanelli (ie Pontardulais and surrounding area) who currently utilise the facilities at Prince Phillip will undoubtedly opt for A&E at Morriston rather than travel to Carmarthen. This was raised to ensure that consideration is given to this likely increase in workload. “At the moment patients who need very complicated treatment travel to a specialist hospital for the best quality of care. The Health Board believes that patients who need other types of complex treatment would receive better care if they also travelled to specialist teams as well.” RESPONSE: Whilst agreeing with the principle of specialist centres where patients could receive expert/specialist treatment, those involved in the discussion did not feel that the question or the documented proposals gave sufficient definition to “complex” or “complicated” for them to be able to make an adequate response to this. “Professional advice has recommended that emergency care should be provided at fewer centres, and the Health Boards across South Wales need to establish the appropriate number. They are considering if a full range of services must always be provided at every centre, or if it would be better to have more centres, even if some could offer limited services” RESPONSE: Discussions raised concerns regarding: • Transport links/accessibility •Patient safety issues in terms of delays etc • Information for patients: in emergency how would people know and understand which services were available where. The member practices of Llwchwr Community Network agreed that there would be a “joint” response on behalf of the network, but that each individual practice would also submit their own response either via the electronic questionnaire and/or a practice letterhead to ensure that if ABM are basing their calculations on “numbers of people who said...” we would get counted as more than a single entity! If you would like to discuss any of these issues further, I would be happy to meet with you. LMC At the special ABMU Board meeting held with press and public on 26th September the 12 week public engagement process for Changing for the Better was officially launched. I hope that by now most of us will have a broad understanding of what the key concepts are and have seen the information booklets that have been distributed. If not I would strongly encourage everyone to do so or to visit the web sites:

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www.changingforthebetter.org.uk and www.youtellus.org.uk If this programme is delivered as planned, it could bring major benefits to patients and be a significant opportunity for primary care. It is clear that a rejuvenated and strengthened primary care is an essential requirement for success for anyone to deliver more efficient and less hospital centred care. I am pleased to say that I received unequivocal assurance from the Board that, against a backdrop of a very difficult financial climate and persistent difficulties in mobilising resources into primary and community services, that renewed investment would be a priority fir the HB and indeed a prerequisite for delivering on any workable plan to restructure services. Gellinudd League I write on behalf of the above organisation (Gellinudd LOF) regarding the of Friends future of Gellinudd Hospital. We are aware that a consultation is currently underway regarding the future provision of services at Gellinudd Hospital in conjunction with Cimla and Neath Port Talbot Hospitals. Therefore we would like to register this letter as part of the formal consultation process and trust that due consideration will be given to its content. Furthermore, we are aware that local media reports contained within the South Wales Evening Post, amongst others, have referred to recent proposals that Gellinudd Hospital may close in the near future. As a group that has supported the hospital’s services, staff patients and their families over the past 30 years we feel that we have an in depth knowledge of the hospital and how much it is valued within the local community. We therefore feel that our opinions on the proposed closure are based on sounds experience and observations and would like to formally register our strong objection to any plan that involve the closure or termination of the current range of services offered at Gellinudd Hospital. We acknowledge that the profile of care needs exhibited by resident patients at Gellinudd has changed over the years resulting in more and more patients with complex medical needs being admitted and others which would traditionally been accommodated being referred to community nursing facilities or care homes. This has resulted in the current situation whereby patients require 24 hour medical attention and care due to the severity of their complex needs. Consequently we have grave concerns in relation to where patients with such complex medical needs could receive such dedicated care in the future if Gellinudd Hospital ceases to function in its current form. We are concerned that there is a lack of capacity and medical specialism within local community facilities which could have a serious detrimental effect on the health of those patients currently cared for at Gellinudd. As stated about, the level of medical attention and care required by those patients currently being admitted and treated at the hospital has increased over recent years. Typically there have been increasing numbers of patients suffering from dementia. Given the nature of this condition, any changes to the current services, number of beds and locality of service delivery will have a serious impact on these individuals and their families. Gellinudd Hospital is a modern building only being reconstructed relatively

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recently in 1995 as a fit for purpose community hospital facility. Services are provided by dedicated, professional nursing staff that ensure the best medical and nursing care for those individuals resident at the hospital. As a result, the team and hospital have continued to receive positive assessments and reports in relation to the services and care delivered at Gellinudd. As an organisations which liaises with patients, families and staff we firmly believe that continuing cares services, such as those currently being delivered at Gellinudd, should remain within the community as close to patients’ homes as possible to ensure that they can continue to receive support from their families. Furthermore, we feel that the level of support the highly skilled and dedicated staff give to patients and their families cannot be underestimated or undervalued. We are therefore very concerned about the future wellbeing, both physical and emotional, of the patients that are typically currently cared for at Gellinudd. Furthermore, understandably, staff are concerned about the uncertainty of their jobs but are equally concerned about patients’ future prospects and care should be the hospital cease to continue to operate in its current form. We thank you in anticipation of your attention to this letter and look forward to your response and further consultation in due course.

Peter Black AM I write to put on record my views as to the necessity for the retention of Princess of Wales Hospital Bridgend as a major acute secondary care hospital in its present configuration. It is my belief that any other outcome to the above review would be a major detriment to the service offered both to local people, and given the specialisms that are located within the facility, on a regional and national basis also.

Given that the Princess of Wales Hospital provides services to 160,000 people not only in the Bridgend are, but also to the populations of the Western Vale, and a significant part of Neath Port Talbot. I consider that any move to downgrade the hospital would bring about a considerable worsening of the services provided by the Welsh NHS in the eastern part of the South Wales West Region and beyond.

In particular, I have noted that Princess of Wales Hospital provides a full A&E medical emergency service; (in conjunction with Morriston Hospital;) as well as dealing with a smaller but still significant number of GP emergency referrals from the Neath Port Talbot area. Maintaining the present ease of access for its present catchment to the effective paediatric, obstetric and gynaecological services that the hospital provides is also of vital importance. The reputation of the staff in these areas is deservedly excellent, and importance. The reputation of the staff in these areas is deservedly excellent, and recruitment at all levels to the areas, and to the hospital generally, is more buoyant than at other hospitals in South Wales.

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I am also aware that a number of specialist services such as the Surgical Materials Testing Laboratory, Forensic Mental Health services, and Learning Disability services presently provided at Princess of Wales Hospital are of both regional and indeed national relevance. Once again, any downgrading of the hospital will weaken the facilities offered to a significant proportion of the populations of South and South West Wales.

In conclusion, the location of Princess of Wales is strategically significant, and the close proximity to major transport arteries is a crucial asset. The hospital site is well-served by public transport, and is close to major concentrations of people in Bridgend, Maesteg and the surrounding communities. The hospital has a high reputation, attracts excellent staff and has no difficulty in recruiting. In addition to nationally-recognised specialism, excellent and well used facilities in accident and emergency, obstetrics and gynaecology, and paediatrics are provided. Finally, it is my view that there is only so much downgrading that a major medical asset in such a location can take before it’s relevance as a major facility of any kind becomes open to challenge. Local councillor Potential Reduction/Closure of A&E Department, Princess of Wales Hospital, Bridgend Further to my recent letter, I enclose a copy of an Issues form which was submitted at a recent consultation meeting in Bridgend by one of my constituents. Issues form: I have a 12 yr old son with a chronic condition. He is usually admitted to children’s ward at least 9 times a year for periods of up to 5 days at a time. I live and work in the Bridgend Borough and at present, I am able to continue with my employment during my son’s hospital admissions. Should this downgrade go ahead I would have to terminate my employment as carer’s leave is 3 days a year and my son requires more than this. At present, my son is happy to be left for periods of time in POW children’s ward as he is familiar with all staff and surroundings, enabling me to work. He has suffered with this condition from 16wks old. We have “open access” to children’s ward and I often transport him there myself, should this ward not be there. I would have to use the ambulance service, every time. People seem to forget this condition can kill. I do not want to make the transition from being a contributing member of the community to relying on state benefits. Member of NHS I myself would like to say that Princess of Wales should be the Regional staff Centre for Mid Glamorgan, Swansea is a long way to travel especially having elderly parents. Member of NHS I believe I have a very achievable cost saving idea which will reduce patients staff length of stay. I am an OT in the trust (east side). The current situation on a typical care of the elderly ward is that when a patient is ready for discharge, the Social Work team will allocate a Social Worker.

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Here is a current case scenario: Monday: A patient is fit/ ready for discharge The ward contact the Social Work manager to inform them of this. The Social Work manager then allocates a Social Worker to the patient. Wednesday The Social Worker will visit the patient to assess The Social Worker contact the home care team and arranges the package of care The package of care could be started Friday. However, they do not like Friday discharges, if the care staff struggle with the patient over the weekend there are no back up services to assist. Monday The discharge goes ahead and carers start. (Remember the patient was ready for discharge the previous Monday) -7 unnecessary bed days have been taken up at a significant cost to the NHS. I would suggest an NHS funded intermediary care team. This would consist of a coordinator and a team of Band 2’S who would carry out the care. This team would just fill in until the Social Services carers could start, which would allow the patient to go home early. Here is a proposed scenario: Monday A patient is fit/ready for discharge - The ward contact the Social Work Manager and the intermediary care coordinator to inform them of this - The Social Work manager allocates a Social Worker to the patient. - The intermediary care coordinator liaises with the ward as to how many calls a day are necessary and for what - The intermediary care coordinator sets up the calls to start the same day/following day - Monday/Tuesday – the patient is discharged. Wednesday - The Social Worker visits the patients at home to assess - The Social Worker contacts the home care team and arranges a package of care Friday - The Social Services package of care starts - 1 possible unnecessary bed day has been taken up , or possibly none! The cost benefits are the 6 saved bed days. The cost would be the 4 or 5 days of care from the NHS care team. This could be for instance; a Band 2 attending to the patients personal care needs and meals in approximately 1 hour 45 minutes per day. Also the cost of the coordinators time for setting up the calls and liaising with the ward. Also the cost of the travel for the Band 2 and from the patients property. Points to consider: The Social Work team would need to treat the patient exactly as they would if they were an inpatient. At present if the patient is discharged home prior to care being arranged, the Social Services treat that person as a community patient and they would have to wait on a waiting list to be allocated a Social Worker. This can take weeks to happen. I hope you have found this interesting reading! Members of CHC comment forms : public • Gellinudd needs to stay open as a community hospital for the community not close to save money. Local people need this hospital because it’s quite calm and the staff there are the best and they don’t want to leave. • I think that Gellinudd’s beds could be filled if they were all still open. .Why are ambulances queuing outside A+E if there are beds available within the Health Board. • I do not agree with the future of the local health services. I believe that patients benefit from the services in Gellinudd Hospital and that it should not be closed. Patients I have known that have been in hospital in Morriston

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became worse. But after moving to Gellinudd become a lot better due to the 24 hour care that I am aware will not be given in the future health service. • Gellinudd provides a valuable service for patients needing extra care. • From a personal point my mother went to Gellinudd after major surgery and the support to her as recovery was all due to the staff their hard work and the support they have to us as a family. The impression is that the staff at Gellinudd hospital are happy with the future plans. I can assure you having spoken and been in the company of Gellinudd staff they are most certainly NOT!! Member of public 2012 has seen a flurry of documentation from ABMU, basically saying that the system underpinning the Health Service for the past 50 years is no longer the appropriate setting and we must get in the mode of changing for the better. It paints an interesting scenario but also gives rise to some disquiet. The implication is that the “Organisation” has lacked the means for continuous improvement especially as it relates to organisational development. Where is there an organisation structure plan indicative of (hierarchical) structures? Where is the continuous oversight, to review and assess plans and structures that maintain their relevance to ever changing and developing situations. If such an organisational reviewing body exists, why has the present hiatus occurred between what presently stands for the NHS and the radical changes proposed? Let me take one example, closure of medical facilities at Neath Port Hospital. How can that happen? The haste of the decision, the knowledge of the facts over some considerable time, the lack of anticipatory actions especially in the area of Training and Recruitment, knowing the standards of care and provision of services already committed to by AMBU. This is indicative of poor performance review procedures and closing the door after the horse has bolted. The Authority must accept its deficiencies of continuous review, its lack of a proper developmental programme which should have identified the decline and taken longer term remedial action at a much earlier date in relation to these serious issues. There is also no joined up thinking in the ABMU recruitment strategy. How would overseas doctors view recruitment to a hospital service perceived to be in decline? The indication is that the overall policies and strategies are largely seen to be short term fixes and lacking an overall plan and structure .What is required is a set of Organisational arrangements which keep in view the big picture. I would be interested to know how the Clinicians decide on clinical needs and how these get fed into the overall decision making process and how budgetary constraints limit outcomes and the prioritisation and measurement of effects on the Community’s expectations. This leads me to responsibilities and accountabilities. The big picture is necessarily constrained by political decision and the limitations that impinge on the ABMU especially as this relates to overall budget. I have the feeling that the role of senior management is too accommodating when it comes to being critical of the Welsh Assembly. The Welsh Assembly set the budget and then Health Minister says over to you, you decide how to deliver those standards of service the Government requires. This is nothing short of a Pontius Pilate act

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and ABMU need to be alert to its responsibilities to the Community it serves and respond to the Minister with its own conclusions about decisions it can and cannot make, directing the political decisions back to where they belong. There are a lot of practical issues that could be raised especially the spin elements of ABMU’s documentation which is too reliant on anecdotal information and lacking in sufficiently rigorous analysis. Whatever the outcome of this “consultation” I hope serious consideration is given to the big picture provided by Organisational Planning on a continuous basis to provide the continuity of Development ,Training and Recruitment and not the discontinuities brought about through the obfuscation of the political process and the accommodations made by ABMU to its political masters. Member of NHS If my views were important the changes to/ abolition of Hospital Medicine staff for the Elderly would not even be proposed. The communications are a blueprint masquerading as briefing/”engagement” and subsequent consultation { which is statutory anyway }. These are my views. Member of public I am writing to express my concern over the proposed reorganisation of services within the Princess of Wales Hospital, Bridgend. In particular the closure of certain departments. I consider to close the A&E department will ultimately result in lives being lost. It will also mean people being transported unacceptable distances. This will cause extra suffering and trauma. I object to the Paediatric and other departments being closed (or relocated!) These proposals are intended only to save money and are not in our best interests. It is very sad that we now live in a time where care, compassion and common sense no longer prevail. Our NHS was once the envy of the World, now look what has been created. Member of public I would just like to give some feedback from the consultation at the Arc Centre. It was very good to be able to talk to somebody knowledgeable about my concerns and actually have our one-to-one discussion and debate. We had a proper Discussion where we talk through ideas and suggestions with real solutions being discussed. This was really positive. It wasn't just a pretend session. It was a real opportunity to air views and discuss ideas.

As I am completely blind some of the material was clearly not accessible but what was really welcome was the fact that an audio CD was available and on hand to post out to me by the very next day. This was excellent.

All too often booklets and documents are not available in audio CD and even if they are promised it takes up to 6 weeks to arrive. Well done.

Academy of Royal As Chair of ARCW I’m pleased and reassured by your confirmation that Royal Colleges in Wales College/Faculty standards and guidance have been used to inform this work to-date and I’ve also noted this during my own engagement with the process as a consultant in ABM.

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As you may know I’m a member of the National Clinical Forum (NCF) representing ARCW. NCF has and will be scrutinising the reconfiguration proposals of the Boards using agreed evaluation criteria and I have ensured these criteria include reference to Royal College/Faculty standards and guidance. To-date the Academy hasn’t commented on the proposals of individual Boards other than through the NCF and before doing so can I suggest I discuss your request with ARCW members in our next Academy meeting on 17 December 2012? I should add that I am due to demit office as chair at that time but I will ask Paul Shipton who is the Academy Project Officer to liaise with you and the new chair about this following the meeting. Pending the next ARCW meeting, I’m sure the Academy would fully support the aim of ensuring College and Faculty standards will be met through C4B and tyhe South Wales Programme. I also confirm that there has been widespread support from College and Faculty Presidents (and also me on behalf of ARCW) for the seven day working and sernior doctor involvement document publicised in the media yesterday and I confirm ARCW will supprt this too. Pending the next ARCW meeting, I’m sure the Academy would fully support the aim of ensuring College and Faculty standards will be met through C4B and the South Wales Programme. I also confirm that there has been widespread support from College and Faculty Presidents (and also me on behalf of ARCW) for the seven day working and senior doctor involvement document publicised in the media yesterday and I confirm ARCW will support this too. Local council I would like to thank ****and *** for attending the meeting of Council held on the 27 November 2012. Members certainly found your address and the responses to the many questions posed both interesting and informative. Following an extended discussion, Council resolved to respond to your consultation in the following terms. Gellinudd Hospital is considered to be a valuable and much appreciated facility in the Swansea Valley providing essential care opportunities close to the homes of the patients and their families, and well supported by local communities. Council is therefore, disappointed that closure is being considered by the Health Board. If a decision is taken to close the Hospital, Council deems it essential that all the replacement arrangements are robust, prepared in advance and in place before closure. These include arrangements with Neath Port Talbot CBC and the private sector for sufficient levels of Social Care, resourcing and establishment of the community resource team, proper proper provision for medical and emergency support, and ongoing engagement and support for the staff at Gellinudd Hospital. Furthermore, Council would encourage the Health Board to consider the future of the Hospital as a properly resourced facility that could continue to prove day care services for local people, as it would be “close to home”, reducing the need for lengthy journeys, often by vulnerable people and their families, to hospitals at Morriston, Singleton and Neath Port Talbot. I hope that you will consider the above comments in a constructive manner, and specifically bear in mind that my Members are concerned for the

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welfare of patients using the Hospital and for tie families. They also value the fact that a local facility such as the present Hospital serves an essential purpose, because it is clearly focused on the Swansea Valley community, and is perceived as a successful bridge between acute hospital care and care in a home environment. In conclusions, Council has asked me to stress that Gellinudd Hospital is a facility which has been appreciated by the wider community here for many decades, and has received considerable support when previously faced with closure. It has benefitted from voluntary activities in particular, with the League of Friends demonstrating significant loyalty, and it would be unfortunate for the Health Board to risk the loss of such collaboration with the voluntary sector, and lose a vulnerable facility within the community. Council would welcome the opportunity to contribute to further consultation exercises as this is an extremely emotive issue in the community it represents, and to this end, I am instructed to copy this response to the Community Health Council and the League of Friends. Postgraduate Thank you for your letter dated 30th November 2012 and enclosure to Deanery Professor Derek Gallen regarding the above which he has happened to me to respond. The Deanery is continuing to work closely in collaboration with all of the Health Boards, including ABMU, to ensure all stakeholders are fully aware of our training reconfiguration plans for a number of specialities. I would also like to assure you that the Deanery and Reconfiguration Clinical Leads will engage in further detailed discussion once our training reconfiguration plans are approved for wider dissemination. As part of our communications strategy the Deanery have agreed to link each of the Health Boards as well as collectively with the South Wales Programme Board. Member of public Just a letter to ask you to consider keeping services at the POW hospital, Bridgend, especially the 24/7 A&E department. My father has had a stroke and a few mini heart attacks in the past and without the proximity of the hospital in Bridgend things may have been much worse. My mother has also had heart attacks and falls at 81 years of age. Again the nearness of the hospital was important in her treatment at A&E. I also have a sister who has overdosed on medication and tried other suicide attempts which needed immediate medical attention. I also owe a debt to the A&E dept in Bridgend following a RTA where my condition was life threatening. So please save our services at POW, Hospital, Bridgend. Member of public I note that the authority is holding local discussions in the different localities, on the hospital services, that are now causing some concern to the public at large, in all areas of the ABM jurisdiction. I appreciate you will be finishing some time this month, but if you can influence some different thinking with the last roll of the dice, at higher level I would appreciate any effort. As a Labour Party Member. The closure’s of A+E services are causing concern. As you may be aware, nothing contributes so much to prosperity, and happiness, of a community than that of the local hospital services. Things are getting remote, not nearer to the people. However, if the public

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seek a sense of purpose, they need to see the local priest! Things are nearer to God then thee. They are not getting it from the WAG. We as a party always promised services nearer to the people, one of our corner stones. There is a need now to get discussions going with local GP’s, taking a lead role in getting their colleagues in the local practices, who specialize in certain fields of medicine, to get them trained up in that speciality, so that they can cover A&E where necessary. This will enable CT2 trainee’s to continue where there is a competent doctor from them to get experience from. It’s the old adage, state a moral case to a ploughman and a professor. The former will decide it as well, and often better than the latter, because he has not been led astray by artificial rules. Member of public I would like to propose a radical re-vamp of our hospitals and working practices. Keep in mind that to travel distances of twenty miles is now simpler than it was to travel five miles years ago. I believe many hospitals could be closed down if we were to make strategically placed hospitals into super efficient ones fully operational twenty four hours a day three hundred and sixty five days a year. At present hospitals open for operations and clinics approximately one third of the day five days a week closed at weekends and bank holidays which equates to one third of the year – how efficient is that? These huge buildings and tremendously expensive equipment are not being used to their full potential yet are fully staffed with nurses and ancillary workers every day all day except for Surgeons and Doctors. Put the Surgeons and Doctors on a seven day twenty four hour rota system the same as all the front line staff. The public would have no problem attending clinics 6am to 10pm overnight operations wouldn’t be an issue. Waiting lists would be a thing of the past. Stand alone A&E’s nationwide could be built and funded from the savings made from closing down a possible 40% of existing hospitals, imagine the savings on equipment for example one scanner working 24hrs instead of three scanners working 8 hours each. A method needs to be found of monitoring the work rate of staff to get a fair days work for a fair days pay from everyone employed. I hope that someone with clout might see some mileage in my idea and in the next few years some drastic changes will take place. Swansea Council This is an initial response by the Social Services Directorate of the City and County of Swansea to the engagement document Changing for the Better. The Council will respond in full to the formal consultation when this is published. I acknowledge and recognise the validity of the case for change set out in the engagement document. The rationale was made by Wanless in 2003. The demographic changes are a significant challenge to both health and social care. The major concern regarding the engagement document is the absence and acknowledgement that changes to the health service model will impact on the demand for social care services. The document (page 41) identifies the need to ‘invest and develop community services using some of the money

188 we currently spend on hospital services’. It would be helpful to have clarity about what community services will be developed and that the shift in the service model will impact on demand for social care. The recent redevelopment of the Cefn Coed site involved a significant reduction of the geriatric/ older people with mental health needs beds. It is unclear if and where the saving have been reinvested in the community. It would be helpful to identify details regarding the financial reinvestment in developing modernised community services. Social care is not resourced to meet anticipated increased demand following a change in the service model. Some of the areas that need to be addressed through remodelling strategy include: • Increased support for carers, including respite. The proposed model will place greater demand on family and friends to provide informal care. Support for carers needs to be a joint (Health and Social Care) responsibility. • Issues around the ‘free at the point of delivery’ health service versus means tested social care need to be transparent. • Investment in Telecare/Telehealth • Palliative care services outwith hospital, need to be developed and funded • Increased support for Reablement • An intergrated Intermediate Care service • Transport to hospital/ specialist services needs to recognise the needs of people on low incomes or who are elderly with mobility problems • The Council’s Social Services Directorate is undergoing a transformation programme to focus on helping people maintain independence. Work carried out by Professor John Bolton with the Social Services Improvement Agency in 2001 highlighted the most common health reason why an older person might need residential care as: • Dementia • Incontinence • Urinary Tract Infections/ Hydration • Strokes • Podiatry • Dental • Falls. All these conditions are treatable or managed more effectively if identified and diagnosed early. There is a need to ensure they are not in the position of having to compete with other top priorities within local Health services. It requires a concerted effort and agreement between the Health Board and Council to ensure that the health care of older people with these conditions is addressed appropriately. This will support the principle of maintaining people in their own home and community. Evidence suggests the biggest single factor indentified as having an impact on admissions to residential and nursing care is what happens for an older person during a hospital admission. Far too many older people are assessed as needing residential care whilst they are still ill and possibly recovering. Professor Bolton’s research demonstrates reducing bed days in hospital can give rise to new

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financial pressures elsewhere in the system. Addressing this will be a key challenge to the Local Authority and Health Board. Engagement with ABMU currently takes place via the Western Bay Health and Social Care Programme Board. It will be important to address the issues raised in the proposals, and in this response, in this multi-agency forum. Royal College of In my view surgical services are the key to the whole reconfiguration debate. Surgeons I met with Jeff James in March and following our discussion emergency surgery was included in the South Wales Programme remit for a period of time but then seemed to be removed again. We have already given formal responses to BCUHB and HDHB public consultations and I believe that this has been influential. Interestingly the College have never done this before and were a bit anxious about it. It would however be nice to be clear on what the various HB proposals are in order to comment. The ABM five year plan is fairly clear but none of the others are. I recently did a talk about this at the Welsh Board and having visited all the HB websites the level of clarity about proposals is very limited at present. Member of NHS Since the launch of the Changing for the Better engagement period the staff Chairs of the Maternity and Newborn work system have undertaken a number of additional engagement opportunities. This has enabled more time with clinical teams to discuss implications, ideas, considerations and feelings of the engagement document. It was also an opportunity to encourage staff at every level to know how to have their say and “myth bust” some of the evolving rumours. Summary of events In total approximately 19 sessions and clinical team meeting were attended with an attendance of 130 members. These included doctors, midwives, nurses, receptionists, nursery-nurses, user representatives and University lecturers. Some of the were Multi-disciplinary in nature and some were stakeholder forums such as the University and Health Board Maternity Services Liaison Committee. Feedback and Emerging Themes • Needs to be more convincing data to support the case for change • Needs to be a balance between medical and socioeconomic models of care • Transport arrangement in emergency situations with assurances that ambulance services can cope • Good to see an increased emphasis on public health priorities such as breast feeding rates • Staff concerned about their own individual circumstances eg travel • Implications for non medical workforce training as important as medical work force training • Concerns regarding perceived cross boundary difficulties when transferring women to the nearest obstetric unit • Consideration regarding perceived flows of women and assurance of their choices• Interface with gynaecology particularly for early pregnancy management needs to have a clear model of care • Once workforce solution could create another workforce risk Response to the South Wales Programme – Matching the Best in the World.

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AM for Ogmore As the Assembly Member for Ogmore, I should like to comment on the proposal to concentrate 24/7 consultant-led obstetric, neo-natal and A&E services at four or five hospital sites in South Wales. As a preliminary observation, I should say that in my view the need for this change has not been well-communicated to local people. There remains a widespread belief that these changes are driven by a need to cut costs in spite of the document’s clear statement that they would be cost-neutral. Many people continue believe that speed of arrival at hospital is the key determinant of the patient’s prospects for survival and recovery and are not aware of the medical evidence that the benefits of specialist care would outweigh the risks of additional travel time. Above all there is a general view that a wide range of services (such as less critical A&E) would be lost to any hospital which did not become a specialist centre. Communication must be improved as the discussions move forward. My priority will always be to ensure safe, sustainable services for my constituents. I recognise the medical arguments in favour of four or five specialist centres. Representing as I do a number of valleys communities with transport difficulties, I am however, keenly aware that this process of concentration will have serious effects on public confidence and practical consequences on for instance patients’ relatives who need to visit them in hospital. I would therefore strongly urge that the five centre option provides the best way of meeting both the need for specialist centres and accessibility within reasonable travel time. I would adhere to that position even if further medical evidence suggested that five centres would be marginally less efficient that four. If the five centre model were adopted, I would argue for the Princess of Wales Hospital and the Royal Glamorgan Hospital to be two of the centres alongside the new Gwent facility, Cardiff and Swansea. As I have pointed out above, many parts of my constituency face serious transport difficulties and I believe that the inclusion of these two sites is important in ensuring that all in South Wales have ready access to a specialist centre. Both have the advantage of being well-placed in relation to the M4 which is important both as a major route for high speed transfers across South Wales and as the site of many serious accidents. Their location on the m4 mid-way between Cardiff and Swansea would also enable them to provide back-up in case of a major incident taking over the full resources of either of those centres, as recently happened in Cardiff. As outlined above, I believe it would be a mistake not to have five centres including the Princess of Wales and the Royal Glamorgan. Should either fail to be included I would wish to see strong safeguards including: • Robust evidence that ambulance and air-ambulance services will e able to cope effectively with the additional transfers required; • Clear plans for transfers back to the local hospital for further treatment as soon as this is safe; • Guarantees of effective communication and liaison between specialist centres, local hospitals and GPs to ensure continuity of care.

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To sum up, I believe that there is still a lot of work to be done to explain the medical evidence to my constituents, I support five specialist centres as the best model, I strongly urge that the Princess of Wales and the Royal Glamorgan be included amongst those five and I would press for some very clear assurances should either not be included. Bridgend Council The council’s interests are for the growing population of Bridgend to have the highest quality of healthcare provision possible, but also want those services to be easily accessible nearby...Members have expressed concern about the distance patients and their relatives will have to travel for specialist acute services if the POW is not a regional centre, this would be particularly difficult for some of the most vulnerable people in the north of the county reliant on public transport. Geographically, in a five centre model, the POW, is the most centrally located of the three hospitals, and has the best transport links to the majority of people it would serve. The table below shown the various distances from across the county borough and travel times, by car and public transport, to Royal Glamorgan Hospital Llantrisant; Morriston Hospital. Swansea; and POW. While the additional travel time from most parts of the county borough to the next nearest hospital other than POW is within an extra eight minutes by car, travel times by public transport are over an hour greater. Another difficulty that many public transport users would face is the restricted and infrequent nature of bus and rail links, making their total time journey more significantly longer, and some visiting/appointment times impossible to e met by public transport. While these travel to hospital problems might be partially mitigated with additional public transport or dedicated travel services, no such proposals are yet proposed. Member of public Being reliant on others for lifts, I’ve not been able to attend the various discussion meeting. However, I must show my concern at the proposed reorganisation of the hospitals in Wales, with particular reference to the POW Hospital at Bridgend and the rehab ward at Maesteg Hospital. The Bridgend Hospital already covers a large area-tree valleys, Porthcawl, Cowbridge and the Vale plus Porthcawl (whose population multiplies in the summer). As I have previously stated, were I had to have travelled further than Bridgend when I had my heart attack, I would probably not have survived. Therefore, while realising that paramedics are wonderful and that treatment begins when the ambulance arrives, when the area enlarges, as is proposed, there must therefore be more ambulances to cope with the extended travelling. Surely this would add a further cost to the NHS, probably proving more costly than leaving this as they are with the status quo. As for Maesteg Community Hospital, while reading that it will not close, that there are plans for it, do those plans include opening more wards for rehab purposes? The wards which, over the years have been systematically closed – rooms available upstairs as well as down which could be used as wards). Having received and seen rehab at work in Maesteg, I can assure you that it is equal to none other, the treatment being first class. Patients receiving rehab treatment there are able to be released more quickly than from other

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hospitals, due to the excellent care and attention received from nurses, physiotherapists and, at one time, from the outstanding meals provided and cooked in situ (which have now also been done away with!). As it was then built, now Maesteg is no longer for the locality, but rehab patients now come from all over the borough. How can this be replaced/ I await your reply with much interest. Member of public Letter which was featured in Seaside News: Six years ago I was misdiagnosed by a Doctor at Riversdale Surgery Bridgend as having a slight chill. In fact I was suffering from pneumonia. A couple of days after the visit to the surgery I had trouble breathing my husband took just a few minutes to drive me from our home on the Broadlands , Bridgend to the P.O.W A&E department. I was rushed in to see a Doctor on arrival and was told my organs had started to shut down I was minutes form death. I am so grateful to have got there in time and for their prompt action which saved my life. Had we had to travel much further I would not have survived. I have had cause unfortunately to visit the A&E dept on several occasions in emergency situations. The A&E department is essential to the many residents in and out of Bridgend who would otherwise have to travel a great distance. Please keep the department open. Local councillors We write collectively as County Borough Members representing the Maesteg East, Maesteg West and Caerau wards in the Llynfi Valley in response to ABMU's engagement process on 'Changing for the Better' and wish to offer the following points for observation. Having read the document, we have concerns in relation to the future of the existing twenty beds at Maesteg Community Hospital (MCH). Whilst we would very warmly welcome and actively encourage the development and enhancement of out- patient and clinical services at MCH, we are worried as to the future of the twenty beds on the Llynfi Ward. he value of these beds, not just to our local community but to the wider region, cannot be underestimated. We know of constituents and in some cases, family members, who have, over the years, received care at this facility of a truly outstanding level. The loss of these beds would be a huge blow. We impress upon the Local Health Board in the strongest possible terms that these beds should remain in situ and continue to provide care in the future. There has already been a loss of beds at the Princess of Wales (PoW) Hospital in certain wards and we believe that a further loss at MCH would only serve to add to the overcrowding problems at PoW. Maesteg Community Hospital has a very proud history of providing the warmest and friendliest of care, often to the most vulnerable and frail patients in our communities. The wider Maesteg community would be devastated should these beds be earmarked for closure. We trust that these points will be taken into consideration and we look forward to engaging with the consultation process early in the new year. Members of NHS In summary: staff (midwifery 1. For women’s safety and to enhance their birth experience, our health and women’s board must provide at least one of each of the following place of birth

193 services) choices: a. Obstetric unit, b. Stand alone midwifery led unit c. Alongside (obstetric unit) midwifery led unit d. Home birth service 2. The health board obstetric unit(s) should birth around 6000 babies per year to enable obstetric rotas to adequately cover the role. However, the priority of our service is to give information and facilitate birth choice rather than focusing on absolute birth numbers in any given area. 3. Our obstetric unit(s) should have a team of care givers, led by at least 60 hours of cover per week by consultant obstetricians, who are highly trained and motivated to give care that reduces unnecessary intervention and promotes normality throughout the birth process. 4. Our obstetric and midwifery led units should have teaching and training provided on site that is of the highest level and promotes the nurturing of women through their birthing experience. 5. Midwifery led units should not be limited by a minimum level of births per year 6. Midwifery staffing levels should be supported by Birthrate Plus. 7. The role of the Consultant Midwife is crucial to work alongside obstetric colleagues and midwives to promote a philosophy of promoting normality and low intervention birth. 8. Investment in pre conceptual care, to ensure women embark on pregnancy in the best possible health, will result in health cost savings in the pregnancy, birth and during the rest of the mother and baby’s lives. 9. Investing in continuity of carer during the antenatal and postnatal period has shown to enhance women’s experience of maternity services. Supporting evidence and discussion Meeting complex needs whilst reducing unnecessary and costly intervention As identified in the engagement booklet, women’s requirements of our maternity service are becoming ever more complex. Providing adequate high risk services for women with identified risk factors is, of course, a priority. However, recent highly regarded evidence (Birthplace in England Collaborative Group, 2011) suggest that for women without risk factors, planning birth out of obstetric units, in midwifery led units, provides the same level of safety for the baby but has added health benefits for the mother. The same findings were found for homebirth for women having their second or subsequent birth. If we are to provide care at the highest evidence based level, we must ensure that all appropriate women have easy access to a midwifery led unit and home birth facilities and their benefits are communicated to them by a midwife who they know and trust. We believe that our health board should be able to provide a woman with a choice of where she gives birth, at home, in a stand-alone midwifery led unit, a midwifery led unit that is situated alongside an obstetric unit or within an obstetric unit. It is essential that all members of the care giving team speak with one voice, promoting all aspects of care that will enhance a woman’s birth experience, through minimising intervention and promoting environments where women feel safe and nurtured. We believe that there are many benefits to centralising obstetric services within the South Wales area and support the recommendation that consultant-led obstetric units should have around 6000 babies birthed there per year. This has clear

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advantages to ensuring more labour ward dedicated consultant obstetrician time, of at least 60 hours cover per week. Hospitals who have already adopted this level of senior cover have shown improvements in outcomes for women and their babies (RCOG 2011). It is essential that a regional centre, must employ obstetricians, whose focus is to work within a team to reverse the rising caesarean section rate, through commitment to learning and developing labour ward skills, that are taught to trainees in an environment that is supportive and nurturing.We do not support the South Wales Programme recommendation that “most clinicians agreed that ideally a Midwifery Led Unit (MLU) should have around 500 babies delivered there per year”, there is no current evidence to support this statement. Different models of midwifery staffing mean that pure birth numbers to do effect the cost effectiveness of midwifery led units (Birthplace in England Collaborative Group, 2011) and our health board experience suggests that women strongly appreciate the individualised care they receive in our MLU’s (Davies 2012). Birth Rate The birth rate in ABMU is increasing, the complexity of women being cared for by our maternity department is also increasing. Midwifery staffing is currently based on the Birthrate Plus workplace planning tool (www.birthrateplus.co.uk) and it is essential this is continued pre, during and post any reconfiguration, in order to meet the needs of women and their families during this time. Midwives response to reconfiguration We know that midwives within our health board are flexible and adapt well to change. Our experience at Neath Port Talbot Hospital showed us, that where midwives are communicated with, prepared for, and feel involved with change of services, the change can be undertaken safely, calmly with our service users feeling confident that the staff understand and support the process. References Birthplace in England Collaborative Group (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study British Journal of Obstetrics and Gynaecology 343 7400 Royal College of Obstetricians and Gynaecologists (2011) High Quality Women’s Health Care: A proposal for change RCOG www.birthrateplus.co.uk Local councillor I write in respect of the above and wish to offer the following points of observation for consideration as a County Borough Member representing Maesteg West ward:

(1) I fully recognise the need to have a fit-for-purpose, 21st Century health service in Wales, and in particular across the ABMU region. These services must clearly strive for excellence and ultimately impact positively on the lives of our citizens as well as addressing future health needs.

(2) I would like to support a 5-centre model, whereby the 3 already identified centres of excellence are supported by the Princess of Wales Hospital in Bridgend and one other. The Princess of Wales is ideally located between Cardiff and Swansea and will have the capacity to serve a far larger population with patients from Neath Port Talbot and the Vale of Glamorgan

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local authority areas - they will be within relatively easy travelling distance (by ambulance or private transport).

(3) I am very concerned, should the PoW not be identified as a centre of excellence, about the vastly increased travelling times for people, in particular the family members of patients from the north of the Bridgend Borough, ie. the Llynfi, Ogmore and Garw valleys. This could involve a one- way bus journey in excess of two hours which is unacceptable and simply takes away from the Health Board's ultimate goal of a 21st Century service right across the spectrum. ABMU must engage with external and statutory stakeholders to alleviate this problem.

(4) In addition to the above, I have added my signature to a collective response on behalf of County Borough Members representing the Maesteg East, Maesteg West and Caerau wards in relation to concerns over Maesteg Community Hospital. Plaid Cymru Remodelling of Hospital Services Glynneath Branch I write in response to the public consultation exercise on behalf of the Glynneath Branch of Plaid Cymru. A public meeting was held at Glynneath Rugby Club on the 12th December 2012 to discuss the implications of the actual and proposed changes to our hospital services. The meeting was well attended and the general consensus of opinion was that the proposed changes are not acceptable to the residents of Neath Port Talbot because of the following reasons: • Neath Port Talbot has a population of over 140,000 residents, many of whom are elderly and are the main recipients of medical and social care. • Neath Port Talbot sits in the upper quartile of the Welsh Index of Multiple Deprivation. • Research carried out by the Local Health Boards and latest figures from the 2012 Census show that there is a higher proportion of ill health and deprivation among Neath Port Talbot residents. • Neath Port Talbot Hospital was built by PFI ten years ago because of the higher proportion of medical needs within the population. • The hospital’s services have already been downgraded since the hospital was built and opened, for example, maternity services, general surgery and emergency medical services. • There has been no public consultation on the changes. Removal of these emergency medical services is having a huge impact on residents who will find it difficult to access Morriston and Singleton hospitals in Swansea and the Princess of Wales Hospital in Bridgend. Many residents who are elderly may not drive and many will not own cars, which will cause problems for accessing outpatient appointments or for visiting relatives. Journeys from the upper Neath valley, for instance will take, by car: 20 minutes (14.9 miles) to NPT Hospital. However, the alternative journeys would be: 27 minutes (18.3miles) to Morriston Hospital; 45 minutes (37 miles) to Bridgend Hospital; 39 minutes (20.1miles) to Singleton Hospital. It must be noted that the journeys to the above three hospitals will for those

196 without cars mean having to make at least two bus service changes. The access to POW Bridgend via the M4 is often congested and can become closed if there is a RTA and is particularly busy at rush hour. Traffic accessing Singleton Hospital just off the A483 crosses the city centre with 21 sets of traffic lights to circumvent before getting to the hospital. This road is extremely busy during the summer and during rush hours. Morriston Hospital is on the M4 corridor but difficult to access by bus. Hospital attendances are rarely just one visit. They often mean several out patient appointments or visiting relatives over a long period of time, causing both physical and financial hardship to residents. • Research carried out at Sheffield University found that each extra 10Km (6.8) miles travelled to A & E will increase the proportion of patients who die by 20%. • There are great concerns that the removal of services at Neath Port Talbot, along with the closure of A&E at Prince Philip Hospital, Llanelli, will have an impact on Morriston Hospital. There is a need to question whether Morriston Hospital has the capacity to cope with the extra demand. A recent trial run of the service had 15 ambulances stacked up outside Morriston A&E waiting to discharge patients into the department. • Emergency medical services have been removed from NPT Hospital because of the lack of medical staff and yet the Trust has already removed three consultants and nursing staff from NPT. It is also suggested that recovering patients can be taxied back to NPT if well enough. Residents need to be reassured that there will be medical cover In the event of a patient suffering a relapse. • Changes include more care in the community but there is no capacity in the community to cope with extra demand and staffing levels would have to increase dramatically. • ABM University Trust already has an over spend and has to save even more this next financial year. Residents need to know whether the Trust is making these savings by cutting the acute services at Neath Port Talbot Hospital so compromising the health and safety of the residents of Neath Port Talbot, who have the poorest health and highest levels of deprivation. • Staff are presently being taxied or bussed to Singleton hospital. The Trust is also suggesting a bespoke taxi service to return patients back to NPT Hospital if they have recovered enough from their initial emergency but not well enough to be discharged. If the Trust has financial difficulties, questions need to be asked regarding how long the Trust can maintain such a service. • Residents need to be told the truth about the services that “may“ be placed at NPT Hospital. Neath Port Talbot residents will suffer if they do not have access to acute services at Neath Port Talbot Hospital and residents deserve to be told the truth about the intentions of the Trust regarding services and the long term future of the hospital because without emergency services the hospital cannot survive and will become nothing more that a rehabilitation centre. We would also like to draw your attention to the 5000 name petition, copies of which were handed into staff at the Public Engagement session on the

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13th December at Glynneath Town Hall. This petition was collected over a relatively short period of time in September, shortly after the removal of emergency medical services at Neath Port Talbot Hospital, and the signatories come from various areas of Neath, Swansea and the Neath and Dulais Valleys. These people are extremely angry over the removal of services at Neath Port Talbot Hospital. This petition is currently under discussion by the Welsh Assembly Government’s Petitions Committee. We understand that there will be a public consultation on the proposed changes in the New Year and we would respectfully request that all communities in the Neath Port Talbot area are given the opportunity to see and discuss these changes adequately. Local councillor I am writing in my role of a parent, Borough and Town Councillor for the Ward of Newcastle, Bridgend to express my own and the constituents deep concern, Abertawe Bro Morgannwg Health Authority are considering down grading A&E at Princess of Wales Hospital, Bridgend. I acknowledge the need for transformation and the difficulties the Health Service in Wales and around the UK, in attracting medical staff to work for the NHS. However with consideration being offered to develop Cardiff and Swansea as City Regions, I believe, Bridgend will have a vital role to play in success of these plans and will be an attractive place to live. Therefore, this will see a growth in the population of Bridgend and the necessity for investment in excellent infrastructure and health services. However, I believe there are other strong arguments for five rather than four centres and why the Princess of Wales, should be chosen and one of the main concerns expressed by the constituents of the Ward of Newcastle. Is fact that patients and their loved ones will have to travel extended and complicated journeys for specialist acute services. Consideration must also be offered to Bridgend, due to its location halfway between Swansea and Cardiff, with the Borough of Bridgend, excellent transport links with the Princess of Wales Hospital. The M4 is less than 5 minutes’ drive at its busiest period and the main and valley railway links are less than 20 minutes’ walk from the hospital, in addition to the regular and reliable bus services, which stops outside the Hospital, with links to Bridgend railway station. Deliberation must also be given to the effect on those with the modest of income, the most poorest and vulnerable in our communities who use the National Health Service the most, will have on them if Princess of Wales is not chosen to be one the enhanced centres. Therefore under the strongest of terms, I ask that Princess of Wales Hospital is chosen as one of the enhanced regional centres not only to serve the residents of my ward, Borough of Bridgend and its unique location to also serve the communities outside of the Borough. my ward, Borough of Bridgend and its unique location to also serve the communities outside of the Borough. Bridgend Council Members of Bridgend County Borough Council (BCBC) discussed the Abertawe Bro Morgannwg Health Board (ABMU) engagement exercise,

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Changing for the Better, in full council on Wednesday 12 December 2012 and asked me to write to you on their behalf.

BCBC recognises the pressures of increasing service demands and the impacts of medical advances on the NHS, and welcomes the wide engagement of clinicians on the future configuration of health provision across South Wales. It was accepted by BCBC that the status quo in the NHS is not an option and that there need to be changes to acute health services.

AMBU’s proposals set out in changing for the better to deliver more health services as close, or closer, to people’s communities was welcomed by BCBC, and is very much in line with the council’s strategic objectives. BCBC wishes to continue to work closely with you on developing your changes for community health services and looks forward to seeing these proposals in more detail so that reforms to health and social care are of mutual benefit to local authorities and the NHS. In particular, members wished to highlight the importance and popularity of Maesteg hospital within the community and see this as a vital part of the health and care system within Bridgend.

It was felt very strongly by members that the proposed reduction in the number of hospitals offering a full range of acute services will lead to significant cost and disruption to many people across South Wales; that the people who will be affect most will be patients, families and friends who are reliant on public transport – some of the most vulnerable in our society. BCBC wishes to highlight to you the real difficulties that will be borne by people in this county borough if they need to travel extended distances to reach a regional centre, as proposed in the South Wales programme.

The council paper (attached to this letter) details some of the specific additional travel times from various parts of the county borough that would be required to reach a hospital beyond the Princess of Wales in Bridgend. While travel by car to the next nearest hospital from some of these towns and villages is within an additional eight or so minutes, the additional time travelling required by public transport is in excess of one hour each way. The impact of such a change would be made worse by the relatively infrequent nature of some of these public transport services.

In order to protect the most vulnerable people with Bridgend CBC, members unanimously favoured a five centre model for regional centres, and within that five centre model, there was complete support for Princess of Wales Hospital to become a regional centre, given its excellent location close to the M4 and the fact that it is equidistant from Swansea and Cardiff. They regard this as not only the best solution within the proposals outlined for the people of Bridgend, but also the best solution for the people of South Wales.

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Neath Port Talbot Neath Port Talbot Council for Voluntary Service is a County Voluntary CVS Council and a Charitable Company set up to promote, support and develop the Third Sector in Neath Port Talbot. Neath Port Talbot CVS welcomes the opportunity to respond to the Changing for the Better engagement document, and in doing so, has sought the views of a sample of 15 staff who live throughout the ABMU Health Board area. A number of Third Sector organisations have also fed in comments through discussion at the Neath Port Talbot Third Sector Social Care and Wellbeing Forum. A number of stories around people’s experiences of the local NHS have also been included in an annexe. Providing Sustainable Health ServicesUsing the scale included in the question booklet, staff were asked to indicate where they fell on the scale. These results are displayed as percentage. 47% strongly agreed; 40% staff agreed and 13% staff neither agreed or disagreed that the characteristics are the right characteristics to make sure health services are sustainable. The majority agreed with the characteristics of sustainable health services; the characteristics are what people would expect the health service to be. It was felt however that there probably should be more characteristics and it was noted that there was no mention of the environment, which many associate with sustainability. Environmental factors will need to be considered, particularly if services are reorganised as people may be expected to travel further for some services. This will have an impact on carbon emissions and also on the financial cost to individuals in terms of increased travel costs. This is at a time when petrol costs continue to rise. It is also worth noting fuel costs are also increasing, which will impact on ABMU’s energy bills. New builds and hospital building improvements should also be carried out with environmental sustainability in mind. There are also a range of issues around transport which will need to be addressed to ensure that services can be used by all of the community as transport is already a major issue. Currently, it can take some people in rural communities a whole day to access tests at hospitals, and there is concern that reorganisation will make it more difficult and will mean people won’t be able to access services. It is important that strong links are made with the Welsh Ambulance NHS Trust and with other transport providers to ensure that people are able to access services. If hospitals are to become regional centres, access and car parking at these centres needs to be improved. Strong links with transport providers will be even more important with anticipated 25% cuts in bus subsidies in the South West Wales Integrated Consortium (SWWITCH) area in the next financial year with further cuts to follow. It was noted that the hospitals have been built around motorways and this will impact on travel times. Will motorways continue to be the focus of the road network in future? The timing of appointments and procedures also needs to be considered to ensure access to services. There is little point scheduling early morning appointments for people who are unable to get to a service for this time due

200 to the lack of available transport. Other factors also need to be considered when scheduling services e.g. giving consideration to child care arrangements. Some people are having difficulty understanding the reasoning behind doctor shortages. They feel that the issues around recruitment could be overcome through more effective recruitment campaigns and as a result of this, that services at Neath Port Talbot Hospital wouldn’t have had to be cut. Staying Healthy and Reducing Becoming Ill Using the scale included in the question booklet, staff were asked to indicate where they fell on the scale. These results are displayed as percentage. 13% staff stated 3, 20% staff stated 4, 40% staff stated 5, 13% stated 6 and 13% staff stated 7 with regards to how they would prioritise between promoting good health and a healthy lifestyle and treating the consequences of poor health and lifestyle. The subtext is that health promotion is cheaper than treatment. Promotion works to an extent, to people who are interested, usually those who have had life scares. There needs to be a lot more work carried out in this area. A core group of people will never respond to promotion, but some will if you “scare” them enough. You will get a number getting healthier in small groups. As an organisation Neath Port Talbot CVS promotes prevention and early intervention, however this question does not reference the early intervention agenda. The role of Health Board staff in promotion and early intervention was raised. It would be encouraging to see Health Board staff becoming role models. Furthermore, it was felt that doctors should ask questions around people’s general health before any issues arise, e.g. asking people about their weight. However, it is important that these questions are asked in an appropriate manner alongside an offer of advice and support to deal with any identified potential health issues. The wider agenda needs to be considered. There are overweight people, close to or below the poverty threshold, who are able to access only cheap, poor quality food. Food production and cost needs to be tackled. The area is still recovering from the loss of heavy industry and the complications of this, which impact on health, unemployment etc. This is too often forgotten. A number of suggestions were put forward to help people to stay healthy: • Target schools. young people are the parents of tomorrow and messages taken on board at this stage can have a lasting effect. However it is important to recognise that not all young people will take the messages on board. • Target physical activity in schools. P.E is no longer a key focus on the curriculum; time spent in delivering physical activity can be low. • The amount spent on promotion and early intervention is currently a very small proportion of Health Board budget. Could some activities be subsidised to ensure that they are accessible, e.g. sport, dance classes which can be too expensive for some families? These are not always viewed as a health issue, but can encourage a healthy lifestyle at a young age • Consistent messages should be provided. Breakfast clubs and school lunches don’t always provide the same messages as to what is considered a

201 healthy diet. There is a need to focus on emotional wellbeing; people need to be able to motivate themselves to keep healthy and to be able to access services. This may not be the case for someone with poor mental health. There was concern that the question guides you to the middle ratings; that you can’t chose between promotion and treatment. There was also a fear that if a mandate is given for promotion, it will give the Health Board a reason to not treat people who haven’t looked after their own health in future. GP and Community Services Using the scale included in the question booklet, staff were asked to indicate where they fell on the scale. These results are displayed as percentage 47% staff stated 4, 47% staff stated 5, 6% staff stated 6 in relation to how they would prioritise between investment in community services and investment in community hospital beds. It was felt that the question was ambiguous. The question groups together services provided in the home and elsewhere in the community. These can be very different services however they are grouped together as one which makes an effective response difficult. The GP service can be an exemplar when it works well, however there are many instances where accessing GP services can be difficult. This question indicates a desire to close community hospitals, and in some instances, people have already been told community hospitals are shutting; the decisions have already been made. How does this fit with engagement? People can be very attached to their local GP surgeries. The issue of the new Vale of Neath surgery was highlighted. New surgeries are state of the art and can provide improved services, however there is resistance as people won’t be able to just pop down as transport may be a barrier to access. People like having services available in their local community, and with larger primary care resource centres/ new centres, there are fewer centres in the immediate local community as GP surgeries become centralised. Concern was raised around hospital discharge, and the role community hospitals play in providing support, including social support when people are discharged home. Would home visits work like this? Are they different services? Home care staff may only have a very small amount of time with a patient due to the time spent moving between patients and this would have an impact on the level of support people receive. People should be looked after if they are ill, but they are also at greater risk of becoming ill if in hospital. It is important that people can access the right level of services in their own home. This should not depend on whether or not they can afford to pay. However, if people have to pay to access services, this could create a two- tier system, between those who can and can’t afford to pay which will increase health inequalities. Furthermore, if individuals have to pay to access services they desperately need, they could fall into poverty. An example was provided of the Afan Valley where older community members have been bussed for flu jabs. This project was funded by

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Communities First and organised by the Local Service Board (LSB) Older Persons Project Officer. If it had not taken place, people could have had to wait a number of weeks to receive their flu jab. If funding is freed up from the closure of community hospitals, where will it go? Will it be used for community projects such as providing transport to access services? Lots of people would rather be at home however there is a need for both services. It will be difficult to change the public perception that hospitals should be the priority and that more services can be delivered in the community. Long-Term Conditions: Using the scale included in the question booklet, staff were asked to indicate where they fell on the scale. These results are displayed as percentage. 7% staff stated 2, 7% staff stated 3. 20% staff stated 4, 13% staff stated 5, 40% staff stated 6 and 13% staff stated 7 with regards to how they would prioritise support for patients with long term conditions. When things go wrong, people feel the need for specialist support. Concern was raised that if more services are moved into homes, specialists will be based further away and will be more difficult to access. There will therefore be a need to have specialist staff in the field, and this could be a challenge in terms of managing the workforce. The impact on carers could be significant. The Third Sector is able to provide support in the community through support and social groups amongst a wide range of other services. It will be important that strong links are established to enable appropriate referrals to be made. The importance of the CVCs in establishing these links cannot be ignored. Concern was raised around medication management, and that some medications can contradict each other. This issue needs to be resolved. Locally in the Afan Valley, pharmacists undertake a medicines health check service. Do people know about this? Is it available widely and universally? If more services are to be delivered in communities, does the physical space available in the community allow for this? Will GP surgeries be able to extend the services available? It is well noted that some GP surgeries already struggle for space. It was noted that long-term condition rehabilitation programmes can be a successful way of supporting people with long-term conditions to avoid hospital admissions. It is important that these programmes are expanded as provision can be very limited. Frail, Older People Using the scale included in the question booklet, staff were asked to indicate where they fell on the scale. These results are displayed as percentage. 67% staff strongly agreed; 27% staff tended to agree and 6% staff neither agreed or disagreed with regards to whether healthcare services should be designed to support frail older people to live at home and avoid hospital treatment as far as possible. Services should be designed to support frail older people. These services need to be delivered and integrated with social care and Third Sector provision.

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The emotional wellbeing of older people is critical and shouldn’t be neglected. It was felt that family support or the ability to pay is needed to ensure a good quality of care. Otherwise, people can be left feeling isolated. Some people may prefer to go into hospital so that they can see and speak to other people. It can be scary for people to leave hospital and go home after a health scare. They can feel on their own, isolated and vulnerable. They need to know the right care and support is available to meet their needs. People can wait up to 3 months for a visit from the district nurse for the flu jab. If this is the case now, it could become a bigger issue in future if greater demands are placed on district nurses. Carers are mentioned. As the number of frail older people increases, support for carers will be important. If beds are no longer available ton community hospitals, facilities for respite will need to be made available. With an increase in early on-set dementia, isolation will increase and services need to be in place to cope with demand. There is a need for people who can provide appropriate in patient care for people with dementia. It is recognised that people are attached to their homes and it is assumed that this is the reason for providing treatment in their homes; however structural problems in some homes, e.g. poor maintenance, can make the home an inappropriate and unsuitable place to provide care. Clinical staff are not trained to recognise these issues, and links need to be established with agencies who can provide this kind of support e.g. Care & Repair to ensure a holistic approach is used. It cannot be assumed that a person wants to stay and receive care in their home and it is important that conditions are right in the home for care and treatment if this is what the person wants. Future Pattern of Hospital Services There is a feeling that the future pattern of hospitals is a fait accompli; that people are being asked to confirm that the Health Board’s decisions are right based on the issues that are faced with staff recruitment. Some strong views have been expressed in relation to the issue of doctor recruitment – and felt that what motivates people to become a doctor needs to be looked at. It was felt that it was right to co-locate services to ensure the right support systems are in place. However, it is a difficult balance between poorer services closer to home versus good quality services further away. There is an inevitability of centralisation. On paper, it saves money, but this is difficult to balance with human factors, such as the emotional impact of being further away from family and friends and the impact on care from longer travel times. When people are in hospital, the ability for people to visit them is important. A lack of visitors could increase the length of stay. There are financial and emotional cost implications in terms of visiting. People don’t always understand the implications of visiting unless they themselves have had to visit people in hospital on a regular basis. For social workers based in hospitals, building relationships with local providers will become more difficult with the centralisation of services. This may make referrals more challenging.People understand that something has to change, but don’t appreciate what this means on their every day lives. For some,

204 leaving their local community to access services can be a huge challenge and a scary prospect. Having to access services further away may be a step too far for many. Specialist Services If specialist services are to be centralised there is a need to consider visiting arrangements. Accommodation for relatives should be provided to ensure that relatives are able to visit, and that the patient can benefit from having visitors. Emergency Care The golden hour of receiving treatment is at risk with the regionalisation of services. Some feel that services shouldn’t be regionalised, due to the time limits of certain treatments however if services are regionalised, work needs to be undertaken with the Ambulance Trust to ensure that people are able to access services quickly and efficiently as well as with the Welsh Air Ambulance, which is dependent on public donations. Concern was raised about access to emergency services, and that people can wait for more than 3 hours outside A & E before being seen, and during this time people can be transferred between ambulances. This also prevents ambulances from dealing with other emergencies. Will regionalisation place greater demand and pressures on the ambulance service, which sometimes already seems unable to cope with current pressures? Will demand on emergency departments be even greater if departments are expected to cover a wider geographical area? The closure of the acute medicine service at Neath Port Talbot Hospital has placed greater demand on Morriston Hospital. Will this demand increase further if the Princess of Wales Hospital does not become a regional centre? Do you have any further comments? There is a feeling that the ideas proposed are inevitable. It is felt that with some services decisions have already been made, and that this doesn’t represent fair engagement e.g. relocation of maternity services to Morriston, and the closure of some community hospitals. Concerns were raised around Neath Port Talbot Hospital, that it hasn’t fulfilled its original purpose proposed in the initial plans and that it has been downgraded. There was also concern that it is mentioned very little in the plans and that this has implications for its future. That staff have had to reapply for positions as a result of services moving to Morriston hospital has also caused concern. A question was also raised around whether too much is expected for the NHS. Annexe A number of personal stories were raised in discussions around Changing for the Better. These can be found below. An example was provided of a mother who had been discharged from hospital, no medication was provided and no questions were asked as to whether support was available at home. Questions need to be asked prior to discharge around what support people need and whether there is anyone able to assist them when they get home. Carers also need to be involved in the discharge process. An example was provided of a father who gets services at home because he is willing to pay e.g. podiatry, optician, dentist. People need to be able to access services in their home regardless of whether or not they have the ability to pay. The family also has a system in place where family members call him at frequent intervals throughout the day to check he’s well. Could

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this be replicated? It doesn’t have to be a family member who calls. There is investment in phone lines which people can call when they need it, but what about a service where people call everyday to check they’re ok. An example was given of a person who suffered a broken leg in a rugby match. The case was classed as a non-emergency case and no ambulance transport was provided. No one knew how severe the break was and the player was transported in the back of a van to hospital. This happened now; what will happen with changes to services?An example was provided of a woman in her 80s who travelled everyday from Neath to Princess of Wales Hospital to provide clean pyjamas for her husband. Could support be provided to relatives to reduce the stress place on them in such a situation? Could Neath Port Talbot patients be moved back to Neath Port Talbot sooner? The wait people experience outside Morriston A & E can be unacceptable. An older man in his 90s waited for more than 3 hours in an ambulance outside A & E and during this time was transferred between ambulances. Member of NHS The wording of some of the questions was very confusing particularly staff questions 2, 3, 4, 7 & 8. 1. Please read pages 10-13 of the information booklet Do you agree or disagree that these are the right characteristics for the Health Board to consider together to make sure that health services are sustainable? Yes there was general agreement that these are the right characteristics. There will need to be an infrastructure in place to deliver this change of emphasis. There will also need to be investment into Community Services and Primary Care Services to support this change. Nutrition & Dietetics will need to be heavily involved in training other health care staff on all aspects of nutrition. 2. Pages 31-32 How would you prioritise between the following two options? Choose one of the following answers Promote good health and a healthy lifestyle - Treat the consequences of poor health and lifestyle We have assumed score of 1 will be low and a score of 9 will be high. There was a difference of opinion on the response to the question and therefore ‘promote good health and a healthy life style’ scored 9, however ‘Treat the consequences of poor health and lifestyle’ scored between 5-9. Some people felt that the second case of treating consequences score highly and there was no difference between both statements.Generally public health and community staff felt very strongly that ‘Treat the consequences of poor health and lifestyle’ should score a much lower score of 5 as they felt that promoting health through lifestyle changes is the priority and long term aim. This is the only way to move away from the Medical Model of health care. Nutrition and Dietetics are currently involved in delivering Nutrition Training to a small proportion of community workers and health care professionals to promote nutrition and public health, however there will need to be an investment to extend this provision to enable the Health Board to change this emphasis. 3. Pages 44-45 How would you prioritise between the

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following two options?Choose one of the following Improve services provided in patients’ home and in the local community Rely on community hospital beds Improve services provided in patients’ home and in the local community-scored 9 Rely on community hospital beds–it was felt this was less important and-scored 2. 4. Pages 42-43 How would you prioritise between the following two options? Choose one of the following answers Patients should regularly attend hospital for specialist treatment Specialist staff should be based in local communities, which would mean fewer hospital beds The team felt the term specialist was confusing and would have appreciated a definition. Does it mean specialist teams or specialist services for example Physiotherapy/Dietetics/Radiology. Transport would be an issue if patients access specialist treatment away from local communities. 5. Pages 40-41 In principle, do you agree or disagree that healthcare services should be designed to support frail older people to live at home and avoid them needing to go to the hospital as far as possible? Agree. 6. Pages 46-53 Do you agree or disagree with the future pattern of hospital services that has been recommended? Agree on the whole. However concern was raised about the lack of consideration with regard to Hywel Dda Health Board as we provide a service to a large proportion of these patients. Transport again will be an issue, a mention of a helipad would be required for the Air Ambulance Service. Clarification is required with regard to the Air Ambulance Service whether it is part funded by the NHS. We are aware that mental health has its own plan in place, however, mental health services need to be considered as part of this overall plan. 7. Pages 46-53 How would you prioritise between the following two options? Choose one of the following answers Be treated at a local hospital Travel to receive care from a specialist team - It depends what service is needed by the patient. Again what does the term specialist mean in this context? There will be implications in community and local hospitals- even though services change we need to ensure that staffing levels are maintained. It will be necessary to deliver nutrition training to all Health Care staff and provide a Dietetic service wherever they are placed. 8. Pages 46-53 How would you prioritise between the following two options? Choose one of the following answers Ensure that all centres can provide the full range of services - Score 2 Accept that some centres may only offer more limited services – Score 9 Are there any comments you would like to make about Emergency Care? Making sure that people are aware of which centres they should attend and for which ailments – ensuring that these services are well publicised in the local press and media. If people are required to travel further for emergency care it is essential that ambulance services are identified as an additional requirement. Member of NHS • Are resources currently available in the community to be able to deliver staff services to patients ‘at home’ or elsewhere? It’s not just about venues – need equipment and sufficient staff to be able to provide this service. Current level of community staff within department would not be able to

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cope with the caseload this could generate. Are existing staff in other areas going to become community-focussed, potentially reducing the number of staff available to undertake acute work? Need to be able to staff both areas adequately and appropriately. • For some patients, a local hospital may be their nearest health facility and they would therefore be happy to attend a hospital for outpatients/diagnostic tests. The local hospital will already have good access to public transport and potentially car parking would be easier than at smaller centres. • Are we going to have resource centres or ‘hubs’ where patients can be seen by a MDT in one place (if this is needed)? As we do a lot of group education, will these venues have rooms large enough, i.e. fit for purpose? It is not economical (or necessary) to undertake home visits for all patients - in terms of staff, travel costs, the fact that it takes longer to do a home visit. • Will these centres/hubs allow for storage of equipment that is used for group training? We should not be asking/expecting staff to carry display stands/boards, etc between venues. • Loss of local services, for the more vulnerable areas e.g. flying start. Sometimes these families are difficult enough to engage with, without the extra pressure of even further travel. If we are expecting these parents to travel to Morriston daily to see their premature infant in SCBU, this is going to be a real challenge. Also who is going to pay for these visits? • The loss of specialist services in POW would be a real shame and could affect staff recruitment & retention. It is already difficult to recruit to some posts – we don’t want or need to make this even more so. Who will want to work in a hospital when all the complex and ‘more exciting’ work is going to another centre? How will existing staff develop more complex dietetic skills? While job rotation, job shadowing or working across sites may resolve some of this, there are staff who appear less willing to share or support others’ learning and development. Also, why develop yourself/ your skills if you never have the opportunity to use them? • Often get more positive feedback from patients/carers who use smaller more local venues – often seen as more friendly, accessible. The feedback you hear about larger centres is not always as good. • How much will it cost in terms of travel and other expenses to provide more and more services in the community? We are already being asked to reduce travel expenses; surely this change in service would push up the cost? If you work as a mobile MDT will all staff be travelling separately or using one car? This will need a lot of co-ordination, which is not impossible but may be difficult. • Will we be asking all to staff to be able to drive and have a car? Relying on public transport if you are community-based or mobile is not ideal. Equally, public transport routes will need to be looked at if we are expecting patients/carers to travel to community clinics or resource centres. Member of staff 1. Please read pages 10-13 of the information booklet Do you agree or disagree that these are the right characteristics for the Health Board to consider together to make sure that health services are sustainable?

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Agreed. However need to protect CPD time to ensure safety quality of service; remove CIP for services such as ours whose staff establishment is far too small, we require stable budget for planning, keep up with inflation and service levels agreements need to be renegotiated in light of estimated losses because of the CIP. Dietitians are uniquely placed to assess, diagnose and treat diet and nutrition problems at an individual and wider public health level. We use the most up to date research to translate into practiced guidance to enable people to make appropriate food choices. Important to recognise our impact on effectiveness of care provided by other HCP – keeping people out of Hospital, safety of feeding, training, infection control etc.2. 2. Pages 31-32 How would you prioritise between the following two options?Choose one of the following answers Promote good health and a healthy lifestyle Treat the consequences of poor health and lifestyle Difficult to rate this. Not everything preventable. More national campaigns – (we need to be involved in local delivery but many multi factional contributors to health problems need to address wider issues and on large scale. New investment needed to do this preventative and promotion of good health. Time line for moving that way is going to be lengthy. Concern about quick fix – need to reinvest not just disinvest. 3. Pages 44-45 How would you prioritise between the following two options? Choose one of the following Improve services provided in patients’ home and in the local community Rely on community hospital beds Improving services in homes and community through proper care packages is important but we need a lot of change and investment to do so. NB. Transition from acute to home and further rehab needs community beds – cheaper than acute beds. Can be expensive model of care at home / on dietetic visits. Safe discharge is important. 4. Pages 42-43 How would you prioritise between the following two options? Choose one of the following answers Patients should regularly attend hospital for specialist treatment Specialist staff should be based in local communities, which would mean fewer hospital bedsSo many teams would be needed that costs prohibitive e.g. Diabetes teams. These are not linked to hospital beds now. They don’t need too be on an acute site – could be mobile and travel to localities. Would even be better to be off acute site – better facilities for education etc. 5. Pages 40-41 In principle, do you agree or disagree that healthcare services should be designed to support frail older people to live at home and avoid them needing to go to the hospital as far as possible? Agree. Are there any other comments you would like to make about healthcare services for frail, older people? Main issue is access to GP services for those with a mobility problem, GPs do not do so many house calls. Social contacts are more limited / fragmented than in past. Need to provide long term care for those who will suffer isolation though care in own homes. Are there any other comments that you would like to make about GP and community services? Gap in services for non elderly vulnerable and ill – lack of social/nursing

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care. Need to develop sheltered housing facility. 6. Pages 46-53 How would you prioritise between the following two options? Be treated in local hospital Travel to receive care from a specialist team If this is about those highly specialist services yes but only if these services can cope in terms of staffing and facilities. Answer depends on what we mean by specialist. 7. Comments that you would like to make about the future pattern of hospital services, in particular about the quality, safety, staffing and access factors that should be taken into account? Specialist serves need to be at full compliment, quality and safety must not suffer because of changes in services overall. These services such as renal, ITU pancreatic and burns are not properly resourced for Dietetic provision at present. Staff feel that there maybe an element panic regarding saving money/closing beds and not taking account of poor investment in all services. 8. Pages 46-53 How would you prioritise between the following two options? Choose one of the following answers Ensure that all centres can provide the full range of services Accept that some centres may only offer more limited services Staffing and standards across Wales need to comparable/and different units – now very inconsistent. Danger for us is closure of beds at a site where Dietetic service under established so no resource to transfer to site where expectations are higher. Saving in beds need to be reinvested in other areas such as Nutrition and Dietetics. Centralisation with limited services ok but concern about the distance between those centres with high level complexity. More minor injury units or better use of current – working together to triage patients to other places with capacity. Transport issues in many areas will limit across wider geograph areas to cheaper to provide transport to take people from one centre to another if capacity there. 9. Pages 46-53 Do you agree or disagree with the future pattern of hospital services that has been recommended? Lack of ‘step down’ stage may create blockage at Regional Centres – gaps in community services can prevent flow. Would lack of community hospitals have impact on other hospital sites which by default would become ‘community’ into use. Big impact on relatives for those in Regional Centres. Balance of different types of beds and facilities is key to success. 10. Are there any other comments that you would like to made about long- term conditions? More investment needed for Dietetics – invest to save. Need to select well – to target those who will respond for taking responsibilities for health. Techniques must also be more that knowledge based. Obstetric We acknowledge the inevitability of a reduced number of consultant led consultants obstetric units in South Wales. We welcome the SWP initiative, intended to loosen the purely financial boundaries of cash flow held within each Health Board and open the Chief Executives’ options to support the best choice of

210 hospital(s) for investment and expansion. Our understanding of the present situation. C4B must consider centring acute maternity services on one location. There is no evidence that this would save money, it did not do so in Cardiff and Vale when two similar sized units were combined in 2005. There is no evidence that clinical outcomes would improve. The immediate driver for change is the shortage of middle grade Paediatricians. As things stand, the Deanery will withdraw trainees from POWH, since there are not enough paediatricians to staff all units in Wales and training opportunities are considered better elsewhere. Without a neonatal unit, the obstetric capacity at POWH would be reduced to that of a Birth Centre. SWP decisions are also driven by shortages of specialist doctors. It is intended that consultant led obstetric services should be centred on four or five hospital sites in South Wales and that Level Three (intensive) neonatal care should be concentrated on two or three hospitals and Level Two (high dependency) should be concentrated on four or five hospitals. The final decision on whether there are four or five consultant led obstetric units depends whether Newport is allocated a double rota of paediatric trainees to provide intensive neonatal care or just one rota to provide high dependency. The latter decision would leave enough trainees to provide another high dependency neonatal rota elsewhere. The final number is likely to be known early in 2013. Assuming that Cardiff, Swansea and Newport continue to provide consultant obstetric services to the three largest cities, then one or two further consultant led obstetric services linked with a high dependency neonatal rota remain be allocated among POWH, Royal Glamorgan and Prince Charles. Allocation of A&E Care is bound to go to the same hospital(s). Either all three services go to just one ‘Regional Centre’ drawing in some added acute cover from specialist doctors at the other two hospitals, or acute services continue at two hospitals, which may share the on call work of medical staff from the one downgraded unit. The net weight of positive and negative factors applying to provision of obstetric, neonatal and A&E care at each hospital will prove decisive in the final allocation. Factors we believe are relevant to SWP decision making. • Clinical Excellence Our first concern is that the excellence of Maternity Services at Princess of Wales Hospital (POWH) is recognised. Whichever unit reduces acute services, it is accepted that some patients will have to travel further. The positive aspect set forth to the public is that the care they travel to receive will be better. When deciding which unit(s) to expand and develop and which to reduce, a prime concern should be to centre activity on the unit(s) already known to have the best clinical outcomes. There have been no direct maternal deaths at POWH since 1996. The Welsh Risk Pool annually assesses each obstetric unit’s safety in order to calculate their insurance premium. POWH has scored 97% for many years. The most common complication and a very serious risk to women in childbirth is haemorrhage. At POWH, in conjunction with our radiology and anaesthetic colleagues, we have developed and successfully implemented a protocol for interventional radiology prophylaxis in cases at high risk of massive haemorrhage. This uterus and/or life saving service is not available at any other unit in Wales.

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Data from the All Wales Perinatal Survey Annual Report 2011 http://www.cf.ac.uk/medic/awps/ summarised on page 56 in Table 20 shows that in 2011, POWH had a lower rate of Caesarean Section than Singleton, Royal Glamorgan or Prince Charles, even though the 472 births at the Birth Centre in Neath Port Talbot were not included, despite the fact that all their transfers of women in labours that are not progressing smoothly are delivered at POWH. This has not been achieved by taking risks with fetal welfare. Table 15 on page 48 shows Bridgend had both the lowest stillbirth rate and the lowest perinatal mortality rate in Wales. A central plank of health care reform is a shift toward care within the community. The recent findings of the Birthplace in England Research Programme strongly support the benefits of delivery outside consultant led units. http://www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1604-140 Table 21 on page 57 shows that the rate of home delivery in the catchment area of POWH (Bridgend and Neath Port Talbot) is exceptional, far exceeding any other area in Wales. The overall homebirth rate of 8% is more than double the Wales average. This success has its roots in midwifery practice and midwifery management. Good practice has been spread by harmonisation under the POWH midwifery lead. Since the merger of Bro Morgannwg with Swansea in 2008, homebirth rates in Swansea have increased by more than 50% (ABMU Maternity Statistics). Making POWH a hub for areas further north would be the best driver of this safe, cost effective and targeted trend. • Efficiency and experience in managing change Our second concern is to highlight our cost efficiency and successful track record with change. In the present financial climate, cost savings would be of immense benefit. While these cannot be relied upon, one would expect better financial outcomes from centring activity on a unit that is already efficient and smoother organisational outcomes from a unit experienced in managing change. Bro Morgannwg was a highly successful and solvent Trust, an early adopter of modern clinical and management practices. From 2005 onward, the Department of Obstetrics and Gynaecology moved steadily towards its current team working, cross consultant cover of acute responsibilities and pooling of waiting lists for surgery and outpatient appointments. This legacy of modern and cost effective practice still stands us in good stead. For example, eight consultants, nine middle grade doctors and five SHOs with four GMP nurses provide the three tiers of round the clock labour ward and acute gynaecology cover. This level of staffing is highly efficient by comparison with Singleton and is likely to compare favourably with other units whose staffing is not known to us. It does not surprise us that research has found that success in promoting birth outside the consultant led unit is highly cost efficient. (Schroeder BMJ 2012;355:e2292) Through the merger with Swansea four years ago, we have learned a great deal about the process and pitfalls encountered in harmonising practice, developing referral pathways and co-operative working. Established common clinical practice and close obstetric and neonatal links with an ongoing tertiary centre in Swansea will prove a future advantage, should POWH be chosen be chosen to expand its acute obstetric service

212 further afield. Our experience with the difficulties of merger, first when providing consultant led acute obstetrics to Neath Port Talbot, then in collaborating with Swansea have taught us how to get it right when building partnerships with another hospital.• Considerations of staff recruitment and retention. Our third concern is that the happiness of medical staff in Maternity Services at Princess of Wales Hospital (POWH) is recognised. While this might seem an optional extra, as things stand at present, it is the single most important consideration for SWP and C4B. The most intractable problem the Welsh Health Service faces is the shortage of Specialist Doctors. Notwithstanding local health care need, the opinions of service users and the interests of politicians, if money is poured into the expansion of a unit unattractive to key staff, acute services will fail, just as they did in Neath Port Talbot. A great strength of this department is its attitude. This is evidenced by Section Three of the 2012 POWH O&G Trainees Feedback collated by the Deanery. Starting with good/excellent assessment of their initial departmental induction, trainees all reported good/excellent supervision and experience. Multidiscplinary team working was rated 100% good. Consultants are described as ‘very friendly and approachable’, ‘accessible and supportive’ and ‘down to earth’. Specialty doctors in non- training grades are vital to running Welsh hospitals and will become even more so as trainee numbers and their hours of service provision are reduced. Rotas dependent on specialty doctors are commonly unstable and crisis prone, because numbers of such doctors are limited and they often move on, We have taken care to support the development of our specialty doctors; three of our four have been with us for more than four years. Cardiff Medical School sends us twice as many fourth year students as are sent to other units of comparable size and has showcased our innovations. Anonymised formal feedback from all students for the last five academic years has been among the best in Wales on all counts. In 2011, the Royal College of Midwives awarded us the Excellence in Partnership Award for joint midwife and consultant teaching. POWH is established in the minds of many future consultants as a desirable working environment. It is easy to commute to POWH from the Vale of Glamorgan and Cardiff, residential areas popular among doctors. One can predict that of the three possible sites, future recruitment would be least problematic in Bridgend. Centring consultant led obstetric services here gives the best chance of sustained provision of specialty doctors and minimises the risk of spending capital on facilities that cannot be staffed in the long term. • Location Geography, population and transport networks are important considerations in ideal planning of provision of care to patients. POWH is close to Bridgend Town Centre Train and Bus Stations. It lies two minutes from the M4 and close to the A48, making access by car or ambulance straightforward for both patients and staff. The road distance from Merthyr Tydfil is less than 20 miles to the hospital, taking under 40 minutes at a current typical petrol cost of £3.30. http://www.distance-calculator.co.uk/distances-for-bridgend-to- merthyr_tydfil.htm Car park space is currently ample. The location of the hospital is familiar to

213 most people in South Wales through the popularity of the McArthur Glen Retail Centre. Bridgend is well suited to be a hub in the Hub and Spoke Model of health care provision. This is particularly important for obstetrics, a service in which home birth and birth centre deliveries are promoted, with the sure expectation of a proportion of cases needing safe transfer to a consultant led unit during labour. POWH is already experienced in providing high quality hub services to the Birth Centre in Neath Port Talbot and to our many home births. In summary, we consider there is a strong case for locating acute services in POWH either as the Regional Centre for Cwm Taf area or preferably, in parallel with Prince Charles or Royal Glamorgan Hospital. Factors relevant to C4B decision making.In the event that POWH lost acute services, the obstetric consultants agree that transferring consultant led obstetric services to a joint unit in Morriston would be an option, so long as the M4 access to the hospital is improved. It seems probable that in units further west, paediatric cover will not be sustained for much longer. Morriston is also the most accessible Swansea site for women travelling from the west for hospital delivery. We do not consider Singleton Hospital to be a good interim or permanent location on a number of counts additional to its relative inaccessibility. Firstly, patient safety would suffer in comparison to the present standard available at POWH. In recent years, the hospital has been stripped of the adult intensive care services needed for the support of major maternal morbidity. There are no longer on site surgical specialties such as urology and general surgery, colleagues whose acute expertise is vital on rare occasions and with whom obstetricians should commonly collaborate in the acute management of undiagnosed pelvic pain in gynaecology. There is no interventional radiology support. Secondly, there would be nowhere in the whole of ABMU to admit girls under 16 with gynaecological problems. At present, such cases presenting to Morriston are transferred to our care and housed on the Children’s Ward at POWH. A potential move to Singleton for however many years it takes to complete works at Morriston could in no way be presented as a change for the better. Should the Deanery withdraw paediatric trainees from POWH and no suitable middle grade paediatricians be recruited, we believe serious consideration should be given to downgrading the Singleton neonatal intensive care to high dependency and transferring paediatricians to sustain the service at POWH for however long it takes to complete the Morriston facility. Alternatively, transferring Swansea neonatal and consultant led obstetric services to POWH, while requiring investment in premises, would truly be a valid change for the better for patient care. A Pragmatic View of Enlarging Obstetric Services at POWH Any of the three possible locations for the available high dependency neonatal rota(s) would need capital investment, not only to provide the beds and cots lost elsewhere, but also to house women who live too far away to travel to and fro for outpatient based consultant monitoring or to be near babies on the High Dependency Unit. Capacity and flow planning is essential. Our management advise us that it is feasible to adapt the whole of our end of POWH to house a 5,000

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delivery per year Mother and Child facility. The speed of change would not be hampered by new building. Other hospital services could be accommodated elsewhere, freeing up the north end of the hospital, which already has its own ambulance access entrance and reception area. The obstetric consultants at POWH freely admit their preference for the status quo. We are well aware that many women dread the impersonal experience of delivery in an enormous maternity unit, not least because so many choose to travel to POWH from Barry and the Vale. We know that communications, co-operation and mutual understanding among staff are of immeasurable benefit to any unit and commonly have inverse proportion to numbers. The unit at the heart of an enlarging process will have to put in a great deal of work. Keeping the patient and staff experience as good as it is at present requires that it be prioritised. Considering our own situation, in speaking out for growth at POWH, we recognise that we should be careful what we wish for. Given the inevitability of fewer, larger units, we have concluded that we are confident in our platform of established success and are ready to provide leadership and give time and energy to making an enlarged service a POWH something we can continue to be proud to be part of. For all the above reasons, we would like to see SWP and C4B supporting POWH as the right choice for locating future consultant led obstetric services. Member of NHS The changing for the better clinical strategy outcome should achieve just staff that and ensure that maternity, neonatal and women’s health services are women centered, able to provide choices for women that respect their right to be equal decision makers in their health and clinical care. There is much evidence to support that women are the pivotal factor to the health and well being of the rest of the family. As such shaping the future service models and the way health care meets this client groups specific needs may not necessarily be the same and measured in the same way as other client groups needs within the Health- Boards areas of responsibility. The health and well being of women should start in school and be a seamless pathway branching off to more specilaised pathways at particular times of our life cycle. These include sexual health screening and contraceptive care, pregnancy care, menopausal care and cancer preventative screening and treatment. However, currently the care is constructed in a fragmented way with variation of services between localities, hospitals and primary care facilities. This makes it difficult for women to access appropriate and timely care and consideration is often not given to flexibility of services to meet the demanding schedules of women balancing careers and home life responsibilities. Public health messages need to be seen and delivered in the context of women’s life styles as the evidence suggests they will “put their families health and well” being first over their own. For example rather than a highlighting the benefits of breast feeding for the baby more focus should be given to the benefits on women’s health in terms of reduced rates of breast and ovarian cancer but not just by midwives the whole health service. Birth rates and conception rates are projected to increase but not significantly with a small peak and then another down ward

215 trend. We need to continue to re educate the public in the inaccuracy that “all births are safer” in hospital. Learn the lessons from producing strategy that’s not based on fact and robust evidence but on ill informed assumptions supported by a powerful but ill informed body of clinicians seen through the well documented “History of Childbirth” literature. Models of care- these need to be carefully planned with robust implementation strategies that afford equal risk assessment planning assumptions. For example significant focus is being afforded to the safety and quality of obstetric consultant units. Its often assumed that the “fall back” position of the Freestanding birth center model is a simple scaling down of the obstetric service. This is an inaccurate and potentially dangerous assumption as has been identified in other examples of high profile such as that of the lessons learned from the Kidderminster model. Workforce planning – Sustainability of any service is as important in terms of the midwifery workforce as that of the obstetric workforce. Recruitment and retention of midwives is improved in organizations where there are choices of models or care that allow career flexibility, development and choice for midwives. Whilst all midwives train to promote normality and are able to be expert practitioners in all aspects of midwifery care this is not how it translates into practice. Very much like our medical colleagues and element of sub -specialisation occurs post registration, with midwives who are skilled in high risk obstetric care and midwives skilled at home birth and Midwife led birth environments. This must be assessed carefully in terms of any reconfiguration plans as models wont be safe or sustainable without the right midwifery workforce assessments. Careful use of the Birthrate plus tool must be used to check and balance flow assumptions and predicted birth numbers of units and environments. It maybe necessary to build in additional over calculation to allow for the inevitable settlement period that ensues post reconfiguration. Midwifery teaching Environments- much focus has been placed on ensuring appropriate environments of learning for doctors and this must equally applied to other professional groups. The Healthboard has won awards from the local universities for “excellence in Learning and supports the training of student midwives from both the University of Swansea and Glamorgan. The midwifery department is also approached for external learning opportunities and supporting return to practice programmes due to its excellent reputation. This must be maintained and its important that any changes do not impact negatively on learning opportunities for student midwives and their midwifery mentors and MUST meet the Nursing and Midwifery standards. Midwifery Supervision- is a statutory requirement require to ensure public protection and a recent audit undertaken by the NMC and Local Supervising Authority identified that the health-board met all the mandatory standards set by the NMC and that there were no areas of concern affecting public protection. Involvement of the local Supervising authority in any service changes must take place to ensure no adverse effect on maintaining supervision of midwives standards. Midwifery Leadership and Management- has consistently been found as a crucial factor in the successful running of a high

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quality maternity and midwifery service. Any service changes and implications of reconfiguration or maternity units merger will need to ascertain that the Midwifery management has the ability and infrastructure in place to deliver an extremely risky and onerous change management process. Leading midwives, the public and other colleagues through often controversial implications needs skill, experience, resources and preferably a proven track record of wide scale service reconfiguration management. The midwifery management team within ABMU HB has such a track record substantiated by the winning of 9 consecutive National midwifery Awards and the NHS Wales award winners. Environments of Care – must be constructed in a manner that meets the recommendations of the National Child Birth Trust “Better Birth Environment” recommendations. Any service changes as a consequence of the South Wales programme need to ensure the units meet agreed standards and the capacity to cope with the changes in flow and increased demands on the environment. There is little evidence to support the absolute size of an Obstetric unit in terms of safety. However there is evidence that very large units have a negative impact on women’s experiences and are often described as “conveyor belt in approach” . Balance must be given to capacity planning but also environments that support a women and family centered approach to care. Maternity Network- the governance infra structure put in place to underpin the potential implications of the South Wales programme recommendations are critical. There are many definitions of a network and often many misinterpretations. Operationally the maternity services in wales are subject to frequent peaks of high escalation with this appearing to happen in all the units at the same time. Ensuring that women access timely maternity care within less units is naturally going to cause anxiety. These peaks are often compounded by a lack of integrated working and senior communication between units. This could be reduced through the introduction of a maternity network responsible for the infrastructure standardization of policies, risk management and escalation. In particular seamless coordinated working between maternity and neonatal is vital to ensuring the right mother and baby are in the right unit at the right time. This would be better achieved if maternity and neonatal were viewed as co dependant essential features of “maternity” care managed by the same infrastructure and not seen as isolated specialities. Engagement of Women of Childbearing Age- It is very often everyone else other than those directly affected by maternity care that have a loud voices about changes. It is notoriously difficult to engage the childbearing and pregnant population in service change as its often a very transient episode of their life. As such you are only often interested if its going to happen to you. Further consideration needs to be given to how we engage users views and not those of political biase. Very few women pregnant attended the engagement events and so a different methodology will need to be considered otherwise the professional, political and planning view will take precedent over that of women directly affected. PT4L Bridgend Those who responded felt the aims of Change for the Better are worthwhile

217 and beyond criticism. There is an acceptance that in the current financial climate and with the pressures of lack of trainees, the current service model in unsustainable and urgent change is indeed needed. There are significant morale and work load problems in Primary and Community Care at the moment with Community Services thinly stretched and often at breaking point. This is against a backdrop of further imposed work from central Government with increasing financial tightening on Primary Care budgets. In addition to this, there has been long standing “creep” where Secondary Care workload has gradually been insidiously passed without adequate planning or consultation onto Primary Care but funding and resourcing for this work has not followed for the patient. We could highlight several examples of this over the past few years, and the Health Board does not have a good record for strengthening and resourcing Primary Care to deal with these pressures. We have our significant doubts that the disinvestment planned for hospital acute services across ABMU and the proposed strengthening of Community Care (which we would all support and have several innovative suggestions for development) will be adequately resourced, and therefore will be unsafe. There was widespread concern that the re-organisation would not address the unpopularity of being a trainee in Wales and would not address recruitment difficulties sufficiently. The All Wales recruitment strategy of the Wales deanery is contributing to the low ranking that the trainees proffer Welsh training. This needs addressing urgently with the deanery. As for hospital reconfiguration, we accept the premise that fewer acute centres will improve care, however, we have significant concerns as to the effect on the population of Bridgend if an acute care centre is not placed at the Princess of Wales Hospital. If such an acute centre were placed in Merthyr or Llantrisant, then Bridgend patients would have to travel much further to receive emergency care and we fear that lives will be lost and services may be eroded locally. This will deepen inequalities in health and deepen the already severe effects, particularly in valley communities, of the ‘Inverse care law’. This will inevitably lead to increased pressure on Primary Care Services in the area and we feel that currently we are not in a position to sustain or influence this. Transport problems for patients and ambulance pressures are likely to further put lives at risk as paramedic ambulances travel greater distances and ‘stack’ outside hospitals at breaking point due to bed pressures. Patients who should attend A&E will self-refer to General Practice inappropriately if the distances and travel/transport difficulties are not solved adequately. Despite our recent issues with the Princess of Wales Hospital which are mirrored by our concerns over other acute hospitals, there was some (but not universal) support that the Princess of Wales Hospital should be strongly considered as the perfect location for one of the acute care centres planned by the South Wales Programme. It has good transport links and is close to the M4, and is situated to large centres of population. It has a good track record of meeting financial as well as clinical targets, and many of the

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Clinicians there are first class. There would need to be significant investment in infrastructure and staffing, but this would need to happen wherever the centre were placed. Secondary care services need to be more timely, reactive and appropriate. GPs should be able to access advice, diagnostics and discharge information in a timely and safe fashion. None of these are happening in the current climate – let’s hope things ‘Change for the better’! In summary, the Change for the Better Programme is difficult to argue with and change indeed has to come. All of your aims in Change for the Better involve disinvestment in Secondary Care services which is inevitable. We would take this opportunity to remind you that proper planning, resourcing and execution of Community Services should not be an after thought, and should be a vital component here. If you do not ‘pump-prime’ and invest in your Community Services the whole project will fail and safety for our patients will irrevocably compromised. Member of NHS Feel that the dietetic service could make big contributions to the work staff streams around staying healthy, frail elderly, children and long term conditions and there were opportunities to work in different ways We agree that preventing hospital admissions is important but that the move to manage more people in their own homes is likely to have time implications to services such as ours- i.e. domiciliary visits are more time consuming and consequently we are likely to see fewer patients in the same time than if they were on hospital wards. There needs to be consideration about suitable locations where patient’s can be seen -in community locations/ resource centres etc i.e. the infrastructure and transport arrangements need to be available to facilitate appropriate community working in a time friendly way Community Resource Teams- we felt that it is important for our service to be visible within community resource teams and closely integrated into the team to allow our expertise to be utilised in the most appropriate way. We recognise the value of training within the CRTs and that this along with our visible presence would allow sharing of transferable skills among team members Loss of expertise- we felt that it was important to ensure that specialisation in centres of excellence did not mean that patients would be handed back to local dietetic services who no longer experienced the number of patients with specific conditions. That the resources of specialist services need to be adequate for them to appropriately manage patients outside their local area on discharge or after out patient consultations We hoped that NPTH would see the movement in of services e,g endoscopy/ GI outpatient services to capitalise on the facilities available Senior medical 1.0 Introduction The senior medical staff at the Princess of Wales Hospital staff Princess of propose that the hospital should be a Regional Centre, as outlined in the Wales Hospital, South Wales Programme. The range and quality of patient care, excellent Bridgend performance and good transport links make the Princess of Wales Hospital the obvious choice for a regional centre to serve the population of central South Wales.The consultant body recognise the need for change in the provision of healthcare throughout Wales, in order to provide safe,

219 sustainable high quality clinical services to our population. In the South Wales area, we believe this would be best facilitated by retaining and expanding the acute clinical services in the Princess of Wales Hospital which is situated in a densely populated area on the M4 corridor with short travel times to Valley towns and villages.This document summarises the aims of the medical staff and also includes an analysis of our strengths, focusing particularly on the wide range of acute clinical services provided at the hospital and the changes required to fulfil the role of a regional centre. 2.0 Our aims As a Regional Centre we wish to: • To retain, expand and further improve our acute clinical services to a greater patient population • To forge stronger links with neighbouring hospitals across existing health board boundaries and consolidate services in the most suitable locations. • To improve recruitment and retention by expansion of the existing specialties and supporting their needs. • To promote undergraduate and post graduate education. • To work more closely with primary care, community health and social care partners to improve outcomes for our patients.3.0 Clinical Services The Princess of Wales Hospital has a long tradition of providing well managed, wide ranging, high quality clinical care to its catchment population. The medical staff has a reputation for innovation and flexibility which enables this care to be delivered in an effective and affordable manner. The emphasis in this summary is directed primarily at the acute services. The current status is described together with envisaged adjustments that will be required as a regional centre. 3.1 Maternity Services The quality of the Maternity Services at Princess of Wales Hospital is widely recognised throughout Wales. There have been no direct maternal deaths at Princess of Wales Hospital since 1996. The Welsh Risk Pool annually assesses each obstetric unit’s safety in order to calculate their insurance premium. Princess of Wales Hospital has scored 97% for many years. The most common complication and a very serious risk to women in childbirth is haemorrhage. At PoWH, in conjunction with our radiology and anaesthetic colleagues, we have developed and successfully implemented a protocol for interventional radiology prophylaxis in cases at high risk of massive haemorrhage. This uterus and/or life saving service is not available at any other unit in Wales. An emergency embolisation service is also available to treat post partum haemorrhage. Data from the All Wales Perinatal Survey Annual Report 2011 http://www.cf.ac.uk/medic/awps/ summarised on page 56 in Table 20 shows that in 2011, Princess of Wales Hospital had a lower rate of Caesarean Section than Singleton Hospital, Royal Glamorgan Hospital or Prince Charles Hospital, even though the 472 births at the Birth Centre in Neath Port Talbot were not included, despite the fact that all their transfers of women in labours that are not progressing smoothly are delivered at POWH. This has not been achieved by taking risks with fetal welfare. Table 15 on page 48 of the report shows Bridgend had both the lowest stillbirth rate and the lowest perinatal mortality rate in Wales.

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A central plank of health care reform is a shift toward care within the community. The recent findings of the Birthplace in England Research Programme strongly support the benefits of delivery outside consultant led units. http://www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1604-140 Table 21 on page 57 of the report shows that the rate of home delivery in the catchment area of PoWH (Bridgend and Neath Port Talbot) is exceptional, far exceeding any other area in Wales. The overall homebirth rate of 8% is more than double the Wales average. This success has its roots in midwifery practice and midwifery management. Good practice has been spread by harmonisation under the POWH midwifery lead. Since the merger of Bro Morgannwg with Swansea in 2008, homebirth rates in Swansea have increased by more than 50% (ABMU Maternity Statistics). Making PoWH a hub for areas further north would be the best driver of this safe, cost effective and targeted trend. From 2005 onward, the Department of Obstetrics and Gynaecology at the Princess of Wales Hospital moved steadily towards its current service model incorporating team working, cross consultant cover of acute responsibilities and pooling of waiting lists for surgery and outpatient appointments. This legacy of modern and cost effective practice is well established. For example, eight consultants, nine middle grade doctors and five SHOs with four GMP nurses provide the three tiers of round the clock labour ward and acute gynaecology cover providing efficient staffing levels. Anonymised formal feedback from all students for the last five academic years has been among the best in Wales on all counts. In 2011, the Royal College of Midwives awarded us the Excellence in Partnership Award for joint midwife and consultant teaching. POWH is established in the minds of many future consultants as a desirable working environment. Bridgend is well positioned, in a populous area, to be a hub in the ‘Hub and Spoke’ Model of health care provision. This is particularly important for Obstetrics, a service in which home birth and birth centre deliveries are promoted, with the sure expectation of a proportion of cases needing safe transfer to a consultant led unit during labour. POWH is already experienced in providing high quality hub services to the Birth Centre in Neath Port Talbot Hospital and to our many home births. Research has found that success in promoting birth outside the consultant led unit is highly cost efficient. (Schroeder BMJ 2012;355:e2292). The platform of established success makes POWH an ideal location for an enlarged, consultant led, regional Obstetric unit. 3.2 Paediatrics Paediatrics at the Princess of Wales Hospital is currently divided into Paediatric Inpatient Services, Neonatal Services, Paediatric Outpatient Services and Paediatric Community Services. General Paediatrics There is a Paediatric Assessment Unit comprising 4 beds and 2 treatment rooms which can serve as cubicles. The unit accepted 2,487 cases last year. The Paediatric Assessment Unit is in very close proximity to A&E facilitating

221 the transfer of patients into Paediatric Services. There is a 20 bedded Paediatric Ward. The ward accepts admissions from different specialties including Paediatrics, General Surgery, Orthopaedics, ENT, Ophthalmology and Dermatology. There were 2,950 admissions last year with 2,412 under direct Paediatric care. A variety of outreach tertiary specialist services is offered at the Princess of Wales Hospital. This includes tertiary outreach clinics provided by the University Hospital of Wales for Paediatric Cardiology, Paediatric Nephrology, Paediatric Palliative Care, Paediatric Endocrinology and Paediatric Gastroenterology. A Paediatric Neurologist provides tertiary Paediatric Neurology services on a part time basis. This is in conjunction with one of the Community Paediatricians with sub-specialization in Neuro disability. There are facilities for prolonged video EEG and the full range of Paediatric Neurophysiology. In South Wales, this combination of expertise and facilities is only available in POWH and UHW Cardiff. Paediatric diabetes services are provided locally and work in close relationship with similar services in Neath Port Talbot Hospital and Morriston Hospital allowing crossover arrangements and 24/7 out of hours specialist telephone advice. Safeguarding is a well established and fundamental part of Health provision. Training, professional support and supervision for colleagues as well as corporate policies are readily accessible. The safeguarding service works closely within an established local clinical network and benefits from close links with other units within ABMU. This allows cross cover arrangements and facilitates further expansion of the service. Inpatient services are provided by 6 General Paediatric Consultants with various specialist interests. One of these is a Tertiary centre Neurologist. The Paediatric Department at the Princess of Wales offers supporting services for Obstetrics, A&E, General Surgery, Adolescent Gynaecology, Max Fax, Paediatric Dermatology and Ophthalmology. The unit also supports a Regional Cochlear Implant Programme locally at the Princess of Wales Hospital. There are close links with tertiary inpatient CAMHS Services housed at Ty Llidiard. Although Ty Llidiard managerially is governed by Cwm Taf Health Board, it is housed in the grounds of the Princess of Wales Hospital. Service arrangements between Paediatrics at the Princess of Wales Hospital and CAMHS at Ty Llidiard are in place. Neonatal services The Neonatal Unit at the Princess of Wales Hospital is a Level 2 Neonatal Unit with 13 cots. The unit accepts neonates with a gestational age of 32 weeks and above (34 weeks if twins). The unit has established facilities for short term intensive care. There are very close links with the tertiary Neonatal Unit at Singleton Hospital. This allows the unit to operate very flexibly as nursing staff can be deployed to both sites according to demand. The unit is medically supervised by 6 inpatient consultants. There is additional support via a tertiary neonatology ward round conducted once a

222 week by visiting neonatologists from the unit at Singleton Hospital. The close relationship between both units allows best utilization of resources as intensive care can be provided in Singleton and ongoing high dependency or special care can then be provided at the unit at the Princess of Wales Hospital. This is further facilitated by the now established Neonatal Transport Service for Wales currently running on a 12 hour 7/7 model likely to be increased to a 24 hour 7/7 model in the near future. 3.3 The Emergency Department is open 24 hours a day, 365 days a year and receives about 65,000 patients a year, ie, 175 per day .The Princess of Wales Hospital has a dynamic, enthusiastic and forward thinking consultant team who embrace developments in their specialties and are committed to consultant shop floor presence, hands-on working, keeping pace with national specialty development and providing the best Emergency Department care possible. The consultant team of four WTE provide extended hours working and function as efficient and effective unit. With one of their number being a regional lead in Emergency Medicine Ultrasound, the A&E department supports training in trauma ultrasound (mandatory for higher EM trainees). The Emergency Department medical staff include good quality specialty doctors who are supported to pursue additional training and development appropriate to their professional needs. The nursing workforce is led by a strong cohort of senior nursing staff who manage a loyal team of dedicated nurses. Despite a lack of organisational support for developing the Emergency Nurse Practitioner role we have two members of nursing staff practicing as ENPs, though currently unfunded.Since 2006 the Princess of Wales Hospital consultant body has included consultants with leadership roles in the All Wales School of Emergency Medicine and continues to do so. Training is central to the future of our specialty: even when recruitment challenges result in much diminished numbers of trainees it is vital that we train well and continue to nurture interest in the specialty in doctors in the foundation programme. The Princess of Wales Hospital track record is excellent in this area having engendered sufficient enthusiasm to result in yearly applications to ACCS (EM) from trainees who have worked in our Emergency Department. Inspiring trainees to choose to specialise in Emergency Medicine can be considered to reflect that their experience working in a department pursuing excellence in Emergency Medicine in a positive and modern environment.The Emergency Department staff enjoy excellent interdepartmental relationships with all inpatient specialties: the value and importance of this in facilitating rapid and appropriate patient care must not be underestimated. The specialties with which we interact on a daily basis would all benefit from increased staffing levels sufficient to fully address the need for senior staff input in acute care in a timely fashion both in and out of hours.Emergency medicine throughout the UK is facing a recruitment crisis on the back of a short fall in established consultant numbers. Consolidation of available skilled staff will be essential for the future of the speciality in a regional centre. The POWH already has the largest number of consultants of the hospitals being considered for

223 additional regional status.3.4 Trauma and Orthopaedics The Department of Trauma and Orthopaedics consists of eight substantive Orthopaedic Consultant and one locum Orthopaedic Consultant. They are supported by two Specialist Registrars, six Middle Grade, four CT2 and one Trust doctor. There are two Trauma Nurse Practitioners, three Theatre Nurse Practitioners and one Nurse Specialist on the ward. They all contribute to the smooth running of the Unit. The Emergency Department works very closely with our Orthopaedic team and facilitates the appropriate processing and follow up of patients.The Department of Trauma and Orthopaedics provides a very comprehensive range of both elective and trauma management of patients:-Upper Limb Trauma ManagementThe Department has two dedicated upper limb trauma surgeons, who undertake the majority of the upper limb trauma and provide a comprehensive range of treatments for active trauma patients. Between these two consultants, they are able to manage both soft tissue injuries and complex fracture treatments. We have a dedicated upper limb trauma session on Tuesday mornings. Both upper limb trauma surgeons carry out a fracture clinic on Thursday mornings. The majority of the upper limb trauma coming through A & E is referred to them. This provides a streamlined service for the trauma patient. Fracture Neck of Femur Pathway The Princess of Wales Hospital receives about 275 -300 fracture neck of femur patients annually. We have a dedicated fracture neck of femur pathway. This provides timely assessment of patients in A & E and early referral to the on call orthopaedic team. These patients are then treated on a priority basis and we were able to meet the targets of treating these patients within 48 hours, as per the national guidelines. The data from our hospital was recently published in a national meeting and the Princess of Wales Hospital was ranked amongst the best hospitals in the management of fracture neck of femur.Enhanced Recovery After SurgeryThe Princess of Wales Hospital routinely uses enhanced recovery after surgery for fracture neck of femur patients. Data collected recently has clearly shown that using such a protocol reduces the hospital stay of these patients. Early mobilization has clearly shown that the majority of complications can be prevented using this protocol. The length of stay has gone down from 19.2 days to 12.9 days with ERAS, an improvement of nearly 33%.The use of opiate analgesia has gone down by 60% in this frail and elderly group. The orthopaedic department was the first to setup a comprehensive joint school and established ERAS for joint replacement. The length of stay has gone down by 60%for elective surgery. The transfusion rate has gone down by 75%, the complication rate is also down, and the patient satisfaction survey shows excellent feedback.Lower Limb TraumaWe have a dedicated Trauma Surgeon who specializes in lower limb trauma who routinely manages complex lower limb traumas. Two of our surgeons specialize in the management of peri prosthetic fractures. One surgeon specializes in forefoot and hind foot surgery.Recently, an independent assessment has reported that in order to fulfill the needs of trauma patients at the Princess of Wales Hospital, Bridgend, a further single trauma session would be required.The Princess of Wales Hospital is able to provide comprehensive

224 trauma services for its local population. It has dedicated trauma surgeons who specialize in both upper and lower limb surgeries. The Orthopaedic team at the Princess of Wales Hospital works closely with the Cardiothoracic and Plastic Surgery teams at Morriston Hospital, Swansea ConclusionThe Orthopaedic and Trauma Unit at POW can provide a Regional Centre for the management of Neck of Femur fractures for patients from East of Cardiff and West of Swansea. The Centre can provide specialist hip fracture management for all these patients. Approximately 800 patients can thus be treated, provided appropriate infrastructure is allocated. The patients can be rehabilitated at Neath Port Talbot Hospital. Expansion of ortho geriatrician cover would be needed at Princess of Wales Hospital. Other trauma patients can also be managed at Princess of Wales Hospital although some reconfiguration will be required. 3.5 Integrated medicine Overview Alongside Emergency Medicine, Acute Care Physicians are based at the front door, together with an Ambulatory Care service. There is a large medical consultant body providing all sub- specialty support across 7 acute medical wards. Acute medicine (CDU) The Acute Medicine service within the hospital includes an 18 bedded Clinical Decision Unit and Ambulatory Care Department, run by 3 Acute Care Physicians.The CDU is designed for the rapid assessment and treatment of patients admitted from the Emergency Department. The Ambulatory Care Department is a medical day unit, open essentially between 9am and 5pm, Monday to Friday. The purpose of the unit is to avoid unnecessary admissions to hospital, therefore taking the pressure off an already busy Emergency Department This is achieved by: - Providing a means of rapid review of patients attending the Emergency Department with a wide range of acute medical problems that do not necessarily require acute hospital admission but do need timely investigation and management. - Providing a safety network to facilitate earlier discharges for appropriate patients from CDU, Acute Medical Wards and other departments, by providing timely follow up appointments as an outpatient. - Having an important role in risk management, by offering a full medical and nursing assessment and ensuring safe, ongoing care and review of patients. Stroke services Ward 2 at Princess of Wales Hospital is a Combined Stroke Unit where 23 beds out of 28 are allocated to acute stroke patients. The unit provides both an acute recovery and rehabilitation service, which maximises the use of manpower and resources. Approximately 300 confirmed strokes are treated annually, with a 20 day mean length of stay. Thrombolysis is available around the clock( rate: 8%) and the overall stroke mortality is low at 16%. The Unit is supported by the CIIS team which helps to facilitate early supported discharge. Readmission rates are low and compliance with Welsh Government Stroke care bundles is consistently high. The rapid access TIA service receives approximately 400 referrals annually at POW (an additional 180-200 patients are seen at NPTH) – around 40% of patients are discharged with a non-TIA diagnosis. It is estimated that an additional 60-80 patients per annum could be accommodated within the existing establishment provided enhanced diagnostics and community

225 services are made available. GastroenterologyServices are provided by an experienced team of 3 consultant Gastroenterologists and 1 Nurse Practitioner with expertise in the management of the full range of inpatient and outpatient gastroenterology. The specialty provides a high quality, inpatient GI service, including nurse led paracentesis. This service is complimented by excellent radiological, pathological and GI surgical support. Within Bridgend we provide an MDT service for Inflammatory Bowel Disease with innovative joint clinics with colorectal surgery and rheumatology. There is also a dedicated liver clinic, and an efficiently run endoscopy service. The endoscopy unit is close to achieving JAG accreditation. Respiratory medicine Our fully integrated Respiratory department provides a wide range of services to patients, including dedicated lung cancer MDT, COPD services, early discharge and an advanced sleep service which also serves patients from Neath Port Talbot Locality. The hospital provides a run ward based Non-Invasive Ventilation (NIV) and has a 6 bedded high care area on its Respiratory ward. A recently commissioned a Respiratory Treatment room allows us to offer ambulatory care facilities to patients with a wide variety of respiratory problems, who would otherwise be managed as inpatients. There has also been successful development of the role of Advanced Respiratory Nurse Practitioner alongside our two Consultant Chest Physicians, and the individual currently in post is now independent and proficient in many procedures including thoracic ultrasound and pleural intubation. Care of the elderly medicineThere is a 25 bedded rehabilitation ward for elderly patients at Princess of Wales Hospital. Specialist services provided are: Integrated Falls and Orthogeriatric Service: At present there is direct involvement of a consultant team for Orthogeriatric service. This consists of ward and inpatient input for patients on Orthopaedic wards, and a multidisciplinary falls assessment service in Pendre Day Hospital, aimed at older patients in the community. The number of older patients requiring this service is anticipated to increase by approx 20 % in next 10 years, and so there are plans and discussions in place for how this service can be developed in the future. Psycho-geriatric Shared Care Unit: Comprehensive service for older patients with almost stable medical problems, but significant Mental Health issues, who require inpatient stay and multidisciplinary intervention due to their unstable condition. Patients benefit from daily combined reviews with COTE Medicine and Mental Health. Parkinson’s and Movement Disorder Service: This is already well established within Pendre Day Hospital, providing outpatient diagnostic, therapeutic and long term management plans for approximately 1200 patients. Dermatology There is a thriving and vibrant dermatology department with an active day unit treatment centre and a busy outpatients department. We

226 have close liaison with the acute and elective services in the hospital and offer a wide range of specialist services including: - A regional dermatology laser service for birthmarks, hair removal and vascular lesions, which receives referrals from all over South and Mid Wales and occasionally England. - Cryotherapy Service- Paediatric Dermatology- Botox for Hyperhydrosis - Patch testing - See & Treat Skin Cancer Clinic - Biologics Clinic for patients with severe psoriasis - Phototherapy - Photodynamic Therapy (PDT) Clinics - Leg Ulcer/Lymphoedema Treatment - Hair disorders clinic - Combined Rheumatology/Dermatology Clinics Rheumatology The rheumatology department in Princess of Wales Hospital expanded over last 10 years to be one of the largest in Wales. It has been at the forefront of developing innovative services to improve efficiency and quality of care for patients by establishing close working links with primary and secondary care colleagues and embedding electronic record systems into routine practice. The success of these developments has been such that the department has historically seen large numbers of out of area patients as well as those from the local community. Despite the high level of clinical activity the waiting times are consistently lower than comparable sites across Wales. The development of dedicated clinic and day unit facilities at the Princess of Wales hospital for assessment of musculoskeletal patients has undoubtedly been a major contributor to this success. Even since the establishment of ABMU the department at the Princess of Wales hospital remains the hub for delivery of rheumatology services across the HB. Rapid assessment of acute patients with rheumatic disease in CDU and ambulatory care is a service provided at the Princess of Wales hospital and often reduces the need for or duration of admission for these patients. To deliver on this would require capital investment for scanners and the appointment of a cardiologist with expertise in imaging, and a consultant radiologist, which would attract a lot of regional diagnostic work. The strength of the clinical model would be to provide diagnostic work with some interventional work. We cannot compete with a 24/7 intervention service or even a 24/7 cardiologist service as unlike Morriston or UHW we have a consultant delivered service. We do not have the 10+ SpR’s to be on the ground covering 24/7 (for the record we have 2 SpR’s). 3.6 Cardiac Services Current provision The Princess of Wales Hospital currently delivers regional services as part of the regional Cardiac Unit. Diagnostic coronary angiography is performed on site in a purpose-built cardiac lab, for patients across ABMU and Hywel Dda. Similarly, non-invasive functional testing such as exercise- and dobutamine-stress echoes are performed in the cardio- respiratory investigation unit on site. Bridgend is one of the highest volume centres for stress echoes in Wales. Bridgend also has the best access for patients presenting acutely with chest pain who then go on to require coronary intervention (angioplasty or surgery). Data from the British Cardiovascular Society in 2009 demonstrated that Bridgend had the best access of all hospitals in Wales and was better that the London teaching hospitals. This reflects efficient patient pathways and close collaboration

227 with our local cardiac centre in Morriston. Innovation has always been a major factor in the way cardiologists work in Bridgend. The department was the first to offer GPs “open access” to diagnostic tests, which has led to a significant improvement in patient access to diagnosis and treatment. GPs can order tests which cardiology consultants then report, a normal or near normal result obviating the need for an out-patient appointment. In contrast abnormal or positive results are reported – and treatment is suggested and the patient is seen in clinic by a cardiologist. This has led to a reduction in patients waiting for appointments, whilst improving access for those who do need to be seen. This service won a NHS award in 2008 Future From January 2013 consultant cardiologists in Bridgend will work 7 days a week providing daily ward round cover for the acute cardiac care unit. We piloted this service last year, and saw the predicted reduction in the length of stay of patients admitted towards the end of the week, and particularly on a Friday. It also facilitates the primary angioplasty (PPCI) pathway when patients need to be repatriated on the weekend from the Morriston cardiac centre. A daily Cardiologist ward round is an essential component of an Acute Cardiac Care Unit (ACCU) as recommended by the British Cardiovascular Society (2011). We have pioneered the ACCU model with redesign of our ward and it has been operational (5 days a week) since 2009. An Acute Cardiac Care Unit accepts patients with all acute cardiac problems, and there is compelling evidence that this approach saves lives. Patients with heart failure admitted to an ACCU, under the care of Cardiologists, have nearly half the mortality of patients admitted to a general medical ward (National Heart failure Audit 2010-11). Similar data exists on survival benefit for acute coronary syndrome patients (MINAP 2008-9). These are clear examples of putting “the right patient in the right place”. The regional centre in Morriston currently provides a 24/7 service for all patients in the Bridgend area who suffer ST elevation heart attacks. This is a high volume service with excellent outcomes for patients. The remainder of patients with ACS – ie the non-ST elevation infarcts and the unstable angina patients do not have such a good service. These patients are admitted to Bridgend where our pathways facilitate early review by a consultant cardiologist. However, European guidelines state that these patients should be risk assessed and if deemed high risk should undergo angiography within 72 hours of onset of pain. Although these patients do undergo angiography it is usually after the 72 hour cut-off. The current cardiac laboratory in Bridgend could be used for angioplasty in this patient group. The lab itself fulfils the criteria set by the British Cardiovascular Intervention Society. The staff are trained in angioplasty (nursing staff rotate through Morriston labs), and if we share consultant staff with Morriston the laboratory could offer this service Monday to Friday. (not a 24/7 service). Clearly, if the future led to a closer collaboration with the Royal Glamorgan Hospital then staff there could also contribute.The pacing service was set up in 2008 and continues to grow, we have a purpose-built pacing room in the cardio-respiratory investigation

228 unit. One consultant cardiologist has a special interest in heart rhythms and device therapy. Currently he spends a day a week in the Cardiac Centre at Morriston Hospital implanting devices and performing EP studies. These activities could now be brought back to Bridgend where our technical staff have the appropriate expertise. One area which requires major investment is imaging. Non-invasive and functional imaging provision requires development to enable the services to modernise further. This is not unique to Bridgend, it is the same across Wales, and for the most part- England. To develop a modern state of the art diagnostic service we require access to:• CT angiography• MRI perfusion• Myocardial perfusion• Stress Echo. At present there is one list for CT angiography per week (in Morriston) delivering 5 scans. There is no MRI perfusion service. The myocardial perfusion service is run locally but is not high volume. The hospital has a high quality, high volume stress echo service.3.7 Surgical Services .The surgical team in Princess of Wales Hospital provide a wide range of services both elective and emergency, including many complex types of surgery. This is true for General surgery, Vascular surgery, Urology and ENT, which is consultant delivered. There is excellent feedback from surgical trainees and their log-books demonstrate that have very good exposure to surgical cases as part of their training. There exists an excellent track record of supporting Morriston Hospital, to allow the surgeons there to undertake highly complex, tertiary centre -type work. There is an excellent track record of meeting targets in relation to efficiency and ‘referral to treatment times’ (RTT), managing finances and prior to the merger, there were no recruitment problems. General Surgery - Major and complex colorectal cases are undertaken (172 in 2009-10). These figures are considerably higher than neighbouring hospitals. The latest 2011 UK National Bowel Cancer Audit report demonstrates the average UK mortality was 3.7% after surgery (in England 3.6% and Wales 5.6%). However data ascertainment was 97% for Wales, whereas some HBs in England only achieved 50%. The three hospitals (Prince Charles Hospital, Merthyr, Royal Glamorgan Hospital and Princess of Wales Hospita) being considered for one or more regional centre status, are described and Bridgend is clearly the busier unit with 50% more operations than Royal Glamorgan. We also demonstrate the best use of pre-operative adjuvant oncological therapies as promoted by NICE and have the lowest death rate. There are 4 colorectal surgeons in post compared to only 2 in the other hospitals. These are supported by 3 colorectal nurse specialists who provide counselling, pro forma led cancer follow-up, prescribing of colorectal drugs and undertake anorectal physiology studies. The NBOCAP report also reveals that Bridgend is performing better than the UK national average in terms of rectal cancer treatment. The latest figures for 2011/12, which will soon be submitted, are even better with 187 new cases diagnosed, 149 cases operated with a mortality of 4% and rectal margin involvement of 2%. As such, this evidence demonstrates that we have a thoroughly competent colorectal unit in Bridgend which is capable of functioning as a regional unit. Complex laparoscopic surgery is performed, including anti-reflux surgery (70 per annum), gastrectomy, bowel resections

229 and complex incisional hernia repair. The series of laparoscopic total/subtotal/and distal gastrectomy is one of the largest in the whole of the United Kingdom. Bridgend is the only unit in Wales performing minimally invasive laparoscopic hybrid oesophagectomy, 12 per annum, with proven reduced recovery times.The unit also undertakes numerous major and intermediate procedures for the tertiary centre in Swansea, to help maintain the RTT position of the Health Board. Since August until the beginning of November 2012, 75 cases have been transferred and treated.There is a well established consultant led emergency surgical service, dealing with all aspects of emergency surgery. Vascular-Vascular surgery outcomes are as good as (if not better) than national reported data, e.g., open aneurysm surgery mortality (3.5%) already met the target for mortality reduction set by the Vascular Society for 2013; symptom to surgery for symptomatic carotid disease is better than national average. Quality of care is as good as national data (probably better) e.g. only 1 open aneurysm postponed in the last 5 years for lack of HDU bed. The senior vascular surgeon instigated an aortic aneurysm screening programme in 2005, on a cost neutral basis, data from which was used by Welsh Government to inform the decision to make this a National programme. We provide a supraregional service for thoracic outlet patients – developed by word of mouth and outcome data. Urology -In urology, apart from major pelvic surgery, all aspects of care are provided. There is a dedicated, purpose built Urology Diagnostic Unit. This is the only unit in Wales providing Blue Light Trans Urethral Resection of Bladder Tumour, Green Light Laser prostate surgery, bipolar saline prostate surgery and giving immediate intra-vesical mitomycin in theatre after TURBT. In addition the unit provides female incontinence surgery and is a regional referral centre for urethral reconstruction. Both open and laparoscopic nephrectomise are performed as well as percutaneous stone surgery in collaboration with the Radiology Department. ENT - The Princess of Wales Hospital’s department of ENT currently provides a comprehensive Ear, Nose, Throat, Head & Neck service for planned and unscheduled patients. We submit all our adeno-tonsillectomy surgical outcome data into the Welsh SISP (Single-use Instrument Surveillance Programme) and contribute to national Myringoplasty and Sinonasal (SNOT22) audits. Bridgend is also a sub regional (South Wales) cochlear implant centre and is a lead Unit establish as a national middle ear implant service. All our hearing implant audit data is collated to BCIG (British Cochlear Implant Group) UK national database. Collaboration takes place with academic colleagues nationally and internationally (currently supervising one PhD student) publishing world class research. Additionally our team deliver hearing implant expertise globally through our ‘Bridgend International Otology Outreach Programme’. Paediatric Pre-assessment - The Princess of Wales Hospital has a well established paediatric pre- assessment service. All children requiring surgery are pre-assessed in dedicated sessions in the Day Surgery Unit, avoiding the need to travel to a tertiary centre for their surgical procedures. 518 children have benefited

230 from the service between Jan-Nov 2012 (including telephone pre- assessment where patients live further afield than Neath). The Day Surgery unit is the only unit providing a children’s GA laser service. Children are referred from outside the Health board boundaries for this service. 3.8 Anaesthetics and Intensive Care. The anaesthetic department based in the Princess of Wales Hospital consists of: 28 Consultants (of which 6 are intensivists) 10 Speciality or Associate Specialist doctors 9 core trainee doctors (CT1 and 2) 4 specialist trainee doctors The department provides ‘anaesthetic’ sessions to POWH and Neath Port Talbot Hospital NPTH: At Princess of Wales Hospital, there are 92 theatre sessions per week (Urology, ENT, General surgery, Colorectal, Upper GI, Gynaecology, CEPOD, trauma, elective Orthopaedic, Ophthalmology, Maxillofacial, Vascular, minor Paediatric surgery, Paediatric MRI and paediatric laser Dermatology) There are 10 obstetric anaesthetic sessions and 14 general ICU sessions. In addition we have 2 resident on call tiers made of trainee and speciality doctors, who cover ICU, emergency theatres, obstetrics, wards, pain, A&E etc. Non resident general consultant and non resident ICU consultant. At Neath Port Talbot Hospital, 44 theatre sessions are covered (Urology, Gynaecology, elective Orthopaedics, General Surgery, Breast, Cardioversion). In addition there is a resident speciality doctor for emergency/resuscitation cover Consultant recruitment is healthy at present and the department is perceived as a good place to work. The department is also recognised for CT and ST level training and receives consistently good feedback from trainees. The ICU is accredited for basic level training. There is also a fully functioning nurse led pre assessment service, supported by generic anaesthetic consultant pre assessment sessions. Anaesthetics in POWH is capable of supporting all of the types of surgery that would be required in a regional centre as well as labour ward cover and general intensive care. There would be a need to increase the on call establishment with dedicated labour ward cover together with expansion of ICU and labour ward facilities. 3.9 Radiology All the clinical disciplines rely, to a greater or lesser extent, on medical imaging and the Princess of Wales Hospital department of Radiology provides a timely and effective service. Approximately 140,000 examinations are performed per annum ranging from basic radiography to the most complex of interventions. A full range of scanning modalities are available and the patient throughput on our scanners is amongst the highest in Wales without compromise in quality of imaging or accuracy of reporting. The department has a long tradition of innovation. Developments, which are too numerous to list completely, include interventional radiology (IR) support for high risk obstetrics in mothers with abnormal placentation- the only multidisciplinary service in Wales. Our IR embolisation service for post partum haemorrhage is well established and has proved to life saving on more than one occasion. To facilitate neuro paediatric management, an MRI scanning service for young children under general anaesthetic was developed - one of only three units in Wales to do so. Double reporting of suspected NAI films was standard practice in POWH long before national guidelines were published and the

231 department is fortunate to have three consultants with an interest in paediatric radiology. The range of nuclear medicine investigations available to our clinicians is equal to that of most large teaching centres. Subspecialisation is well developed in all the radiological disciplines. Interventional support to surgical specialities and palliative care services are of the highest quality. A recent audit of ERCP services has demonstrated one of the highest technical success rates in the published literature and the unit receives tertiary referrals for difficult cases. Consultant radiologists support 9 different MDT meetings, participate in national research projects and support both undergraduate and radiology trainee education with good feedback. There are well developed governance systems in the department.Recent benchmarking indicates that our radiographers are the most productive in the health board, but the radiography establishment requires additional manpower to optimise throughput. 9.4 WTE Radiologist currently provides the excellent service outlined above but this is insufficient to sustain services and locum input has been needed over recent months.It is felt that recruitment prospects will improve if regional status is attained. 4.0 Education and Training The Princess of Wales Hospital is fortunate to house a state of the art, multi-professional education facility. The Multi- professional Education Centre (MPEC) has extensive facilities including a 120 seat lecture theatre, nine seminar rooms with integrated video conferencing facilities and sophisticated IT facilities. There is a high fidelity simulation training suite with multi-projectional video conferencing facilities along with a high fidelity simulation suite and wireless 3g simulation manikin (SimMan). In addition, there are two lecture rooms with interactive board facilities and a fully functional extensively equipped clinical skills lab. The excellent library also has good IT and internet links. In addition to the facilities within the MPEC, there are also simulation suites in other parts of the Hospital including the paediatric department more readily available to doctors in training. The MPEC is highly regarded by all of its’ regular users and visiting internationally renowned speakers have been complimentary about its’ facilities. There is intense demand for these training facilities, which caters for the educational needs of undergraduates and professionals involved in health care. The Princess of Wales Hospital remains popular with medical undergraduate trainees. The annual review by Cardiff University students ranks the Hospital as a favoured training centre and continues to accommodate the largest number of undergraduates outside of Cardiff. The training of medical students is an important part of the Hospital's function and the undergraduate department within the MPEC is closely involved with the C21 Curriculum Project, which is the new curriculum for Cardiff University medical students. The Hospital is playing a crucial role in the introduction of this new curriculum and any significant change in the casemix at POWH will impact on undergraduate training opportunities in Wales.The undergraduate and postgraduate medical training departments are closely integrated. This staffing arrangement supports the harmonisation of final year undergraduate and foundation programme training, as set out in the C21 project . There is a close relationship with the

232 deanery in the delivery of continuing professional development opportunities across the Health Board. The postgraduate training within the Hospital also remains popular with trainees. There are regional and national educational leaders within the the POWH consultant body. These includes core medical training leads and specialty leads in emergency medicine, radiology and occupational medicine. 5.0 AccessGeography, population and transport networks are important considerations in ideal planning of provision of care to patients. The Princess of Wales Hospital is close to Bridgend Town Centre Train and Bus Stations. It lies two minutes from the M4 and close to the A48, making access by car or ambulance straightforward for both patients and staff. Car park space at the hospital is well provided. The location of the hospital is familiar to most people in South Wales through the popularity of the McArthur Glen Retail Centre. This has allowed the hospital to be accessed for a range of South Wales developments, including the Tier 4 Child & Adolescent Mental Health Service, the Surgical and Eye Treatment Centres.Bridgend has a static population of 137,000 but the Princess of Wales Hospital naturally services the Western Vale of Glamorgan which increases the catchment area to around 160,000. In addition, during the summer months the coastal areas see a considerable influx of people either on a daily or semi resident basis. With the progressive centralisation of Cardiff and Vale Health Board acute services in the University Hospital of Wales, it is inevitable that more and more of the Vale of Glamorgan residents will be looking to the Princess of Wales Hospital for their services. The road infrastructure naturally flows into Bridgend from the Vale of Glamorgan and the travel time along the A48 to the Princess of Wales Hospital will be significantly less than to UHW. The Health Board has just invested circa £20 million in the development of an inpatient facility for the Child & Adolescent Mental Health Service at the Princess of Wales Hospital. As part of the Business Case process it was necessary to develop the Main Benefits and Benefits criteria and these included:- • CAMHS patients needed access to a range of health services • Access to specialist services such as paediatrics and A&E/Acute Medicine The relationship between the acute service and CAMHS has developed considerably whilst on site and there are clear interdependencies. 6.0Recruitment Historically, the Princess of Wales Hospital has been regarded as a very attractive place to work. It has a good reputation with excellent clinical and educational facilities and provides a comprehensive range of quality services. Medical recruitment and retention is a serious issue throughout Wales and regional status will attract high quality doctors and other health professionals to the locality. 7.0Waiting Times The Waiting Times performance measures for all specialties within the Princess of Wales Hospital have consistently achieved target levels as required by Welsh Government. Under component waiting times rules, services within the Hospital always meet target levels and this has continued with the introduction of Referral to Treatment Time (RTT) targets. Capacity is used flexibly across the Health Board in a number of specialties and the strong performance of the Princess of Wales Hospital has enabled activity to be

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moved from other Hospitals within the Health Board to ensure that waiting time targets are delivered on a Health Board wide basis. Sustainable levels of RTT delivery and excellent access times to diagnostic and therapy services ensure that patients are able to receive swift diagnosis and subsequent assignment to the appropriate clinical pathway at an early stage. In particular access times for MRI, CT and non-obstetric ultrasound is comparable with best in Wales and endoscopy access times are sustainably delivered within target. This is true for patients waiting for routine elective surgery and for patients on either urgent elective or urgent cancer pathways. 8.0ConclusionThis document provides ample evidence that the Princess of Wales Hospital is an eminently suitable site to establish a regional centre and the medical staff are fully committed to this goal.We are certain that the retention of acute services in Bridgend will be an essential element in achieving the optimal configuration for the future provision of safe, high quality, sustainable hospital care throughout South Wales. I would like to thank ABM for taking the time to arrange the public AM for Neath engagement on the Changing for the Better programme. Clearly the changes outlined in the document will impact on the lives of the vast majority of people living within the Health Board’s borders. I am therefore very glad to see the Health Board bringing patients, employees and other stakeholders into the process of shaping its future. I would agree with the general principles contained within Changing for the Better – increasing efficiency, moving services closer to patients and ensuring the 24 hour availability of top quality services will be essential if the NHS is to respond to the challenges it faces. In terms of the application of these principles I would like to offer the following comments. In your consideration of the challenges facing ABM you note the shortage of doctors and the difficulties that this causes. I appreciate the extent of this issue, particularly following the changes to service provision at Neath Port Talbot Hospital. Evidently, many of the changes proposed elsewhere in the document will, to some extent, mitigate the problem. However, in the context of the underlying causes of the shortage of doctors at Neath Port Talbot hospital, I hope that ABM will consider closely consequences that service changes may have on training and development of staff and will be in regular contact with the Deanery to discuss this issue. In addition I hope that ABM will continue to work with the Welsh Government on its ‘Work for Wales’ campaign to attract medical professionals to the Welsh NHS. In order to tackle the doctor shortage it will be necessary to both reduce service pressures and increase the supply of properly trained professionals. Recruitment drives, both within and outside the UK, a network of clinical ambassadors and support for clinical innovation, such as that provided by the ‘Invent’ programme, will be important in achieving the second part of this solution. In the list of emerging ideas I am very glad to see the focus on preventative medicine – this will clearly pay dividends both in terms of long-term savings and, more importantly, in improving the general health of people in the ABM region. I note that ABM is committed to supporting the UK and Welsh Governments in their efforts to tackle environmental health factors such as air quality

234 housing and the economy, and I commend this. I would suggest, however, that it may be desirable to explicitly include Local Government in this formulation. I hope that the next stage of Changing for the Better will include further details on this subject. In terms of working with wider partner organisations I would suggest that ABM may wish to look at developing a strategy for integrating the third sector into both the delivery and design of services. Hywel Dda Health Board has, for example, produced a report called A Co-Designed Future: The Third Sector Role in Health and Social Care in Hywel Dda. This document is intended to provide the basis for the involvement of the third sector in patient pathways, for future contractual arrangements with third sector partners and the principles guiding the use of Health Board resources. I would very much like to see ABM build on the work it has already undertaken in the Changing for the Better programme to produce a similar document for its own region. Finally, with regards to preventative medicine, I would like to support the move to produce a directory of services already available from partner organisations and the voluntary sector. I would encourage ABM to publicise this directory as widely as possible and to ensure that it is available to third sector organisations, elected representatives and organisation such as the Citizens’ Advice Bureau. In the section discussing the future of maternity services in the Health Board I note ABM hopes to increase the number of mothers giving birth either at home or in mid-wife led units. Whilst this will be appropriate for many mothers there will be births that require more intensive support, and it is not always possible to predict when complications will arise. I would therefore emphasise the importance of ensuring that there is adequate provision in the event where urgent, more specialised, care is needed. I am pleased to note, in your discussion of planned care, that ABM intends to ensure that most scheduled operations will still take place at a patient’s local hospital. In this section you also mention the use of technology in scheduled care. This is an excellent idea and could greatly improve efficiency by helping to ensure that patients turn up for appointments. I believe that the use of such technology could also have a beneficial role to play in the management of chronic conditions. Powys Health Board have, for example, developed apps to allow patients to video conference with doctors, help them plan long term care and allow patients with Asperger’s to contact help when anxious. As I mentioned above, I would welcome ABM’s intention to, where possible, move services closer to the patient and to shift resources into the community. This will, of course, be especially important in terms geriatric medicine and long term care. Such a change will however bring challenges with it. Most importantly, collaboration and joint working with Local Authorities’ Social Services Departments will be absolutely crucial to ensuring that this works. I know that ABM is already working cooperatively with Councils in its area but I believe it will be vitally important to further develop and build on these existing collaborations. I would also urge the Health Board to conduct, in conjunction with the Local Authorities, an assessment of the capacity that currently exists in the nursing and residential homes and social care sector in

235 its area. A move to increased community provision will also make support for carers even more important. I hope ABM will look to develop systems to provide first class advice, guidance and direct support for carers. Again, I would hope to see further detail on these issues in the next stage of public engagement. In a related point, I feel that in discussing the future of Community Hospitals in ABM it is important to consider care for patients able to be discharged from acute medical facilities but as yet unable to return home. Whilst existing Community Hospitals will not be the only way to provide interim care for these patients they do currently provide an essential facility that allows for the freeing up of beds in more specialist hospitals. As suggested in the Changing for the Better document, where in- patient facilities are to be removed from Community Hospitals they could be used as community medical facilities. In this role they could provide accommodation for day clinics and a base for health workers and other professionals. This would help bring medical services closer to the patients that use them and also, importantly, provide a venue for ‘on the ground’ contact and communication between health and social services. Regarding the South Wales Programme and the consolidation of major accident and emergency departments, consultant led obstetrics units and other services in Regional Centres I would like to make the following comments. Firstly, I would strongly advocate the maintenance of Morriston Hospital as a major trauma facility. Having a base in the Swansea area greatly reduces the travel time to a major trauma unit for many people living in South West Wales. The proximity of the specialist burns unit to areas of heavy industry, such as the Tata steel works in Port Talbot, has also proved invaluable on numerous occasions. In addition the recent investment and increase in treatment space would be best used by maintaining the current balance between Cardiff and Morriston. Secondly, while the South Wales Programme does provide a clear road map for cross border services within the area covered it does not consider in detail relationships with Health Boards outside this region. Developments in Hywel Dda and Powys Health Board will undoubtedly impact upon services in ABM. I would therefore encourage ABM to develop a full cross-border protocol to facilitate the movement of patients and the sharing of services between these other Health Boards and between Health Boards and their constituent local authorities. I believe it would be desirable for this to be included in the next stage of Changing for the Better. Finally, the changes to the hospital service proposed in the South Wales Programme, and to some extent those put forward in ABM’s own programme, could potentially create transport problems for many patients and their families. Older people and those relying on public transport may well struggle to reach the new Regional Centres to access services or visit patients. I believe that this issue is inextricably linked to the restructuring of the hospital system as a whole. I am given to understand that ABM has commissioned work looking at how this problem could be addressed. I would hope that this analysis would be included in the final proposals to be published next year. I would like to thank you for your consideration of my comments, I hope that they will be of use to you in

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moving forward with the improvement of health services in the Health Board. I look forward to seeing the detailed proposals at the next stage of public consultation. AM 1. One of the drivers of change is the desire for more localised access to more service, which is an aspiration all will welcome. This will be in exchange for the centralisation of specific ‘high end’ services which will help meet the challenge posed by ABMu’s inability to hire or retain sufficient consultants and consultancy recruits in those specialisms. In the 2013 consultation document, it would be helpful if you could give a detailed account of what various elements of improved community care will cost. There is little point telling us that hospital admission costs £180 a day if you don’t tell us what treating equivalent patients in the community and achieving the same outcome costs. Will the 2013 consultation document provide a timetable for what services you hope to provide locally, where and by when. The public engagement document refers to the Mobile Response Unit, for example, but that only serves Bridgend. It would help if we knew how much rolling that service out would cost and how much it would save. The CISS system is still not functioning as intended. When will that be fully functional, how much will it cost and how much will it save? In particular, while it may be true that people prefer to recover at home, there is a level of anxiety expressed by or on behalf of older frail people who live alone that they are being sent home too soon. The loss of recovery beds in non-acute settings has not been matched by acceptable levels of supervision at home yet. Without this information, the public will not be able to make an informed choice about whether your plans for improving GP and community services are viable and whether the bargain referred to in para 1 is a good one. There will be no point exchanging one poor model of delivery for another. You will need to able to show that, if high-end A&E and paediatric care is centralised, the money saved will be spent community care which prevents the need for hospital admission, and particularly to A&E and paediatrics. Further, without figures, it is difficult to both challenge ABMu assertions and suggest alternative models. 2. The problem of insufficient specialists is not new. The EU working time directive has been in place for some time and affects all UK DGHs. Immigration policy allows for non-EU foreign nationals to train and work here if they have skills we need.

The centralisation of ‘high end’ care is presented is a response to a chronic symptom rather than solving the underlying problem. There is no problem with attracting undergraduate students to train in Wales, rather a disinclination on the part of those students to pursue particular specialisms.

The consultation document needs to be clear about this (not refer to a separate website) and it also needs to explain what work ABMu has done with the government and the Deanery to overcome the recruitment

237 problem. Otherwise, the public will be entitled to think that centralisation is for the convenience of ABMu and Cwm Taf, and saving money, rather than trying to maintain excellence with too few doctors.

3. ABMu already understands that changes to unscheduled care, which people think of as “emergency care”, will cause concern. It needs to understand that, for many, it causes real fear. Any discussion about moving A&E level services further away from where they live is going to be a problem because the common view will be that it is better to get to a good A&E quickly, with good recovery, than fail to get to an excellent A&E , with no recovery, because it is too far away. The role of the ambulance service is critical to the part of the proposals relating to centralisation, especially of A&E. The 2013 consultation document will be fundamentally flawed if it is not completely up front about the limited control that ABMu has over the ambulance service. Of course, ABMu will not want to say anything which may veer towards being political in nature, but a failure to be clear on how emergency transport will (not “could” or “might”) be improved means that the public will be entitled to assume that added travel time will put them at risk. There is an argument that ambulances are better equipped and paramedics better trained these days, meaning that a patient is treated on site and in the ambulance before arrival in A&E. However, at the moment, I understand that there are only 5 teams which are capable of dealing with more serious cases. What are the plans and cost for rolling out that service for example? Evidence from paramedics in rural Wales makes it plain that, despite their expertise, time, distance and road conditions do make a difference to outcomes. It is difficult to carry out some procedures when the vehicle is driving at speed or on winding roads. As no deaths are recorded in transit, it is not easy to get official information about the effects of distance and time on outcomes, so people will be inclined to assume the worse. I am pleased to hear that Morriston is introducing a priority admission system for ambulance patients to help reduce ambulance queues. Is the same happening at POW? What effect has it had on consultants (and middle grades) being able to treat patients more quickly? It would be helpful if the 2013 consultation paper could reassure the public that it has examined problem experienced for years in rural Wales and explain what it will be doing to avoid replicating those problems in these proposals.

Incidentally, the acquisition of a single air ambulance would be helpful but no silver bullet. Could the 2013 consultation paper also confirm that no decision will hinge on whether there is a helicopter landing pad on site.

4. Centralising paediatric care causes specific worries around children being able to be visited by parents, not least because those parents may have other children at home. Short term accommodation facilities for families

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(not just a room for a parent) may help resolve those problems. I hope you will consider this idea.

5. The First Minister has already said that POW patients would not have to travel to Prince Charles hospital. How is he so sure? Remarks like that do not inspire public confidence in ABMu’s transparency on these proposals and do not alleviate fears that the consultation is just window dressing.

The 2013 consultation paper must annex detailed impact assessments for each scenario, how each possibility would look, affect access and affect cost. Carwyn Jones AM 1. Introduction. A number of issues are clear to me. Changing demographics for Bridgend and a growing population will change and increase the demands on the NHS. The ambition to deliver world class services can only be met by careful planning and efficient use of resources. People tell me that they want high quality, safe and reliable services, as close as possible to their home. The status quo will not serve us in the future. I have received a great deal of correspondence regarding the Princess of Wales, raising concerns in particular about the potential for a decline in Accident and Emergency waiting times, ambulance response times and cover for obstetrics and maternity wards. This demonstrates recognition that services will not remain sustainable as they are. Our Health Board has a number of constraints to factor into the planning of service delivery, most notably centred on difficulties in recruiting enough specialist clinicians. It is not possible to create fully staffed specialist centres across a range of disciplines at all hospital sites across South Wales. The changes to the way services should be delivered are focussed on a small proportion of people who have complex needs when they are taken into hospital. This covers high risk births and emergency admissions where patients have severe trauma such as from road accidents. The majority of admissions to hospital do not require such highly specialised services. By locating specialist centres strategically and ensuring that people are taken to the most appropriate place for treatment, all departments will be better placed to run more efficiently and safely. With appropriate staffing levels better quality of care and improved outcomes will be delivered for all patients, most importantly, for those who are extremely unwell, requiring highly specialised care.To inform my response I have taken on board the views of constituents who have written and spoken to me about the engagement process. I have also spoken to clinicians who approached me for discussions and with representatives of the ABMU Health Board and Ambulance Service.Based on this, I am arguing for the Princess of Wales hospital, Bridgend to be one of the additional Regional Centres for South Wales. 2. Accident and Emergency Provision The majority of feedback I have received from constituents raises the concern of potential journey times in emergencies. This includes people making their own way to hospital during an emergency, during labour or when a birth becomes unexpectedly high risk and also for incidents where an ambulance is needed to take a patient to hospital. There is recognition from people that the current delivery of

239 services will not be able to achieve the highest standards expected unless the delivery of services changes to cope with increasing demand. People have been unnecessarily concerned that A&E at the Princess of Wales could close altogether. A&E should not close, neither will the Princess of Wales hospital and this is clear in the “South Wales Programme” and in “Changing for the Better”. There are two solutions; one being for the most complex needs to be taken to another hospital with fully staffed specialist facilities and by developing a Minor Injuries Unit at the Princess of Wales. This could improve the service delivered, in a similar way to the Port Talbot Minor Injuries Unit. The second option, which I strongly argue for, is for the Princess of Wales to become one of the Regional Centres, enabling people from Bridgend and surrounding areas to access specialist provision on a 24/7 basis on this site. The Princess of Wales is equidistant between Cardiff and Swansea which already serve as Specialist Centres. It is already accepted that patients with brain injuries are taken to Cardiff, and those with severe burns go to Swansea. It is important that the services provided by the Princess of Wales are able to strategically complement the highly specialised services already developed elsewhere. By utilising the Princess of Wales as a Regional Centre, people across Bridgend will retain quick access to A&E. The catchment area can be opened up further afield due to ease of access via the M4. A more efficient A&E service will reduce delays and release paramedics once patients have been transferred to a bed, improving waiting times.Both scenarios need to be underpinned by efficient and appropriate staffing for on-scene emergency treatment, avoiding unnecessary trips to hospital and also improving ambulance response times in an emergency. The Ambulance Service across the ABMU region has trained a number of Specialist Paramedics with a wider range of skills who are able to assess and treat patients based on clinical need. This is part of a new “Pathway” initiative, which ensures that patients are treated on the scene if appropriate, or referred or taken to the most appropriate place for care. This reduces unnecessary ambulance trips and hospital journeys, creating a more efficient service.There is clear good work creating improvements to the Ambulance Service across the region which will continue whatever the outcome of the South Wales health reorganisation. The Welsh Ambulance Service and ABMU have worked well together throughout the engagement process and it is crucial for the success of health reorganisation that they continue to work closely throughout the future consultation period. 3. Maternity and Obstetrics provision. People feel passionately that there should be no reduction in services within paediatric, obstetric and neonatal care. The aim of reorganisation of services is to ensure that there is only improvement in the services delivered. Where consultants are currently spread too thinly, all healthcare sites risk running a service that is below standard. People want services to be delivered as close to their home as possible but there are not enough staff to provide 24/7 specialist provision at all hospitals. I have received correspondence from constituents praising the hard work and dedication of NHS staff. Staff are under immense

240 pressure due to staffing shortages and it is clear that the services currently being delivered cannot be sustained and this could put lives at risk. As with A&E provision, there are two options here. The first is for specialist provision to be sited elsewhere with a midwife-led unit at the Princess of Wales. However, people are rightly concerned that during an unexpected emergency in labour or with a very young child, travelling further could reduce the chances of a good outcome. I argue for specialist paediatric, obstetric and neonatal care to be delivered from the Princess of Wales, so that complex births and at least level 2 and 1 tier patients be treated on site. This would complement specialist A&E provision at the Princess of Wales. 4. Staffing Improvement to the NHS in South Wales relies on attracting staff at all levels and specifically, doctors in training within a particular specialism, and specialist consultants. To attract more doctors-in-training, specialist centres are needed. Since doctors’ hours are capped by the European Working Time Directive, specialist centres provide a higher number of patients allowing doctors to gain experience in their specialism. Specialist centres also ensure enough Specialist Consultants to support training and to provide sufficient cover on a 24/7 basis, to deliver consistently high quality services no matter what day of the week or time of day that a person needs this level of medical help. It is crucial to ensure the Princess of Wales remains attractive for doctors-in- training and Specialists in order to fill vacancies. Higher patient numbers and a concentration of other specialists to provide training will encourage more doctors in. Discussions with clinicians highlight that the Princess of Wales has the best undergraduate facilities in Wales, which is an achievement we can all be proud of. The Princess of Wales needs to become a Regional Centre in order to secure the high quality facilities and attractiveness of the Princess of Wales for training undergraduates for the future. Geographically, Bridgend can also be promoted as a good place to live and work. There is easy access to the M4 and nearby cities, as well as our stunning coastline and countryside. Current patterns of service delivery will not provide enough specialists enough of the time in the future, creating inconsistency for patients. By concentrating specialists on a smaller number of sites, it is much easier to attract staff to fill the vacancies, further improving outcomes for patients. The Princess of Wales should be a Regional Centre, developing specialisms to complement those already in existence at other regional centres. 5. Conclusion I argue for the Princess of Wales to become one of the additional Regional Centres in South Wales. Being equidistant between Cardiff and Swansea and situated just off the M4, the Princess of Wales Hospital is accessible to people living in a large geographical area. Accessibility of health services is important to people. Bridgend County Borough has a population of over 139,000 residents with a reasonably symmetrical population spread to the East and West of Bridgend within the

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ABMU catchment area. The hospital also attracts significant numbers of people from Neath Port Talbot. There is a strong logistical case for the Princess of Wales to become a Regional Centre. The hospital is well situated to develop specialist services that complement those offered by Swansea and Cardiff, providing a more attractive prospect for both training and experienced specialists. However, all potential scenarios for the siting of Regional Centres must be underpinned by close working with the Ambulance Service in order to realign ambulance provision to complement reorganisation of services. Quick response times, appropriate on-site assessment and treatment and quick journey times to the appropriate hospital are absolutely crucial in improving outcomes for patients. In drawing up proposals for the realignment of health services across South Wales, it is essential for the role of the Ambulance Service and paramedics to be integral to any steps taken towards improving service delivery. Local councillor As the Councillor for the ward of Rhos, which contains Gellinudd Hospital, I would like to convey some of the views expressed to me by local residents regarding this specific hospital and more generally about the sections of Changing for the Better relating to the future of community hospitals in Abertawe Bro Morgannwg . The support which Gellinudd Hospital has, over very many years, received from the surrounding communities, and in particular from the dedicated work of the League of Friends of Gellinudd Hospital, demonstrates the extent to which it is valued in the local area. The staff are motivated and highly skilled and, I am told, the standard of care is appreciated by patients who have spent time there. It provides an excellent service close to the homes of many of its patients and their families. The residents of Rhos would therefore, I feel, be extremely disappointed if closure of the hospital was to be suggested in the final proposals to be produced next year.

The majority of the people I have spoken to understand the arguments for the transfer of resources into the community services and the drive to provide as much care as possible in the patient’s own home. I myself believe that this would, if successfully implemented, both increase efficiency and the quality of care. The increased use of community resource teams to allow people to return home rather than remain in hospital for long periods will inevitably affect the role of many community hospitals.

This said, several residents have expressed concerns, which I also share, regarding the implementation of this policy. Where patients are able to leave acute medical facilities but still require some medical attention or other forms of care there is frequently a delay in making necessary arrangements to allow them to return home. In order to tackle these delays there will be a need for strong joint-working between Council social services and the Health Board. I would hope that robust arrangements for cooperation between the two service areas will be put in place before ABM seeks to move ahead with the expansion of community care. In some cases

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however, even with the best collaborative working, delays will occur due to factors beyond the control of the Health Board. Families, for example, may need time to make arrangements to provide care for relatives or physical adaptations to the house may be required. In these instances there will remain a need for interim care in order to prevent ‘bed blocking’ in larger hospitals. I am aware that in some areas this form of care is partially provided through arrangements with nursing homes. However, given the existing pressures on nursing home capacity in Neath Port Talbot, and the fact that these circumstances may in certain cases apply to younger people, there would seem to be a good argument for maintaining, at the very least some of, the beds currently available in community hospitals. Given the quality of care provided at Gellinudd it would seem an appropriate setting for an interim in-patient facility of this nature.

Should, despite the above factors, the decision be taken to remove in- patient services from Gellinudd I believe there would be an extremely strong case for its use as a community health facility. Rhos and the surrounding communities have an older age profile than most areas of the ABM region. There is also, unfortunately, a very high number of people in Rhos and nearby villages with limiting long term illnesses and other chronic conditions. These factors, as well as the good road and public transport links to Pontardawe and the suburbs north of Neath, would make Gellinudd a highly suitable location for a community resource centre. In this capacity the hospital could be the setting for day clinics for diabetes, high blood pressure and the management of other chronic conditions. The highly skilled physiotherapists and occupational therapist currently at the hospital could continue to offer those elements of therapy that could not be provided in the patient's own home with the equipment already available at the hospital. It could also function as a base for social workers, health visitors and community health teams.

In conclusion, given the high standard of care, the dedicated staff, the support from the local community and the demographic profile of the surrounding area I feel that there are strong arguments for Gellinudd Hospital continuing to play a significant role in the provision of health services in the ABM area.

Finally I would like to thank ABM for providing a seminar for Neath Port Talbot Councillors to discuss the issues surrounding the Changing for the Better programme with your Chief Executive and other senior officers and clinicians, and also for the very many public events and exhibitions that have taken place over the course of the public engagement programme. I hope that this level of extensive public discourse will continue during the next round of consultation. Local A recent meetings of the Council discussions have been held on changes, parish/community both actual and proposed at the above, including the recent amendment to council the catering service at Maesteg Hospital.

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I was directed by the Council to stress how much the Maesteg Community Hospital is valued within our community, and state that is essential that the current service provision is maintained locally, as well as at the Princess of Wales Hospital at Bridgend particularly during the re-evaluation process due in 2013. Residents fear for future local services in health care. The council would be grateful if you could provide assurance that as many services as possible will be retained locally at the Maesteg Community Hospital. Regional Health, The Regional Health, Social Care and Wellbeing (HSCWB) Network would like Social Care and to thank ABMU Health Board for the opportunity to contribute to the Wellbeing Changing for the Better engagement phase. This response reflects a recent (HSCWB) Network HSCWB Network workshop involving a range of Third Sector health and social care providers. To ensure the workshop reflected the views of the Sector and the priorities and the challenges it faces; attendees were presented with three key questions, as outlined below. 1. What positive impact do you think Changing for the Better will have on the local Third Sector? • Changing for the Better provides a steer for the Health Board to work differently. Previously there have been some difficulties in engaging with health, this process presents an opportunity to join up services and increase co-ordination; • The development of specialist centres is a good thing as the quality of care will increase, particularly when the Sector is utilised as more of a resource to provide a holistic service, rather than a medical approach; • Changing for the Better is expected to assist in raising the profile of the Sector; increasing awareness of what is available from the Sector locally. It is acknowledged that the Sector knows its communities and therefore provides services which are fit for purpose. • A focus on the prevention agenda (preventing crisis) is welcomed especially as it is based on engagement. The implementation of the Mental Health Measure and its focus on Primary Care is already looking at shifting to community provision; • The emphasis placed on supporting people to manage their condition is positive. There are lots of programmes and projects that are available, but people are not necessarily accessing them. The inclusion and recognition of the Sector as a contributor to the health agenda is therefore welcomed; as closer working on the ground, which will lend itself to quality referrals and care; • In order to embed a collaborative holistic approach there is a need to examine value for money. To ensure that the value for money the Sector offers is fully unitised the overall investment in the Sector needs to be scrutinised; • Staff roles will change – the Sector is a lot more flexible, which may have an influence on statutory sector job roles. However it is likely that more resources will be required by the Sector to ensure support for people in the community; • It is acknowledged there are opportunities for integrated business

244 development in the Sector and a need to reconfigure the budgets. In taking this forward it brings an opportunity for the Sector to develop their own services to meet local needs; • To ensure the sustainability of a collaborative health and social care approach further opportunities for social enterprise need to be explored. There is a recognition that the Sector will need to professionalise to improve its image. • Changing for the Better provides an opportunity to break down traditional barriers regarding data protection or what some people perceive as the needs of data protection. 2. What challenges will Changing for the Better pose for the Third Sector? • Communication is a key component of a collaborative approach; further work is required to ensure all stakeholders including providers are engaged on level terms to avoid a competitive approach for funding. A transparent funding formula/mechanism is required; • Concerns were expressed on the length of time required to make the shift from hospital to community care. The main concern being access and is this going to be a direct cost to the Health Board that could impact on other health areas; • Transport will be a big issue. Many transport providers will be unable to run services if they are not profitable. The timing of appointments can also lead to additional difficulties for older people, people with disabilities or carers. Transport and appointment times can impact on Sector staff transferring service users to hospitals for appointments, procedures etc; • An outcomes based approach i.e. measuring and monitoring the difference made brings challenges for the Sector, particularly as often the difference made is difficult to measure, such as increased confidence or improved quality of life. • The Sector is disparate – all independent and separate. To harness this whilst maintaining individual organisational value base requires effective co- ordination. Very often working in localities or with own areas of specialism leads to a competitive approach in going for the same pot of funding, which is recognised as a challenge; • The need for service provision to regionalise is acknowledged but there is a need to maintain an awareness of the different issues in different localities, which are a priority for locally based providers. 3. Do you have any possible solutions for the challenges you have identified? • The Community Voluntary Councils (CVCs) and HSCWB facilitators are pivotal to supporting coordination, collaboration and partnership working which are identified as the key components to moving forward; • The CVCs are well placed to assist local organisations in their understanding of an outcomes based approach and to enable them to develop appropriate measuring and monitoring tools; • Information sharing and communication has also been identified as integral to Changing for the Better. The regional and local HSCWB Networks can assist with this however a true engagement of partner providers through local and regional partnerships is essential;

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• Community Hubs have an important role in providing a range of services to support patients in a holistic way with improved systems in place. • CVCs can provide support to Third Sector organisations around the development of Social Enterprise enabling them to take forward new enterprises and projects. • Community transport: initiatives could be developed to assist people in accessing services. There are already pilot community transport projects taking place within health which have been successful, and this is something which could be developed and expanded further to enable people to access outpatient services. • The Sector can access funding from other sources which can support the delivery of projects and add value to services commissioned by the Health Board. • The flexibility and innovativeness of the Third Sector itself is a solution to some of the challenges ahead. The Regional HSCWB Network will continue to work in partnership with the Health Board and looks forward to engaging in the Changing for the Better consultation phase in the New Year. Petition We the undersigned call on the National Assembly for Wales to urge the Welsh Government to halt the decision to move all CT2 Doctors from Neath Port Talbot in the Autumn, without prior consultation with the public. This decision will mean that acute medical services will not be provided at the Hospital, and patients will be forced to travel to Morriston in Swansea, or the Princess of Wales in Bridgend for services. Neath Port Talbot hospital is a state of the art, PFI hospital, and the people of this area want such vital services to be retained at Neath Port Talbot Hospital. Member of NHS 1. Knock all the hospitals down to centralise surgery staff Member of NHS 2. I am speaking as a member of staff and for relatives of inpatients. Public staff transport is a major concern. In the morning it is impossible using public transport to arrive at work for 07:00. On an evening it takes 2hrs to get home. The metro (4) from hospital to Swansea bus station and the 224 to Port Talbot. The last 224 leaves Swansea at 17:25 each day. Some patients have no visitors because of the lack of public transport ths causes upset to both relatives and patients. A knock on effect is more ambulances are being used when people are discharged for follow up appointments. The issues of public transport need to be addressed as an urgency. Member of NHS Concern expressed about current delays/ waiting times in Morriston A&E staff and the impact if there was any further reduction in access to emergency services across ABM. Lack of clarity about post – discharge support of elderly inpatient who had been treated for a cardiological condition. Member of staff wished all emergency services to be maintained and capacity increased in Morriston – to reduce waiting times. Member of NHS If Cimla Hospital was to close, I think it would be a great loss to the area, and

246 staff the patients’ that attend our ward, may be worse off due to extended separation from relatives due to travelling problems. This could be a problem with their recovery of their medical or psychological problems. Not only is this a vital factor for patients and families, but also increase spending for the NHS on longer stays in hospital. Member of NHS From past experiences there needs to be a booking system for appropriate staff wheelchairs’ for disabled patients. Our experience last year was far from satisfactory when we were told there was not a booking system in place they couldn’t guarantee a wheelchair when we arrived. This needs to be addressed because there will always be a need for wheelchairs in a hospital. Member of public The Princes of Wales Hospital should be retaining a full time A&E department. In December 2012 unfortunately my mother was taken ill with vomiting, feeling unwell and breathing difficulties I thought it was her heart and I took her to the A&E at the Princes of Wales Hospital it was 11.15hrs approx there was only two people there in the waiting area. I booked her in and went to park the car, which took about 5 to 8 minutes , when I went back to the waiting area my mother was in the treatment area being seen to by a doctor. I had to wait about a further few minutes then the doctor call me in. In the treatment area all the cubicles were occupied. The doctor wanted blood tests and an x-ray, we were asked to go back into the waiting area to be called for her blood tests. We were there about 5 minuets when a nurse called us to go back into the treatment area for here blood to be taken. The waiting area had a few more peoples waiting to be seen.After the blood was taken we then went to have an x ray taken of her chest. After that was taken we were shown to another waiting area, we were here about 10 minuets with in that time mother was starting to few unwell. A junior doctor call us and took us to one of the resuscitation bay’s as there was not other bay or cubicles available as there were all taken and he told us that is a emergency came in we would be moved out from the resuscitation bay. Mother was unwell when we were in their and more tests like blood gases were then and was put on oxygen and her heart/blood and oxygen were monitored. At bout 16.00hrs I had to came back home and to the Guest House to see my brother who lives next door to the Guest house to ask him to see to a guest that was booking in at about 17.00hrs. When I got back to the hospital the waiting area was full and as well as the area where the ambulance personnel wait with they’re casualties. About 17.30hrs mother was better and the consultant told us that mother they believed to have suffered a ‘gastric asthma’. We left the A&E about 18.00hrs. The waiting area and Ambulance waiting area were even fuller than earlier. If we had to go to another A&E department I think that the waiting areas would be fuller and waiting times would be longer. We were at the Princes of Wales for nearly 7 hours. You take the incident that happened in Cardiff ain November time when the van drove down a number of peoples and killing one in Ely. The A&E department had to closed because there were over stretched. If we had to go to Cardiff, Merthyr or Swansea the same thing is going to happen.

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Not because of a major incident but because the number of casualties taken there from a lager area that it has to serve? If you the A&E department was made a Minor Injuries Unit like Port Talbot (which the people of Port Talbot are not that happy with as there got to come to Bridgend or Swansea, I was told by a relation that lives in Port Talbot. Again year ago there was a 24/7 A&E department in the Neath old General Hospital which is now closed). The Princes of Wales should the second option, which you argue with, one of the Regional Accident and Emergence departments.I agree that with specialist centres for Maternity, Obstetrics, Cancer, Brain injuries and Burns. I remember when we had to travel up to Chepstow to the Burns unit. But A&E should stay in the Princes of Wales. Feedback from Issues Raised public • I live in Cowbridge and we have two surgeries.One sends patients to UHW, engagement the other to Morriston. I question the logic for sending people to Swansea event in when UHW is closer. I have received treatment at Barry Hospital, UHW and Cowbridge Royal Glamorgan. • My wife required a cardiac stent. She was sent to POW Bridgend, then transferred to Swansea. A direct referral to UHW would have prevented an additional 20 miles travel distance. Doctors have an element of choice; they look at the service provided and not Health Board boundaries. Cwm Taf Health Board staff explained the difference between elective and emergency services and emphasised that community services would need to be strengthened in all areas. They also explained that GPs work on list size, Health Boards work on population – confirmed that there is a need to look at overall referral pathways. • Why is there a shortage of doctors in hospitals? There appear to be ample opportunity for UK trained doctors to work abroad – why can’t we retain them? The Working Time Directive and Visa restrictions impacted on the number of hours doctors can work so more are required to cover 24/7 shifts. This is a UK issue not just Wales. • Why is there a lack of specialist doctors? Doctors have a lifestyle choice and can choose what specialities they wish to work in. The issue isn’t restricted to the number of specialist medical posts – in order to train and retain expertise Doctors need to see high numbers of patients with specific conditions. • Have there been pressures on the service? Patient activity has been greater this year. • The issue is not the number of doctors – rather the demands made upon them. The challenge is providing care for 100,000 immigrants each year, and the cost of doing so. • The older population remember a different service, when GPs were more readily available and there was less pressure on the Hospitals. I have received a very poor response from the out of hours service when seeking help for my dying mother.

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GPs have opted not to work Out-of Hours and this service is now provided by the Cardiff and Vale University Health Board. • Will we lose A&E provision at Princes of Wales and what about ambulance problems, travelling further distances? No decisions have been made about specialist A&E provision, but there will be some level of A&E provided in all hospitals. Communication is ongoing with colleagues at WAST regarding the requirement to support travel arrangements. • Nurses in Bridgend are worried about the possible closure of Princess of Wales A&E. No decisions have been made as to where services may change, but there will not be any closures. • Are the changes about finance and pressure from Welsh Government? We all recognise the public sector financial freeze. However the options are not about finance and pressure from Government, they are clinician led and are about safety and quality, having the right staff in the right place. • Why are we unable to afford 24/7 cover in all hospitals? Is this the first step toward a gradual reduction in services? These changes are not financially driven. But we cannot afford to replicate very expensive packages e.g. trauma requires not only a 24 hour consultant presence but supporting services. Interventional radiologists / Theatres / Intensivists etc. we also need a critical mass of circa 250,000 patients to make the service safe and sustainable. Consideration was given to using Bristol as the major Trauma centre. This would have taken patient numbers up to 500,000 and was deemed detrimental to patient care. • Who will be affected if you go ahead with specialist services? Only a small percentage of patients would be affected, as only specialist services. • If there is an emergency, how will the ambulance service know where to go? The Ambulance service have agreed protocol- driven decision making tools for specific clinical conditions and will know where the patient needs to go. • Will the patient need to stay once stabilised by specialist services? The current situation is that patients who receive specialist services are transferred back to their local hospital once they have been stabilised. • Can you give an idea what specialist services will be moved from surrounding hospitals. We cannot give a final scenario as we are only at the engagement phase. All Health Boards are undertaking scoping works across South Wales. There will be no closures, but there may be change. • Advanced Emergency Practitioner roles have increased. • What are the qualifications for this role? The Advance Emergency Practitioner is a Nurse or Paramedic who has qualified at Master Level to reach a competency to practice; it would not be a junior member of staff. • I am worried about the loss of A&E services at Princess of Wales, what if the ambulance has to go elsewhere and the patient is a child and cannot be treated at their local Hospital. There are no specifics around where specialist Paediatric Services will be

249 provided, we will need to look at the criteria, the work force required and where there is most critical mass. • What if the Ambulance is unable to transfer in the time required. Also I understand that the air ambulance service is already stretched and is being downgraded. We are looking at Helicopter transfers and are currently in discussion with the Welsh Ambulance Service. There have been Improvements to the Air Ambulance service and they are currently looking at increasing their scope to enable 24/7 cover. • Extra finances are need for WAST. Their “head chaps” are regularly changing. They are initially enthusiastic but can’t get anywhere. They are struggling, which means we struggle. • Just this weekend a man had a cardiac arrest on the village rugby field. 4 First responders, a doctor and a paramedic fought to save his life. They struggled to keep going as the ambulance response time was so slow. What will happen if a cardiac arrest or trauma happen and all the ambulances are transferring people long distances between Cardiff and Swansea? WAST are familiar with challenges and trying to address them. CHC confirmed recent evidence to support an improvement in services in recent years. • I feel that 24/7 cover for specialist services is a positive move by the Health Boards and will attract the best in the field. There will be the right expertise in the right place. • On a local level would Cowbridge residents have to go to Morriston? No decisions have been made yet, but only those patients that require the specialist services being discussed would need to go further afield. Patients safety requires 24/7 cover and this is the reasoning for us looking at concentrating certain specialist services, we do not know where they will go at present. There are better survival rates at UHW presently because there is 24/7 cover. • Recent press coverage revealed that chances of survival increased if there was 24/7 Consultant cover. Why can’t we have 24/7 trauma services at all hospitals? • We want to go to the hospital that gives us the best chance of survival. I will illustrate this with a major trauma. A major trauma will require a multidisciplinary team of specialists, this cannot be replicated everywhere if there are too small numbers of patients seen. Doctors need to keep their skills up-to-date which require a critical mass of patients. 90% of patient care will still be provided locally. Paediatric doctors need to see at least 4,000 patients a year to retain expertise so there is a need for this service to be provided in a specialist centre. People already receive specialist services i.e. Morriston Burns Unit. Colleagues from Cwm Taf illustrated other methods of ensuring “access” to a consultant i.e. telemedicine – where a specialist does not need to be physically on site to deliver an expert opinion and treatment plan. • Will these changes mean that we will lose our community hospitals which

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are supported by on call GPs? No. We are talking specifically about highly specialist top end clinical services. • How are you going to be ready for consultation, as the engagement phase does not end until 19th December and you are looking to go out to consultation in January? We will need to review the timing; there may be a need to start consultation at a later date. • What / who is the SCCC? Specialist Critical Care Centre in the Gwent Region. • Is the SCCC a private venture, and can NHS patients use it? NHS facility • The NHS is precious and we want to support it. Key Themes • Need to develop consistent referral pathways from primary care • Concern that plans will lead to closures • Transport - WAST need to be part of the plans - Emergency transport struggling to meet current demand • Access – clarity required on where to go for what • Support for plans that ensure patients get the right expertise in the right place • Timescales for when consultation will start Feedback from Youth Forums from Bridgend, Neath Port Talbot and Swansea. children and What does health mean to you? young people’s Swansea: event • Being active• Healthy diet• Looking good• Mentally fit• Doctors/ Hospitals• Being alive • Emotionally aware• Physically aware• Stable• Being fit • Independency/ looking after yourself • Health – well being • Information to look after yourself • Healthy living • Asthma clinic• Healthy relationships• Support emotionally • Not being ill• Able staff to look after pregnant women Health issues in the Community Swansea: • Too much/too little sleep • Appropriate training around issues• Industrial jobs affect health • Treat the person not the condition• Smoking • Obesity • Focus – balance • Money – food – cooking• Passive smoking• Pollution • Lack of housing – issues in school – bullying – impact on the person – impact on the family• Lack of facilities• Budgeting • Lack of activities • Relationships – family relationships• Drugs/alcohol• Lack of support around drug use • Self belief • Mind stimulation• Lack of information• Education around learning – sexual health – university • Lack of respect What does health mean to you? Bridgend: • Mental, physical and social wellbeing • Absence of disease Health issues in the Community Bridgend: • Drugs• Mental health in young people• Teenage pregnancy • GP

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Doctor appointments• Outpatients – after care• Hospital appointments – not always successful • Physio waiting list• Postcode lottery • Care in community • Mental health for terminally ill (CMHT)• Complaints procedure• Dementia/ elderly care – training for staff• Eating disorders What does health mean to you? Neath Port Talbot: • Looking after yourself • Eating healthy and exercise • Taking care – limiting risks • Not ending up in hospital • Maintaining weight/ balanced diet • Preventative measures Health issues in the community Neath Port Talbot • Mental health – depression- Self harm- Eating disorders - Substance misuses- Stress- STI’s • Poverty • Follow- up care• Social life – family/friends• Lots of energy/ positivity/ outlook • Overweight/ underweight• Sleep deprivation• Accidents • Young people are not taken seriously by medics• Health services (limited provision)• Young people focused surgeries• Access/ SEN support• Diet/ exercise • Mentally active• Diseases i.e. cancer• Numerous problems including substance misuse, smoking, lack of confidence/ self esteem Ideal Children and Young Person’s services Bridgend: • All GP surgeries to be improved and have more for young people• Advice on anything- Alcohol- Drugs- Nutrition - Sexual health - Physio- Counsellors - Disability- Mental health - Self harm• Have a paramedic based at the GP surgery • For serious health issues NPT agree that travelling a further distance for treatment/care is acceptable. Swansea:• Look at a person’s whole life: listen and work together • One service – not separate for young people and adults – so there is a smoother transition of support • Use of wider resources – partners ( 1st responders, St Johns)• What would we like? - Outreach service, different places, centres. - Peer educators - Emotional support/counselling- Health promotion - One stop shop (health providers) for information – sign posters • Location – central vs. Discrete?• Good range of facilities – information on where people can access facilities. • Good network of partnerships• (All professionals represented in one building, one day per week – health substance misuse, midwifery, relationships, family centres, careers etc.) Neath Port Talbot: • Young person focused website/magazine- Mascot for younger children to promote health• Support staff - for injections• PHSE health classes• Information of teen pregnancies and drug use• Staff trained to help work with younger people – listen to young people’s needs• Councillors - Mental illness - Self harming - Peer councillors - Drug help• Young people surgeries – teen pregnancy focus clinics• Localise nurses – male/female clinics •

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Annual checkups

Any questions? “If there are a lack of doctors, why is it so hard to get onto a medicine course even if you are qualified?” “There should be more OAP homes that can provide care and offer the support needed – possibly create and estate where they can stay?” “Why don’t you use St John’s Ambulance for Port Talbot as we are fully trained volunteers that do it for free? We are also ETA trained - one under paramedics.” “I want to discuss the benefits to the elderly in home care and care plans.” “Why don’t we ban smoking and alcohol and use the money towards the NHS?” “Lower prices on healthy food” “Stop targeted funded projects and open it to all.” “Offer more grants around healthy living or aid to do so?” “Peer mentor group to provide sessions around issues.”

Long Term Carer concerns regarding transport. How will they get to different hospitals? Conditions Patient Will they need to rely on family? Will this put increased pressure on the Focus Group/ Ambulance Service?Anxiety in Bridgend area, goes beyond initial emergency Three Crosses situation? What happens with ongoing care once the initial care has been Stroke Club provided by A & E? Will they be transferred back to a local hospital? You can’t assume everyone can drive. The concern is enormous. It’s difficult to know the right place to go for care. My mother had a fall, and then later had a sudden loss of sight. We took her to Morriston. What about the logistics – how do you get there? I am a wheelchair user, if I was going to visit my mother, I would need someone to take me. It can be daunting to think of a relative 40 miles area. How do we know whether we are talking about specialised care or not? Distances can be daunting, especially for people with learning disabilities, to a lot of people. Anything over 10 miles can feel like a very long day. There can be a lack of staff when they get there, there can be long waits, and staff don’t want to listen to family/ patient/ carer as they feel they know better. This makes hospital a strenuous, concerning situation for these people. This can include admissions via blue light as people can still have to wait. Staffing problems can add to the problem. It may seem trivial, but it’s not for the person. Don’t mean to knock the service, appreciate services are specialised, but there are knock on effects other ways caused by blockages. It is difficult to know where to go and how serious things are. My wife had a bang to the head and was bleeding. We didn’t know where to take her, so I took her to Morriston. I was told in Morriston that we should have gone to Neath Port Talbot MIU. However, the announcement at Morriston said about MIUs in Singleton and Neath Port Talbot. I asked a nurse and she said Singleton was for illnesses only, for GP referrals and that it isn’t a MIU.As someone who moved to Wales, I can’t understand why

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doctors don’t want to come. Can the Welsh names of the Health Boards be off putting from a recruitment point of view? Should they have a little name underneath saying which areas they cover?Bilingualism in hospitals? AM said that information should be available in Welsh however it didn’t come across that way on the news. A & E image is that of drunken Friday and Saturday nights. There is a need to look at how disorderly behaviour is dealt with. I’m confused regarding the intentions around regionalisation of services. I have 5 consultants who work out of 3 hospitals and I would like to see them brought together. Will I be expected to see them as separate locations etc? I have 1 illness which affects different parts of the body.There is a carer who is involved with the Carers Centre. She has cancer, she cares for 4 children with disabilities, and she attends different hospitals across Cardiff and Vales and ABMU. As a lone parent she can struggle to attend different hospitals across one week.Transport issues – could be a problem anyway. If people can’t get there, they will use blue light as a first response which will block up A & E.I live in Pembrokeshire. Non- emergency patient transport was discussed a year ago; seems like you are behind. Consultant moved to Bridgend and I was transferred to another consultant at Neath Port Talbot. I am still waiting for an appointment to see the consultant in Neath Port Talbot. People should be seen on an annual basis and it’s not happening. Used to be referred to the COPD team who would come to the house, but they are too thin on the ground. Everyone at Breathe Easy is still waiting. The nurse team could refer to the GP or consultant. It is not happening and is way out of time. NHS staff member Q: How can individual clinicians influence the programme to retain services here rather than lose them to elsewhere?

Q: 1 or 2 regional centres of the 3. What is the process? Who is responsible and what are the timescales?

Q: Seems sensible to put 3 ‘mid glam’ hospitals together into 1 regional centre – is it? Therefore likely there will be 1 new Health Board?

Q: The document is already saying 1 is the likely outcome so is this really a consultation on 1 or 2?

Q: Will there be a sensible process between the HBs? Hywel Dda as an example, there are significant implications for Morriston on Llanelli but Hywel Dda are not part of the discussion.

Q: I understand the point of moving care to the community but will the finance follow? Also is there evidence that this is more cost effective and cheaper?

Q: Medical and non-medical staff in this hospital have excellent skills. If this isn’t a regional centre, where will they be? People will lose their skills.

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Q: If only 1 hospital of the 3 remaining as a regional centre and it is in Merthyr, what impact will this have on acute medicine? What will happen here and for this population if this service isn’t here?

Q: Will this affect Cardiac? Is there a view that we should have only one cardiac centre in Swansea or Cardiff and not maintain the 2. A: No, this is not part of this process. There is a lot of cardiac work going on at both the sites. However, this may be something considered in future, along with certain cancer sit specific issues. - Q: There are similar issues in N Wales. All choices could be unpopular and solutions are a bit of a fudge in N Wales. Will we do the same? What can we learn from Betsi Cadwaladr?

Q: There are queues of ambulances outside all emergency departments, having fewer of them with more resources does not solve this. Or make them more efficient and we have already stated that there is a ceiling of effectiveness at 100,000 attendances

NHS staff member Q: Is there still an opportunity to feed in to other services changes that affect other Health Boards e.g. Hywel Dda and the South Wales Programme? Q: Are the accessibility issues for patients being considered as part of the “Changing for the Better” process? Q: How much do we as a Health Board rely on the recruitment of overseas doctors and how does this affect our changes? Q: What is the programme doing to address the political issues of the proposed changes? Q: Some rural communities rely on the services provided by other Health Boards in their neighbouring communities, have these dependencies been factored in to our plans? NHS staff member Q: What input has there been with Social Care in keeping people out of hospital? Q: Following the situation in Neath Port Talbot what is the Health Board doing to secure Junior Doctor Training in hospitals such as Singleton Hospital? Q: How can we differentiate which patients should receive treatment in hospitals and which patients should receive treatment in the community? .Q: There is talk of building a “Super” hospital in Felindre. If this is the plan why are we expanding Morriston? Q: How can you explain to communities that you are improving services by moving their locally provided services elsewhere to other hospital?

NHS staff member Q: How much of our strategy will be affected by the views of local authorities? .Q: How will these changes be conveyed to the public? Q: How much support is there for the Princess of Wales Hospital being designated as a regional centre? Q: Given the current demand on our services, how are we going to reduce the number of emergency departments that we have and still cope with the demand? Q. We are currently downgrading maternity services in the Princess of Wales Hospital, instead of utilising the skills and services available. Why can’t we continue to offer these services? .Q: Is it possible that the current situation in the Princess of Wales Hospital could collapse before the completion of the consultation period? Q: The

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threat to the provision of healthcare services in England is massive. How do we prevent that from happening in Wales? Q: Will the consultants be moving across the Health Board sites? Q: What is the budget for these service changes? Q: Can we afford this new Model? Q: After the engagement period ends in December what will happen next? NHS staff member Q: I think I understand why we need to make changes, but the question is how do we do it? Q: How does ABMU’s Changing for the Better and the SWP fit together? Q: How will we be affected by Hywel Dda Health Board not being part of the SWP? Q: It is good to see that transport links are being looked at as part of the ongoing work but are we just transferring the financial burden to patients? Q: What about Local Authority involvement? Their involvement is particularly important when looking at care for elderly. NHS staff member 1. Junior Doctors felt there was a need for weekend working. Their experiences on working at weekends where investigations are needed is that they have to wait, possibly till Monday because of queue of work for on-call teams where as if a weekday would have had it as and when needed. 2. If more individuals are expected to work 24/7 then the impact this will have on employees needing to source and arrange Child Care support should be considered 3. We need to ensure that the public understand that they are not losing a local hospital 4. Another observation - the Royal Colleges support for major change NHS staff member Q: Will there be transport links to specialist centres provided by the Ambulance Trust and if so are they on board with these plans?

Q: What consideration is being given to the knock-on effect for specialities if they rely on working together?

Q: What happens to patients that are cared for in a less acute setting but have a range of things possibly wrong with them? NHS staff member Q: Won’t reducing the number of hospital beds increase waiting lists and cause problems at the sharp end? Q: If some services are moving into Morriston Hospital, and there is limited capacity, what services will move out? Q: What will be the impact on theatre capacity? Q: I am concerned that by taking beds away that this will impact on theatre capacity (elective surgical patients are often cancelled because there isn’t a bed for them). It is important to move services out before you take the beds away to limit the impact on theatre capacity. Q: I can see that in the long terms that it will work, but in the short term I can see it costing a lot of money – but we are always told that there is no money. Q: It appears that there will be plans to split complex and less complex surgery. But we all know that you can increase efficiency by combining complex and less complex cases. Q: We have the makings of being a major trauma centre - burns unit, heli pad and we now have a spinal service. We need an emergency spinal centre to be a trauma centre – I would be very interested in working with the Health Board to establish this. Q: What are the implications of the South Wales Programme on the Health Board’s relationship with other Health Boards?

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Q: Would surgeons have to move if the services were moved into this Health Board? Q: How much input will there be from the public and how much notice will you be taking? Member of public We feel strongly that specialist care should stay at POWH. Deaf people already have enough issues accessing basic care without having to fight other obstacles. Transport is a massive issue! How will emergency retrieval work for rural areas? If POWH loses specialist care, how long will it be before it loses other services and get downgraded like NPTH? There should be no movement of Outpatient services as they have to stay near key geographical locations. The air ambulance needs major investment if they are to cope with service change on this scale. Are there plans to invest of continue reliance on charitable funding? There needs to be more investment in ambulance cars and bikes in order to reach people quickly. You mention ‘pre-hospital’ care but will this be sufficient enough if you have a major accident and need a hospital quickly? Bridgend Carers’ Page 55 in booklet – for people to make a valid judgment on the SWP then Forum the public need the data from Prince Charles and Royal Glam on the table. These need to include population numbers, levels of deprivations etc. Transport is a major issue – need more investment in WAST. Who is the clinical lead for SWP? What is the decision making process for C4B/SWP and what role do ORS play? Recruitment issues are worrying, but also in primary care. The suggestion is shifting more to community, but there care is not there at the moment. People attend A+E due to lack of out of hours services in community. You need to establish community services before addressing community hospital beds. It’s not the number of people you can demonstrate work in the community it’s the responsiveness of the service that’s important. Care in people’s homes is a great idea, but it’s got to be great care!! MSK pain management is good but once you’ve completed it you automatically get asked if you want to be taken off waiting list. Serious issues with ASD pathway/lack of pathway. Member of public Patients referred to Gellinudd have complexed needs requiring the specialist skills of the multidisciplinary team. The patient’s length of stay may appear protracted but this is often caused by their needing time to make advances in recover from illness and also to allow comprehensive assessments to be completed. The outcomes from the assessments guide the decision process as to whether the patient can be safely managed at home of whether alternative placement is necessary. Frequently, these decisions are not only emotionally charged but also have great financial implications. Patients identified as requiring community support by either social services or community reablement teams require multi disciplinary team support to maintain their level of independence while they await their package of care. The level of community support is not adequate to supply the demand. Many elderly patients in early stages of recovery from illness require more support than could be offered in their own homes/ Failure to give recognition to this face will cause multiple readmissions. The skills of the staff at Gellinudd Hospital have developed to be able to offer a excellent standard of care to patients suffering from dementia. The focus on the

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patient’s individual needs and discharge planning give opportunity to patients to maximise their level of independence. Dementia patient’s find it difficult to cope with the disruption of an acute ward. Many of the patient’s relatives are elderly and would have great difficulty in travelling to other hospitals to visit regularly. NHS staff We are writing in response or engagement regarding the Change for the Better Programme commissioned by ABMU Health Board over the last year or so. As you are aware, three of us within the Practice have been involved in three work streams including Dr Judith Davies as Chair of the Children & Young people work stream. We like to think of ourselves as a proactive and fully engaged Practice who are not change averse and continually have an eye on service improvement and patient safety. The aims of Change for the Better are worthwhile and beyond criticism. We accept that in the current financial climate and with the pressures of lack of trainees, the current service model is unsustainable and indeed is unravelling before our eyes. The old certainties of quality of care and continuity of approach from our hospitals appears to be deteriorating rapidly, and urgent change is indeed needed. There are significant morale and work load problems in Primary and Community Care at the moment with Community Services thinly stretched and often at breaking point. This is against a backdrop of further imposed work from central Government with increasing financial tightening on Primary Care budgets. In addition to this, there has been long standing “creep” where Secondary Care workload has gradually been insidiously passed onto Primary Care but funding and resourcing for this work has not followed for the patient. We could highlight several examples of this over the past few years, and the Health Board does not have a good record for strengthening and resourcing Primary Care to deal with these pressures. We have our significant doubts that the disinvestment planned for hospital acute services across ABMU and the proposed strengthening of Community Care which we would all support will be adequately resourced, and therefore will be unsafe. As for hospital reconfiguration, we accept the premise that fewer acute centres will improve care, and may indeed improve through put and execution of planned care where unscheduled care is delivered from certain sites and not others. However, we have significant concerns as to the effect on the population of Bridgend if an acute care centre is not placed at the Princess of Wales Hospital. If such an acute centre were placed in Merthyr or Llantrisant, then Bridgend patients would have to travel much further to receive emergency care and we fear that lives will be lost and services may be eroded locally. This will inevitably lead to a degree of pressure being placed on Primary Care Services in the area and we feel that currently we are not in a position to sustain or influence this. Indeed, moving an acute centre away from Bridgend may be the straw that broke the camel’s back as far as General Practice in Birdgend is concerned. Despite out recent issues with the Princess of Wales Hospital which are mirrored by our concerns over other acute hospitals, we would wholeheartedly support that the Princess of Wales Hospital should be strongly considered as the perfect location for one of the acute care centres

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planned by the South Wales Programme. It has a good track record of meeting financial as well as clinical targets, and many of the Clinicians are first class. There would need to be significant investment in infrastructure and staffing, but this would need to happen wherever the centre were placed. In summary, the Change for the Better Programme is difficult to argue with and change indeed has to come. However, if we can influence the nature of that chance to include an acute care centre in the Bridgend locality, then we would wholeheartedly support that. All of your aims in Change for the Better involve disinvestment in Secondary Care services which is inevitable. We would that this opportunity to remind you that proper planning, resourcing and execution of Community Services should not be an after though, and should be a vital component here. If you do not pump’prime and invest in your Community Services the whole project will fail and safety for our patients will irrevocably compromised. Local councillor Potential Reduction/Closure of A&E Department. With reference the above, I have inundated with responses from individuals and groups within my ward, with specific regard to the possible reduction of services at the Accident & Emergency Unit, Princess of Wales Hospital, Bridgend. The effect of any reduction/closure of this threatened area has potentially calamitous ramifications for the elderly, infirm, partially-sighted and disabled, as well as infants and children, whilst not forgetting all those in between. Pontycymer is one of four wards within the Garw Valley which falls under the Ogmore Constituency, the Garw Valley itself being an old mining valley which, in its heyday, boasted of five collieries, today there are none and very little employment opportunity in the valley itself. What we have inherited is a large percentage of former miners and their nuclear and extended families, so many of these families having a variety of respiratory problems. Others being the victims of accidents as a legacy of their time spent in the mining industry. I am aware, also, that many of the elderly residents do not have their own transport, accessing public transport, with great difficulty or unable to access it at all. The reduction/closure of A&E would be catastrophic for this group in terms of travelling times. The ambulance cover provided is working under enormous pressure; certainly not achieving statutory response times. In the Garw Valley, a First Responders team has recently been set up and is now operating with the small team they have recruited, but the service they can provide is limited, awaiting the arrival of paramedic/ambulance in the majority of cases. Recently, the desperate shortage of ambulances and crew resulted in an ambulance being dispatched from Fishguard to an emergency call in the valley. This, in itself, was a desperate measure, imagine how much more desperate things could get should the decision be made to close the A&E Department at the Prince of Wales Hospital, Bridgend. Finally, I would appeal to you on behalf of all present and prospective patients in the Garw Valley that may need to access Accident and Emergency treatment to consider the myriad of practical and emotional problems, coupled with their inherent independent attitudes that prevent them from attending A&E departments outside our area, with all compassion to reconsider this unwise and totally unnecessary decision.

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Member of public I am a member of Swansea self-help Group and a committee member of the new Bridgend group. I have considerable, personal experience of Bridgend A& E, and have nothing but praise for them. I cannot understand the idea of travelling 15 or 20 or more miles in an emergency, would be advisable. Perhaps a hidden pathway, agenda, certainly seriously ill patients would be at great risk and possibly not reach their destination alive. Imagine, two elderly patients who do make it will be miles from home, and visiting would be very difficult, if not impossible for some people. The result would be lonely, solitary, frightened patients, certainly not the way to treat our fellow citizens when they are ill, and possibly adding their names to “Pathway”. Garw Valley I write on behalf of the Garw Valley Community Counil to express their grave Community concerns regarding the planned restructuring of the Princess of Wales Council Hospital, Bridgend. There has been much speculation and rumours in the press and word of mouth regarding the downgrading of the Accident & Emergency Department and the closure of the Maternity Ward. The Councillors are deeply opposed to any changes that are planned which will affect the level of care being offered to patients. I should be grateful if you would respond to this letter to inform the Councillors of the Garw Valley Community Council of the future plans that Abertawe Bro Morgannwg Health Board has for the hospital. This will ensure that the Councillors know the facts about the proposals rather than hearsay. I should also be grateful if you will keep me informed of the consultation process. Member of public Issues Raised – A&E/ Trauma The Princess of Wales A&E is overused it is overflowing and police are always on duty, people seem to use the service like a GP Practice. There is a need to signpost people to go to the right place for treatment. There are ambulance problems they are delayed at A&E. People call ambulance services inappropriately . I have been impressed by the ambulance paramedics and the detail that they go into when managing responses. What about Barry Minor Injuries Unit? Barry Minor Injuries Unit does not provide Accident and Emergency services. Are boundaries going to be changed because of the South Wales Programme? All Health Boards will work across organisational boundaries. The distance and access to the Health are an issue. Is the Ambulance service aware of the need to go to the health for strokes? This is a good example, sometimes there is a need to bypass local hospitals to get to a hospital that already provides a specialist service and the Ambulance Service are aware of which hospitals currently provide specialist services. The decision is made at the scene by the Doctor/paramedic and the person is then take to the appropriate A&E. For example, the Burns Unit at Morriston in Swansea which is the specialist service for Burns in South Wales. Will the issues we raise be included when you go to consultation? We will take all issues into consideration when consulting on final proposals. What about the ambulance service and the cost to changing how they currently operate. No decisions have been made but the Welsh Ambulance Service will be involved at all stages if there are changes. Will the Princess of Wales become a specialist centre? No decisions are being made at this engagement phase. If the Princess of Wales is not to

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become a specialist service will they still have A&E services? No decisions have been made, but all hospitals would have come level of A&E service provision. General Worried about transport and access issues if we have to go to UHW – parking is a big enough problem now without further people accessing the site. All issues will be fed back prior to public consultation. Cwm Taf Health Board are also receiving feedback on similar issues: What effect will change will have on the Ambulance Service and public transport. There was understanding from the public that clinician skills cannot be maintained with such small numbers in some hospitals. Communication to the public is a major issue and will need to be addressed by all Health Boards if there is to be change. Why don’t we just find more doctors? Not an issue with funding – there are over 100 training places unfilled across Wales currently. Is there an efficiency spin off? Probably, but only in the longer term. This is actually likely to cost more in the short term. Communication over these events not good. 5.30 in the evening is not the best time – perhaps better to hold it later in the evening. Key Themes Transport - better transfer between sites -involvement of WAST ; Access – need local access to all specialist services – how hospitals on the Cardiff and Vale boundaries will be affected by the changes and consequent effect for people currently using them – communication with the public where to go for what – travel for people for poorer areas. Timescales for when more detail will become available – need to ensure effective collaboration with partner NHS organisations during full consultation. Communication with public about how to use services appropriately. Member of public A. Recently Morriston A&E was closed for a period of time, why? The UHW in Cardiff A&E was closed due to that man in a white van mowing into women and children causing a fatality and serious injuries. What would have happened if a major accident had occurred? Eg. 1. Plane/light aircraft/ glides crash 2. Riding accident resulting in a head injury, broken bones etc 3. Motorway accident, involving multiple vehicles, with persons requiring immediate attention 4. Boating accident 5. Industrial or farming accident resulting in the loss of a limb, severe lacerations, severed artery, burns etc 6. A building collapsing eg, a school resulting in extensive casualties with numerous injuries requiring attention This list is probably endless. Without an A&E in Bridgend how are these people going to receive immediate treatment. Ambulances caught up in traffic, and on motorways at peak times will be up, we haven’t got enough Air Ambulances – No funds to keep them in the sky anyway. B. Children and infants require immediate attention when they are ill/ They deteriorate rapidly as we all know. If the necessary help is not available to them quickly they will DIE. We all know how serious meningitis is, but even asthma,

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especially if not treated immediately. C. Strokes need to be diagnosed + treated as soon as possible. There is no special unit for these patients in Bridgend but the treatment can be started + the patient warded. D. Heart attacks – yes they need a special unit with trained staff, but with everything else immediate help is essential. Diagnosis, pain control, bloods, ECG, xrays all need to be done. Blood pressure + tachycardia, treated a patient reassured ASAP. This can all be attended to in a local A&E in Bridgend and the patient warded until a bed in available in a specialist cardiac unit and the patient can then be transferred for suitable treatment eg, a stent or coronary bypass surgery. Recently I travelled daily to Morriston Hospital for 4 weeks when my husband was a patient in the Coronary unit, prior to his operation and afterwards. He was worried about his pending surgery and concerned about me visiting daily. His recovery was uneventful and he’s now fit and well, but the daily travelling was quit3e exhausting and I’m under 70 years old. E. The other thing that concerns me is getting patients out of the valleys for treatment in Morriston or Cardiff, when the snow is think on the ground and black ice is everywhere. Ambulances with tyre chairs on have difficulties getting around the roads and patients from their valley homes to Bridgend Hospital although a further journey to another hospital. F. The elderly are once again at risk, as falling resulting in fractures require immediate attention as they become confuse and disorientated very quickly. How are their elderly spouses and family expected to travel to distant hospitals? Morrisotn would require 3 different buses at least, to get there and another 3 to get home. The times are limited, which would give added stress to the person travelling which could result in the need to hospitalise him or her due to exhaustion. Not everyone has their own transport eg a car, and it would be quite unsafe to expect more elderly people to be travelling several times a day on our motorways to visit loved ones causing more congestion on our roads and further delays and accident. I could go on and on so I’ll stop there. To summarise I do believe changes have to be made and more specialised units of excellence are needed but not at the expense of our Bridgend Hospital and its A&E dept. As it’s catchment area is quite extensive from Cowbridge to Port Talbot including the Afon, Garw and Llynfi Valleys. Petition 70 signatures against the planned closure of POW A&E

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