Healthcare in North Wales is Changing
Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services
Assessing the Evidence:
Executive Summary
Opinion Research Services January 2013
Opinion Research Services | The Strand • Swansea • SA1 1AF | 01792 535300 | www.ors.org.uk | [email protected]
Healthcare in North Wales is Changing
Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services
Assessing the Evidence: Executive Summary by Opinion Research Services
Opinion Research Services
The Strand Swansea SA1 1AF 01792 535300 | www.ors.org.uk | [email protected]
As with all our studies, findings from this survey are subject to Opinion Research Services’ Standard Terms and Conditions of Contract.
Any press release or publication of the findings of this survey requires the advance approval of ORS. Such approval will only be refused on the grounds of inaccuracy or misrepresentation
© Copyright January 2013
Opinion Research Services | The Strand • Swansea • SA1 1AF | 01792 535300 | www.ors.org.uk | [email protected]
Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Contents
Executive Summary and Conclusions ...... 6 Public Consultation ...... 6 Need for Interpretation ...... 7 Accountability...... 8 Executive Summary and Full Report ...... 8 Key findings: Healthcare Services Where You Live ...... 9 Healthcare Priorities ...... 9 Hospitals in our Communities ...... 9 Hospital ‘Hubs’ ...... 10 Minor Injuries Services ...... 10 X-Ray Services ...... 11 Local Services in Blaenau Ffestiniog ...... 12 Local Services in North Denbighshire - Rhyl and Prestatyn ...... 13 Local Services in Llangollen ...... 14 Local Services in Flint ...... 15 Older People’s Mental Health ...... 16 Neonatal Intensive Care ...... 17 Vascular Services ...... 19 Submissions ...... 20 Introduction ...... 20 Selected Abstracts ...... 20 Petitions...... 25 Towards Conclusions ...... 26 Introduction ...... 26 Reviewing the Evidence ...... 26 Overall Conclusions ...... 27 Introduction ...... 27 Healthcare Services Where You Live – the principles ...... 27 Healthcare Services Where You Live – the specific proposals ...... 27 Older People’s Mental Health ...... 28 Neonatal Intensive Care ...... 28 Vascular Services ...... 28 Scope of BCUHB’s Review ...... 29 The Board’s Dilemmas ...... 29
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
The ORS Project Team
Project design, management Fieldwork management and reporting Kirsty Millbank Dale Hall Leanne Hurlow Jonathan Lee Kester Holmes Data analysis Kelly Lock Richard Harris David Harrison Joe Marchant Claire Thomas Hugo Marchant Hannah Champion Anna Shakeshaft Kathryn Middleton
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Acknowledgements
Opinion Research Services (ORS) is pleased to have worked with Betsi Cadwaladr University Health Board (BCUHB) on the important consultation regarding the future of health services in North Wales, as reported here.
We hope this report of the consultations will contribute to the Health Board’s thinking; and we hope the ORS contribution is been constructive and instrumental in ensuring that the views of the people of North Wales are captured and considered as part of the overall review process.
We are grateful to BCUHB’s managers for their helpful and positive liaison throughout the detailed preparation and management of the consultation. ORS’ status as an independent social research organisation was respected throughout.
We also thank the members of the public who took part in the consultation by a wide range of routes; participants shared their views and took a full part in the process.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Executive Summary and Conclusions
Public Consultation
1. ‘Together for Health’ was published by the Minister for Health and Social Services in November 2011 to offer a five-year vision in the context of the challenges facing the health service in Wales. The document declares that Health Boards need to change to provide the very best quality of services for their population in the future. In this context, Betsi Cadwaladr University Health Board (BCUHB) embarked on a major review of its services to clarify both general principles and particular proposals for changes to services. The formal consultation on the proposals ran from 20th August to 28th October, and included an extensive programme of engagement with staff, stakeholders and the public. 2. BCUHB conducted a wide range of consultation activities with staff, stakeholders and the public and it has taken all of them into account and responded to many contacts from interested parties. This report concentrates on some particularly important elements of the consultation process in order to provide an independent report and interpretation of the outcomes. The elements included in this report are:
ORS activities Open Consultation Questionnaire (both on-line and paper versions) – widely distributed by BCUHB and with responses from 1,899 residents and organisations Household Survey of Residents (by post) – with responses from 683 (14%) of the 5,000 randomly selected households Eight focus groups with members of the public
BCUHB activity 48 public meetings over 16 days (three sessions per day) – attended by a total of more than 1,300 people
Other activities Written submissions from stakeholders Petitions. 3. As a research practice with wide-ranging experience of controversial statutory consultations across the UK, ORS is able to certify that the formal consultation processes undertaken by BCUHB has been both intensive and extensive. Overall, there is no doubt that the exercise has been conscientious, competent and comprehensive in eliciting the opinions of stakeholders and many members of the public. 4. In the submissions and elsewhere, there has been some understandable criticism of the way in which the 48 public meeting sessions were organised; but BCUHB took independent advice on the conduct of these meetings from the Consultation Institute and the decision to hold 48 separate sessions with a team of senior managers present at each was certainly scrupulous – so those who believe there were shortcomings should take heart from the conscientiousness and scale of the of consultation programme taken as a whole.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Need for Interpretation 5. Proper interpretation of BCUHB’s consultation programme should distinguish the findings of the various elements – for example, to compare the results of the Open Questionnaire with the more representative random sample Household Survey, while also comparing the quantitative outcomes generally with the qualitative deliberative focus groups, the public meetings, the submissions and the petitions. 6. The Open Questionnaire elicited nearly three times as many responses (1,899) as the Household Survey (683) – but, as an important and accessible consultation route open to everyone, it was distributed unsystematically and in many cases circulated at public meetings and other events, and by groups. Therefore, it is unsurprising, but important, that the Open Questionnaire achieved responses that are less representative of Betsi Cadwaladr’s population than the Household Survey. Because the former’s larger size does not compensate for the fact that its respondent profile is an imperfect reflection of the Betsi Cadwaladr population, the results of the Open Questionnaire have to be interpreted carefully and compared throughout with the Household Survey findings. 7. For example, in the Open Questionnaire data, Denbighshire is very over-represented due to its high response rate (42% of responses but only 14% of the Betsi Cadwaladr population) whereas Wrexham is under-represented (5% of the responses compared with its 19% proportion of the total population). Similarly, older people (aged 55 to 74) are highly over-represented compared with those aged under-35 who are very under-represented. 8. Crucially, this does not mean that the Open Questionnaire findings should be discounted: they are analysed in detail in this report and should definitely be taken into account as a demonstration of the strength of feeling of residents who were motivated to put forward their concerns. For example, a Prestatyn-based pressure group successfully co-ordinated Open Questionnaire responses from 418 residents with the same views – amounting to more than a fifth (22%) of the 1,899 responses from the whole of Betsi Cadwaladr! As a consequence, though, the Open Questionnaire results cannot plausibly be interpreted as representative of the views of the total population. 9. Of course, neither the Open Questionnaire nor the Household Survey achieved fully random samples; but the point of the Household Survey was to contact the general population, and questionnaires went to 5,000 randomly selected households across the whole of the BCUHB area and got a ‘reasonable’ 14% response. In contrast to the Open Questionnaire, the achieved Household Survey sample, though smaller, is broadly representative of the population overall and within each county. In other words, it is a more plausible basis for considering the likely views of the general population; and given the need for BCUHB to consider the interests of the whole of the Betsi Cadwaladr area, the representativeness of the Household Survey means its findings should carry more weight than the less representative Open Questionnaire results. 10. In any case, influencing public policy through consultation is not simply a ‘numbers game’ or ‘popularity contest’ in which the loudest voices or the greatest numbers automatically win the argument! Instead, consultation is to inform authorities of issues or arguments, implications they might have overlooked; or to contribute to the re-evaluation of matters already known; or to reassess priorities and principles critically. However popular proposals might be, that does not itself mean they are feasible, safe, sustainable, reasonable and value-for-money; and unpopularity does not mean the reverse. The allegedly Confucian statement, When all applaud: verify; when all condemn: verify! summarises the approach we should take when confronted by the big battalions of numbers.
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11. Of course, the responses to the Open Questionnaire reflect the strength of feeling of many people in Denbighshire (particularly Prestatyn) – which is democracy in action; but the BCUHB has to make public policy choices on the basis of the safety, quality, sustainability and accessibility of services across the whole of Betsi Cadwaladr. 12. All of this means that interpreting the overall meaning of the consultation outcomes is neither straightforward nor just ‘numerical’, for the different consultation methods have not only to be respected and recognised, but also evaluated or assessed: they cannot be simply summated. In this context, ORS attaches particular weight to findings that are representative of the general population (the Household survey and focus groups) and/or deliberative (based upon thoughtful reflective discussion in non-emotive forums, focus groups or public meetings) and/or based on professional expertise (submissions from professional bodies, staff and other informed groups); but, of course, all the other consultation elements are important and should be recognised and taken into account as well. 13. While ORS makes the above assessments, there is no single ‘right interpretation’ of all the consultation elements, for professional and political judgement is needed. Ultimately, an overall interpretation of the consultation will depend upon the executive and non-executive members of the Health Board itself: they will consider all elements and determine which seem the most telling – above all, by considering the relative merits of the various opinions as the basis for public policy.
Accountability 14. The Board consults the public and stakeholders because it is accountable – but, in this context, accountability means giving an account of its ideas and then taking into account public and stakeholder views: it does not mean that the opinions of the largest majority should automatically decide public policy. After all, consultations are not referenda: they should inform, but not displace, professional and political judgements, which (above all) should assess the cogency of the views expressed.
Executive Summary and Full Report 15. Although the submissions are dealt with separately (due to their length, complexity and scope), in this executive summary, as far as possible, the outcomes of consultations are integrated under headings for the main proposals; but in the full report the results of each consultation method are reported in separate chapters. 16. We trust that this executive summary is a sound guide to the consultation outcomes and how they might be interpreted, but readers are encouraged to read the full document for more detailed insights. Whereas this summary travels towards overall conclusions fairly quickly, the full report traverses public, professional and stakeholder opinions and feelings in considerable detail to achieve a more comprehensive understanding – and it is the journey, as well as the destination, that will matter to those wishing to understand the assumptions, arguments, conclusions and feelings about current and future healthcare services in Betsi Cadwaladr. We trust that both the summary and full reports will be helpful to all concerned.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Key findings: Healthcare Services Where You Live
Healthcare Priorities
Open Questionnaire and Household Survey In the Household Survey in relation to the three key priorities for healthcare – targeted prevention, enhanced care at home and moving care from acute hospitals to the community – the absolute majorities in favour were respectively 86%, 80% and 56%. The only priority with which more than a quarter disagreed was moving care from hospitals into the community (27% disagreed, but more than twice as many agreed). In the Open Questionnaire the majorities in favour of these key priorities were only very slightly smaller (82%, 67% and 55% respectively). More than seven in ten of the organisations completing the Open Questionnaire also agreed with the three priorities.
Public Focus Groups There was general approval for the principle of providing ‘care closer to home’ – but many worried about its deliverability in practice. There was also general support for moving services out of hospitals and into the community, providing community services are properly resourced. The main concerns were: the need for greatly increased resources to ensure it is done properly (and the costs associated with this); that some frail older people may be better cared for in hospital; that it may lead to isolation insofar as it is promoting people to stay in their houses and never come out; and that it may result in a greater burden on patients’ families and friends.
Hospitals in our Communities
Open Questionnaire and Household Survey – Providing healthcare services at fewer hospitals In the Household Survey an absolute majority (54%) agreed with the principle that resources should be focused into fewer hospitals, while 38% disagreed. There was more disagreement, though, in the Open Questionnaire – with just under two-thirds disagreeing (64%) strongly and only three in ten agreeing. Analysis showed that, if (as a result of all the proposals) respondents would no longer be able to use their local hospital, then their disagreement increased in direct proportion to their additional distance of travel to the nearest hub. In the Open Questionnaire more than half of the organisations responding agreed with the principle of providing reliable healthcare at fewer hospitals; more than two fifths disagreed.
Public Meetings - Providing healthcare services at fewer hospitals Although people recognised the need to address existing service pressures, many concerns were expressed about the transport costs to patients in accessing health services in fewer locations across North Wales.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Open Questionnaire and Household Survey – Same healthcare services within 40 minutes In the Household Survey there was overwhelming support (80%) for the principle that the same healthcare services should be available within 40 minutes’ drive for as many people as possible, whereas only one in six disagreed with this approach. Support was less pronounced in the Open Questionnaire – but there was still absolute majority support (57%, with 37% disagreeing).
Hospital ‘Hubs’
Open Questionnaire and Household Survey In the Household Survey three quarters (74%) agreed that the ten hospitals proposed by BCUHB are the most appropriate hospitals as ‘hubs’, while only 17% disagreed. However, in the Open Questionnaire opinion was divided: 43% agreed and 49% disagreed. Analysis showed that, if (as a result of all the proposals) respondents would no longer be able to use their local hospital, then their disagreement increased in proportion to their additional distance of travel to the nearest hub. Disagreement was more pronounced for those who would have to travel an extra 10km or more. Organisations completing the Open Questionnaire were divided in their opinions on the ten ‘hubs’: 48% agreed and 42% disagreed.
Public Meetings Hospital hubs were fiercely debated at most of the public meetings, where the main queries, issues and concerns raised were: Earlier reviews and alleged broken promises by BCUHB, resulting in a lack of confidence in current proposals The chosen locations (with various alternatives proposed) – and whether projected population changes have been accounted for in making these choices The potentially high costs involved in accessing ‘hub’ services, which may mean more pressure on local GPs BCUHB’s plans for redundant assets no longer required when ‘hubs’ are developed Whether BCUHB has undertaken a Health and Equalities Impact Assessment on the ‘hub’ proposal.
Minor Injuries Services
Open Questionnaire and Household Survey In the Household Survey absolute majorities agreed with the proposals for Minor Injuries Services: 56% agreed with the principle that Minor Injuries Services should be provided at fewer hospitals and 54% agreed with the Health Board’s specific proposals. Around a third (35% and 33% respectively) disagreed with the principle and with the proposals. In the Open Questionnaire there was more disagreement with the proposals for Minor Injuries Services, with six in ten (61%, (44% strongly)) disagreeing with both the principle and proposals.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Further analysis showed that if (as a result of all the proposals) respondents would no longer be able to use their local hospital, then their disagreement increased in direct proportion to their additional distance of travel to the nearest hub. In the Open Questionnaire the organisations responding were divided in their opinions on the proposals for Minor Injuries Services.
Public Focus Groups At Chirk, a majority of more than two-to-one agreed that centralising minor injuries services is reasonable in principle – but the group also opposed the closure of the Minor Injuries Unit (MIU) at Chirk Community Hospital by the same majority, mainly because people would have to travel further to Wrexham. The proposed closure of the MIU at Colwyn Bay was not controversial for the Conwy group. In fact, many were not aware of its existence and, of those who were, most tend to use Llandudno due to the greater range of services there. There was, however, some concern about the distance to Llandudno or Glan Clwyd for those without their own transport, and the potential extra demand on ‘hub’ hospitals – especially Glan Clwyd. At Ruthin, it was said that the MIU is not well-used because local people are unaware it exists. Indeed, there was considerable concern about the impact of its proposed closure on demand at Ysbyty Glan Clwyd – and it was suggested that better promotion of the Unit would increase usage and lessen demand on the acute hospital. If the MIU is closed, participants strongly desired the provision of routine appointments (e.g. dressing changes) locally.
Public Meetings The issue of Minor Injuries Services was keenly debated in many meetings, where the main areas of discussion were: BCUHB’s decision-making process, particularly with regard to how decisions on where to locate the hospital ‘hubs’ were made The need for more detail on current and projected service usage – as well as on the cost savings from individual (local closures) and collective changes (full service review) Transport and travel difficulties (particularly using public transport in rural North Wales) The implications of the proposed changes for GP services.
X-Ray Services
Open Questionnaire and Household Survey In the Household Survey absolute majorities agreed with the principle of X-Ray services being concentrated in fewer places (56%) and with the specific proposals for X-Ray services (55%). Around a third disagreed with the principle (36%) and the proposals (30%). However, in the Open Questionnaire the majority of respondents opposed both the principle (53% (37% strongly)) and the proposals (54% (36% strongly)) for X-Ray services. In the Open Questionnaire the majority of the organisations (52%) responding agreed with the principle of concentrating X-Ray services in fewer places, whereas their opinion was divided on the proposals.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Public Focus Groups Mold residents were greatly concerned about the proposed closure of the X-Ray department (and indeed the MIU) at Mold Community Hospital. These were considered to be well-used services that are very much needed by Mold’s growing population, as well as the large number of schools in the area that rely on them. The Mold Community Hospital League of Friends has apparently offered to buy a new X-Ray machine in a bid to retain the service – an offer that it was considered prudent for BCUHB to accept.
Public Meetings There was little or no discussion about BCUHB’s proposals for X-Ray services at most meetings, but there was debate at Tywyn, Ruthin, Pwllheli, Caernarfon and Mold. The main areas of discussion were: BCUHB’s decision-making process, particularly with regard to how decisions to focus X-Ray services at chosen ‘hubs’ were made Whether people’s views will influence decisions on ‘hub’ locations The need for more information on the evidence (financial and statistical) that led to BCUHB’s proposals The cost/benefit of various service location options Travel costs for patients and the reliability of public transport Whether staff recruitment issues influenced the location of the proposed ‘hubs’ The risk of closure for remaining services after the ‘hubs’ are developed.
Local Services in Blaenau Ffestiniog
Open Questionnaire and Household Survey In the Household Survey absolute majorities supported the proposals for a new facility (58%) and the expansion of primary care services (58%) at Ffestiniog Memorial Hospital. However, there was less support for the proposal to remove community inpatient beds from Ffestiniog to Ysbyty Alltwen, with only three in ten (29%) agreeing with this proposal. Most residents (43%) neither agreed nor disagreed with removing beds. In the Open Questionnaire there was support for developing a new facility (45% agreed and 28% disagreed) and expanding primary care services (57% agreed and 14% disagreed) at Ffestiniog. However, there was opposition to the proposal to move community inpatient beds (49% disagreed and 23% agreed). Analysis showed that opposition levels to all proposals were higher from respondents living within 10km of Ffestiniog Memorial Hospital, particularly with regard to the proposal to relocate community inpatient beds. In the Open Questionnaire the majority of organisations agreed with the proposals to develop a new facility and expand primary care services at Ffestiniog; however, more than half disagreed with the proposal to move community inpatient beds.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Public Focus Groups There was a great deal of concern at the Gwynedd group about the loss of inpatient beds from Blaenau Ffestiniog Memorial Hospital (and Dolgellau Community Hospital), mainly due to the reduction in local respite and convalescent services and the potential for increased pressure on general wards and patients’ families. There was significant support for retaining Blaenau Ffestiniog Memorial Hospital where, it was thought, excellent care is provide in an adequate setting. People’s main concern was the distance and journey time to Ysbyty Gwynedd and Ysbyty Alltwen – but they were also worried (a concern that has apparently been fuelled by the local press) that the hospital will be used for drug rehabilitation in future. The development of a full A&E service at Alltwen Hospital was strongly advocated.
Public Meetings The public meetings at Blaenau Ffestiniog were preceded by a protest meeting of circa 150 protestors. In the meetings, participants expressed concern about the consultation process and how seriously it will be considered – and worried that their questions and responses to BCUHB had received no response. They also sought reassurance that the petition gathered in the area would be taken into account.
Local Services in North Denbighshire - Rhyl and Prestatyn
Open Questionnaire and Household Survey In the Household Survey an absolute majority (62%) agreed with the proposal to develop a new hospital on the Royal Alexandra Hospital site to replace other health service facilities in the area. Further analysis showed that the majority of residents supported the proposal regardless of their distance from Royal Alexandra Hospital. In the Open Questionnaire there was more opposition to the proposal - with more than half disagreeing (55%). However, it should be noted that responses from a Prestatyn pressure group substantially influenced the overall balance of opinion in the Open Questionnaire – partly because all of them strongly disagreed with the proposal, compared with only a third of other respondents who disagreed. Further analysis of the Open Questionnaire showed that opposition was highest amongst respondents living within 5km of Prestatyn Community Hospital, and within 10km of Royal Alexandra Hospital. In other words, the opposition is intensely local on this issue. In the Open Questionnaire almost two thirds (65%) of organisations supported the proposal to develop a new hospital on the Royal Alexandra site.
Public Focus Groups The Royal Alexandra Hospital (Rhyl) and Prestatyn Community Hospital were typically considered expensive to run and unsuitable as modern healthcare facilities. The Denbighshire focus group generally welcomed the proposed new integrated facility, with the strong caveat that it is in place prior to the removal of existing facilities. There was also some interest in how the Royal Alexandra building will be redeveloped given that it is Grade II listed and thus subject to restrictions.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Public Meetings The most significant concerns at the public meetings related to Prestatyn Community Hospital. People sought reassurance on the future use of the building (and questioned whether BCUHB will dispose of it) – and were concerned that current services will cease before new services are launched. There were also concerns about the risks to local older people with mental health problems as a result of the proposals.
Local Services in Llangollen
Open Questionnaire and Household Survey In the Household Survey there was absolute majority (57%) agreement with the proposal for an extended primary care centre in Llangollen. However, in the same survey, opinion was broadly divided on moving community inpatient beds from Llangollen Community Hospital to local care homes or Chirk Community Hospital – with 35% agreeing, 35% neither agreeing nor disagreeing and 29% disagreeing. In the Open Questionnaire the majority (52%) in favour of an extended primary care centre in Llangollen was only slightly smaller than in the Household Survey. However, unlike the Household Survey, a majority (50%) disagreed with removing community inpatient beds. Further analysis showed that those who live within 10km of Llangollen Community Hospital were much more likely than average to disagree with removing beds. In the Open Questionnaire more than two thirds of organisations responding agreed with the proposal for an extended primary care centre; but more than three fifths disagreed with removing community inpatient beds.
Public Focus Groups There was little concern in the Wrexham Focus Group (held in Chirk) about the proposed changes to Llangollen Community Hospital - even among the participants from Llangollen itself. The group was unanimous that it is reasonable on the basis of the evidence, and commented that the hospital is an old, unsuitable building and that some services (such as the MIU) are unavailable much of the time.
Public Meetings The proposed closure of Llangollen Community Hospital was discussed at both Llangollen and Wrexham. There were more significant concerns at the former – particularly in relation to the loss of inpatient beds. People’s other main concerns were: Travel distances, the cost of transport and overall access to other hospitals The potential for current services to cease before new services are in place Whether the proposed new primary care centre (and local GPs) will be able to cope with future demand increases Whether funding has been secured for the new service.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Local Services in Flint
Open Questionnaire and Household Survey In the Household Survey there was absolute majority (62%) agreement with the proposal for an extended primary care centre in Flint. However, in the same survey, there was a broad division in opinion on the proposal to move community inpatient beds from Flint Community Hospital to Holywell Community Hospital – with 36% agreeing, 25% disagreeing and many residents (40%) neither agreeing nor disagreeing. In the Open Questionnaire a similar majority (57%) were also in favour of an extended primary care centre in Flint; but nearly half (48%) opposed moving community inpatient beds. Further analysis in both surveys showed that those who live within 10km of Flint Community Hospital were much more likely than average to disagree with both proposals, but moreso with moving community inpatient beds. In the Open Questionnaire the organisations responding were broadly divided in their opinions on an extended primary care centre in Flint. However, more than half disagreed with moving community inpatient beds.
Public Focus Groups Three public focus groups were held in Flint due to the strength of feeling locally about the proposed closure of Flint Community Hospital. The first group discussed the full range of BCUHB proposals and the remaining two focused only on those for Flint. All participants across the three groups were initially strongly against the proposal for the following reasons: It is a community resource that has ‘always been there and always should be’ It provides well-used, efficient, flexible services The distance to Hollywell is too great (and the hospital is not easily accessible via public transport) Flint’s large and expanding population warrants a community hospital The potential for increased demand on other hospitals and the Ambulance Service An emotional attachment to the hospital due to personal experience or the experience of loved ones It allows terminally ill people to die close to home (and family and friends). After discussion, while still inherently opposed to the closure of their local hospital, participants at two of the three groups softened their stance somewhat after considering the proposed new Primary Care Resource Centre (which some people were wholly unaware of). However, they wished to reserve their judgement until they knew what will be in this new centre, when it will be built and where exactly it will be – and also felt they could only accept it if the community hospital remains open until it is complete and that it provides Minor Injuries and Phlebotomy services. Some people in these two groups did not consider it reasonable that the town should have to wait until 2016 for the new facility – and would thus prefer to see BCUHB developing the existing hospital to house the Resource Centre. Participants in the third group remained wholly opposed to the closure of Flint Community Hospital and the development of a new Primary Care Resource Centre at the end of the session.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Executive Summary January 2013
Public Meetings There was considerable opposition at Flint to the proposed closure of the town’s Community Hospital (and reference was made to the ongoing campaign to save it). In relation to the proposed new Primary Care Resource Centre, people at Flint were mainly concerned about: Whether it will adequately serve the community Whether the predicted costs for its development are accurate Whether the required funding is sufficient and secure.
Older People’s Mental Health
Open Questionnaire and Household Survey
Older People’s Mental Health In the Household Survey there was overwhelming support (91%) for the proposals for older people’s mental health. Further analysis showed support for the proposals regardless of which District General Hospital residents lived nearest to. In the Open Questionnaire the majority (64%) also agreed with these proposals, though more than a quarter (27%) disagreed. In the Open Questionnaire more than three quarters of the organisations responding agreed with the proposals for older people’s mental health.
Additional Proposals for Conwy and Denbighshire In the Household Survey an absolute majority (64%) agreed with the additional proposals for Conwy and Denbighshire. However, in the Open questionnaire there was majority opposition to the additional proposals for Conwy and Denbighshire: just over a third (35%) agreed with the proposals, whereas one in two (47%) disagreed. In the Open Questionnaire almost half of the organisations responding agreed with the additional proposals for Conwy and Denbighshire.
Additional Proposals for Gwynedd and Anglesey In the Household Survey there was a balance in favour of the additional proposals for Gwynedd and Anglesey – 40% agreed and 30% disagreed. However, in the Open Questionnaire the majority (52%) opposed the proposals. In the Open Questionnaire more than three fifths of the organisations disagreed with the proposals; almost half strongly disagreed.
Public Focus Groups Although there was a great deal of support for the proposal to provide more community-based care for older people with mental health issues, there was also considerable scepticism about its implementation. People’s main concerns were that: The change will place pressure on families to care for their elderly relatives (which could lead to more patients being placed in care homes)
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It may not be safest or most practicable option for many BCUHB will be unable to recruit enough staff to provide a sufficiently decent standard of care Patients could end up in inappropriate care settings to make room on acute wards. If implemented, it was felt that proper community services must be in place prior to the removal of inpatient beds from hospitals. The Llangefni group strongly desired the retention of inpatient beds at Cefni Hospital to provide respite care for elderly patients with mental health issues. In fact, this group was concerned generally about the reduction in the number of inpatient beds at their local hospital, especially with respect to: the loss of local convalescence facilities; the potential for bed-blocking in acute hospitals; and the possible additional pressure on Ysbyty Gwynedd and Ysbyty Penrhos Stanley and on patients’ families, neighbours and friends.
Public Meetings Older People’s Mental Health was a topic of considerable concern to attendees, particularly with respect to: The recognition of projected demand (especially with respect to dementia) and the implications for services Older people living alone and the need for a preventative ‘at home’ care service Levels of respite care provision for carers The need for an effective out of hours service for older people The quality and range of private nursing homes The recruitment and retention of specialist staff Travel and transport (and the particular challenge of rural North Wales).
Neonatal Intensive Care
Open Questionnaire and Household Survey In the Household Survey the majority (47%) disagreed with the proposal to provide long term Neonatal Intensive Care Services from Arrowe Park Hospital, while 37% agreed. There was more disagreement in the Open Questionnaire - with seven in ten (71%) disagreeing and only a fifth (22%) agreeing. However, it should be noted that responses from a Prestatyn pressure group substantially influenced the balance of opinion in the Open Questionnaire – partly because all of them strongly disagreed with the proposal, compared with three fifths (60%) of other respondents who disagreed. Further analysis showed that there was general disagreement with the proposal across all of North Wales. However, the Household Survey showed that residents whose nearest District General Hospitals are Bronglais and Ysbyty Glan Clwyd were more likely than average to disagree. In the Open Questionnaire more than half of organisations responding disagreed with providing long term Neonatal Intensive Care Services from Arrowe Park Hospital. We should note, though, that it seems likely that the Open Questionnaire and Household Survey were both influenced by the wording of the question in this case – which said “all intensive care
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neonatal services” when, in fact, the proposal was for only long-term intensive care (affecting about 36 babies a year).
Public Focus Groups Majorities at Anglesey, Conwy, Flintshire and Gwynedd felt they could support the proposal to provide Neonatal Intensive Care Services from Arrowe Park, given the small number of babies involved and BCUHB’s recruitment issues in this area. However, people sought reassurances that: There will be no service inequality based on nationality Special Care Baby Units (or at least some specialist neonatal equipment) will be maintained at the North Wales acute hospitals After-care can be provided closer to home. There was also some concern that the proposal will worsen recruitment, as the Welsh centres will be seen as ‘second best’ and will struggle to attract good quality staff. All at the Denbighshire group and five of 11 at Wrexham opposed the proposal. They felt services should be developed in North Wales for the following reasons: The distance to Arrowe Park (especially from western areas) – and the impact of this on babies, their parents and their siblings Arrowe Park’s capacity to care for North Wales babies The lack of Welsh language provision at Arrowe Park The issue of nationality (i.e. ‘Welsh’ children being born in a different country) The potential for Welsh patients to be treated with less urgency The possible worsening of recruitment issues (as above). It should also be noted that all groups had difficulty distinguishing between long-term complex and ‘routine’ short-term neonatal intensive care; and were unaware of the small numbers involved with respect to the former.
Public Meetings The provision of Neonatal Intensive Care Services from Arrowe Park was discussed keenly in all sessions. There was no overall consensus on the issue of local services versus excellence. There was, however, a great deal of regret about the loss of specialist neonatal skills from North Wales – and people sought reassurance that Arrowe Park has the capacity to take the affected North Wales babies and can meet BAPM standards. Other issues raised were: the potential difficulties involved in transferring serious cases and the impact of this on affected babies; the need to provide a bi-lingual, professional service at a difficult time for parents; the need for the service level agreement between BCHUB and Arrowe Park to be comprehensive, able to cope with future demand, and deliver on quality and cost; and the implications of Welsh money being spent in England, and ‘Welsh’ babies being born in a different country.
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Vascular Services
Open Questionnaire and Household Survey In the Household Survey an absolute majority (68%) agreed with the proposal to provide vascular services at one specialist centre in North Wales, though one in five (19%) disagreed. In the Open Questionnaire a majority (50%) also agreed with providing vascular services at one specialist centre in North Wales, although more than two fifths (42%) disagreed. Once more, responses from a Prestatyn pressure group substantially influenced the balance of opinion in the Open Questionnaire – partly because all but one of them strongly disagreed with the proposal, compared with less than a third (31%) of other respondents who disagreed. In the Household Survey the majority (48%) favoured Glan Clwyd Hospital as the location for a specialist centre for vascular services, followed by Wrexham Maelor Hospital (33%) and Ysbyty Gwynedd (19%). In the Open Questionnaire there was even stronger support for Glan Clwyd Hospital as the preferred location for the specialist centre (69%). There was proportionally less support for Wrexham Maelor Hospital (17%) and Ysbyty Gwynedd (13%). In the Open Questionnaire around three fifths of the organisations responding supported the proposal to provide vascular services at one specialist centre in North Wales. Half of organisations identified Glan Clwyd Hospital as the preferred location for the centre.
Public Focus Groups There was widespread support for centralising complex vascular services, with before- and after- care being provided at local hospitals. People’s main reasons for offering their support were: the small numbers of patients involved; that most people would be prepared to travel for specialist care; and that the change will improve patient outcomes (if BCUHB can attract and retain sufficient specialist staff). There were a couple of main concerns, however – namely the increased travelling distances for some patients; and the pressure on a single centre in terms of having single points of failure. Opinions were divided on whether there should be one specialist vascular centre or two. If BCUHB decides on one, there was an overall preference for Glan Clwyd as it is more central and the fairest location for the North Wales Community.
Public Meetings The proposals for Vascular Services were discussed in most meetings where people were broadly in favour of them. There were, however, some concerns about the implications of having just one specialist centre, particularly in relation to transport (and the risks of travelling) for very ill patients. People were also worried about how the proposed service would cope with emergency cases. There was no clear consensus in terms of location, but it was clear that people in the west of North Wales feared having to travel furthest. People urged BCUHB to consider carefully the issue of location, as it was argued that the recruitment of specialist staff will be dependent on this.
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Submissions
Introduction 17. During the formal consultation process 779 written submissions were received from professional, political, interest, voluntary and community groups as well as from many residents and staff. The full report contains a detailed tabulated analysis of the points made by the various organisations and people making submissions. 18. In addition, as well as identifying the important general themes and topics in the tabulated analysis, a selected range of the submissions (which were often very long) has been summarised in detail by ORS in the main report, in order to make them more accessible to interested readers. It was neither practical nor necessary to summarise all the submissions in the same manner (for their general content is tabulated), but we trust we have chosen a fairly wide range of important submissions for illustration. Our summaries cannot do full justice to the arguments and evidence of the many detailed and lengthy submissions, but they at least make them accessible and capture important arguments. If readers wish to go into further detail, they are encouraged to refer to the submissions documents available from BCUHB.
Selected Abstracts 19. As a guide to the content of the important submissions selected for summary in the full report, key abstracts are given immediately below. The submissions selected for detailed summary were chosen on the basis of the nature and importance of the organisations/individuals concerned and/or their relative prominence in public debate of the issues. 20. Many of those below are broadly positive about BCUHB’s proposals, but there is also important and forthright criticism from some community groups, staff and organisations. The overall impression these submissions make on readers will depend primarily on the relative weights that readers give to the sources of the submissions and to their respective arguments and reasoning. For example, readers must decide how to balance the judgements of key professional bodies compared with community and other organisations’ views. Key abstracts of the selected submissions are as follows.
Professional Bodies and NHS Organisations Royal College of Surgeons Professional Affairs Board in Wales (RCSPABW): disagrees with BCUHB’s proposal to continue emergency general surgical services on all three main sites because it is unsustainable and not in the interests of standards, staff and patients. The review is too limited insofar as unscheduled general surgery was not included; but the RCSPABW supports the proposal to centralise vascular surgical services onto a single site. Royal College of Midwives Wales: main concern is that neonatal intensive care services should be safe, sustainable and as accessible as possible; it does not oppose the Arrowe Park proposal. Royal College of Paediatrics and Child Health and Paediatric and Child Health National Advisory Group: the reconfiguration of paediatric services should be determined by the needs of the local population and the resources available; and BCUHB and the Welsh Government are best placed to make the difficult decisions. The guiding criteria should be the quality and safety of care, rather than simply access.
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Royal College of Nursing in Wales (RCNW): supports BCUHB’s case for change, but opposes outsourcing neonatal intensive care services to Arrowe Park. It does not oppose the other main proposals, but says that better financial and general planning is required for their successful implementation. Royal College of Psychiatrists in Wales (RCPW): supports the move towards community rather than inpatient care, but wants to know how sustainable 24-hour emergency mental health care will be provided. [This submission is the same as the one from the National Specialist Advisory Group: Mental Health]. Wales Deanery (WD): The WD says it is important for BCUHB and the Deanery to work together. National Clinical Forum (NCF): supports the proposals since they will aid the development of quality, sustainable services for North Wales. The review should have been wider in also including an examination of the sustainability of other specialist services. The NCF supports as much care in the community as possible; but it is crucial to develop community services before reducing inpatient care. Chartered Society of Physiotherapists (CSP): supports care closer to home and sees opportunities for physiotherapists and other health professionals to make a greater contribution within ‘extended primary care teams’; but says that transport is a key issue to get right. Hywel Dda Health Board (HDdHB): recognises the need for the modernisation of healthcare services and wishes to work in collaboration with adjoining health boards. Powys Teaching Health Board (PTHB): supports BCUHB’s direction of travel and believes the boards should work with Hywel Dda to enhance joint planning and delivery of healthcare across rural Wales. Wales Abdominal Aortic Aneurysm Screening Programme (WAAASP): recommends that BCUHB should have a single inpatient arterial site in order to meet professional and training standards. Public Health Wales (PHW): supports BCUHB’s approach while recognising that further work is required on some issues. British Medical Association: Clwyd North Division (BMACND): the status quo is unsustainable; but the Arrowe Park proposal should be reconsidered in favour of keeping level three services at Glan Clwyd. It supports centralising vascular emergency surgery, also at Glan Clwyd, but is concerned about the loss of community beds and believes some of BCUHB’s planning has been too vague. Welsh Ambulance Services NHS Trust (WAST): BCUHB’s general strategy is correct, but wants to see more detailed service models and information on funding to meet additional costs. Older People’s Commissioner for Wales (OPCW): expresses some concern about the consultation process. Community Pharmacy Wales North Regional Committee (CPWNRC): does not comment directly on BCUHB’s proposals, but supports the transfer of more care into the community and urges a bigger and more positive role for community pharmacies as “healthy living centres.” Liverpool Women’s NHS Foundation Trust (LWFT): makes a formal objection to BCUHB’s proposal to commission services from Arrowe Park without considering LWFT as an alternative provider. LWFT has a superior neonatal unit that already provides important services to BCUHB, would not involve significantly different travel times from North Wales, and could provide the services more cost-effectively.
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Unison Wales: agrees with BCUHB’s mission statement but urges that changes to services should not be implemented before alternative provision is in place.
Local Authorities and Statutory Bodies Conwy County Borough Council (CCBC): supports the centralisation of some specialist services, including vascular services at Glan Clwyd, but questions the Arrowe Park proposal. Is particularly concerned that services at Colwyn Bay hospital should be retained in full and that community services should be well established before current services are withdrawn. Is not confident that enhanced community care can be successfully delivered. Denbighshire County Council (DCC): pleased that three DGH sites are being maintained while accepting the need for specialised services to be concentrated on fewer sites, including vascular services at Glan Clwyd; but it doubts the need for outsourcing to Arrowe Park. It broadly supports most of the proposals for community hospitals, but emphasises that existing facilities should not close until new services are properly in place. Gwynedd County Council (GCC): recognises the need for change and welcomes the change of emphasis from acute hospitals to community care, but the new approach will need improved joint working with local authorities and the third sector. Finds strengths and weaknesses in proposals for local hospitals, and stresses that changes should not be implemented until new services are in place. Flintshire County Council (FCC): broadly supports the Arrowe Park and vascular services plans, but urges BCUHB to withdraw all its proposals because, although strategically sound, they lack proper planning. Isle of Anglesey County Council (ACC): wants to strengthen Welsh language provision and move more services into the community to reduce pressure on acute hospitals and provide accessible care. Accepts the centralisation of some services, including long-term specialist neonatal care at Arrowe Park, but accommodation should be provided there for patients’ families. The best use should be made of Cefni and Penrhos Stanley community hospitals, and sufficient resources should be available to strengthen mental health care and other community services. Wrexham County Borough Council (WCBC): asks questions about neonatal intensive care, vascular services and older people’s mental health, but does not oppose the proposals. Raises questions about how enhanced 24/7 community care will be delivered. North Wales Fire and Rescue Service (NWFRS): recognises the need for healthcare changes and says that BCUHB’s plans balance local access against requirements for specialist services. Does not comment on specific proposals but wishes to develop the current partnership in the context of community care. North Wales Police - Chief Constable (CCNWP): does not comment on the individual proposals, but makes observations on delayed ambulance responses and access to services for those with mental health problems.
Betsi Cadwaladr University Health Board Staff Cardiology Department (Glan Clwyd): Glan Clwyd’s accreditation for the catheter laboratory’s interventional cardiac procedures requires the availability of on-site vascular surgery – and this interdependency should be taken into account when vascular services are reorganised.
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Two Consultant General and Vascular Surgeons (Wrexham): concentrating major arterial surgery on a single site would make routine vascular services unviable at the remaining two acute hospitals without improving overall patient safety; so a two-site model is more reasonable. North Wales Advanced Neonatal Nurse Practitioners (Glan Clwyd) (NWANNPs): the dangers of post-natal transfers to Arrowe Park have been under-estimated while the merits of care there have been exaggerated. There are risks and inconvenience associated with transfers to the Wirral.
Special Interest, Voluntary and Community Groups Mold Labour Party (MLP): Mold needs small injuries and X-Ray services because it is a natural hub to a sizeable community. Dwyfor Labour Party (DLP): BCUHB should rethink its proposals radically in order to meet the health needs of rural communities in upland areas of North Wales. The Board should not close community hospitals, but make better use of them with step-up-step-down facilities while also developing level three intensive care neonatal service in North Wales. Wrexham Plaid Cymru (WPC): all neonatal intensive care services should be retained in North Wales because of deficiencies at Arrowe Park and access difficulties. Blaenau Ffestiniog Hospital Defence Committee (BFHDC): Very strongly opposes the proposed closure of the Memorial Hospital: it should retain its 12 inpatient beds and five (already removed) should be reinstated, as well as the minor injuries service. Community Hospitals Association (CHA): the proposals for community hospitals, minor injuries units, X-Ray facilities and hub hospitals jeopardise healthcare by reducing both access and community capacity, leading to a greater not lesser reliance on specialist acute services. National Specialist Advisory Group Mental Health: supports the move towards community rather than inpatient care, but wants to know how sustainable 24-hour emergency mental health care will be provided. [This submission is the same as the one from the Royal College of Psychiatrists in Wales]. North Wales Social Services Improvement Collaboration (NWSSIC): supports the strategic changes that BCUHB is making and accepts the proposals for vascular and intensive neonatal care services; but objects to closing/downgrading community hospitals. Accepts the principle of hubs, but questions the choices made. There should be a more detailed business case with costs, timetables and continuity of care during organisational change. There should be clarity and joint planning about the impact of health service changes on social services.
Assembly Members and Members of Parliament Rebecca Evans AM (RE): questions aspects of the consultation process and raises a number of issues about the data used to justify the outcomes of BCUHB’s planning process. Janet Finch-Saunders, AM for Aberconwy and Shadow Minister for Local Government (JFS): funding cuts are jeopardising patients by leading to undue centralisation of services and undesirable outsourcing of level three neonatal services. Mental health and other services should achieve a balance between care in the community and access to local inpatient beds; and Llandudno hospital should continue as a major facility.
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Llyr Gruffydd, AM (LG): objects strongly to the proposals for neonatal intensive care and community hospital services: both proposals will worsen standards and access for patients. Also encloses a range of anonymous submissions. David Hanson MP (DH): passes on the concerns of Flint Town Council about the closure of Flint Community Hospital and also asks questions about Mold Hospital. Ann Jones AM (AJ): passes on the objections of “Cuddles” about the outsourcing of level three neonatal services to Arrowe Park. Elfyn Llwyd, MP (EL): Tywyn’s services should be protected due to its remoteness and visitor numbers. Sandy Mewies AM (SM): passes on residents’ objections to the proposals for Flint hospital and Mold minor injuries and X-Ray services. There is no objection in principle to hubs, but their location is important. Darren Millar AM (DM): accepts the proposal for vascular services, but criticises plans for neonatal services while also objecting to proposals for minor injuries and X-Ray services at Colwyn Bay and Ruthin. Aled Rhys Roberts AM (ARR): accepts the need to reform healthcare, but more evidence and implementation planning is required before changes can be justified in practice. Chris Ruane, MP (CR): expresses concerns about the conduct of the consultation. Antoinette Sandbach AM (AS): the distribution of information about the consultation proposals has not been effective in all cases and so the response timetable should be extended. Level three neonatal services should be retained at Glan Clwyd, not outsourced to Arrowe Park, and community hospitals should not be closed on the basis of current evidence. Ken Skates AM (KS): supports health service reform and the new health centre in Llangollen, but seeks information to set the record straight and to ensure that all avenues are explored before changes are implemented at Chirk and Llangollen. Joyce Watson AM (JW): objects to the closure of Blaenau Ffestiniog hospital, which will lead to considerable access problems for local people. 21. All of the above submissions were selected for detailed summary in the full report on the basis of the nature and importance of the organisations/individuals concerned or their relative prominence in public debate of the issues. 22. It should be recognised, though, that there was a total of 779 submissions, with 535 from individual residents. Whereas many of the professional bodies and others cited above are relatively favourable to BCUHB’s proposals, the submissions from residents and other organisations were almost uniformly critical. Their concerns are clearly detailed in the main report and should not be overlooked because they deal with important local issues. Briefly, the main issues and themes raised in the majority of submissions were as follows: Opposition to the proposed closure of local hospitals or departments Distance, travel and transport considerations Increased pressure on acute and other proposed ‘hub’ hospitals – as well as the Ambulance Service Loss of local rehabilitation, convalescence and respite facilities
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Needed to cater for growing and ageing populations Lack of information about proposed replacements (i.e. Primary Care Resource Centres). Opposition to the provision of Neonatal Intensive Care Services from Arrowe Park Distance, travel and transport considerations Practical and emotional strain on parents and families Nationality issues (i.e. ‘Welsh’ babies born in a different country and the need for Welsh language provision at Arrowe Park) BAPM standards not met at Arrowe Park More cots and a better staff/child ratio at North Wales hospitals currently De-skilling of North Wales staff – and a negative effect on future recruitment to North Wales services. Support for more community-based care in principle, but concerns about its practical implementation – and a strong desire for good community provision to be in place prior to removal of existing services. Most support for (although also some opposition to) proposals for Vascular Services.
Petitions
23. During the formal consultation the total number of signatures on petitions received was 12,068, but a petition with 3,891 names from Blaenau Ffestiniog is also relevant despite being submitted during the summer (before the consultation period began). The petitions were as follows: 3,457 signatures to save the MIU at Chirk Community Hospital from closure 2,403 signatures to oppose the closure of the MIU and X-Ray service at Mold Community Hospital – and to urge BCUHB to make Mold the ‘hub’ for the area (since Deeside Hospital has no MIU currently) 42 signatures to oppose the closure of the Minor Injuries and X-Ray Units at Mold Community Hospital 1,990 signatures (organised by the organisation Cuddles) to oppose the provision of Neonatal Intensive Care Services from Arrowe Park 1,249 signatures against the closure of the X-Ray service and reduced MIU hours at Tywyn Community Hospital 1,240 signatures against the proposed closure of Llangollen Community Hospital 1027 signed template letters to oppose the closure of the MIU at Colwyn Bay Community Hospital 76 signatures (collected by the Colwyn Bay Action Group) against the closure of the Minor Injuries Unit at Colwyn Bay Community Hospital 228 signatures to protest against the need to pre-book spaces at BCUHB’s public meetings 168 signatures on an e-petition (organised by Mike Parry) entitled ‘medical emergency - preventing the introduction of a poorer Health Service for North Wales’ 92 signatures calling on BCUHB to improve services at Ruthin Community Hospital
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78 Signatures (petition organised by Clwb-y-Ffrith in Prestatyn) against the proposed closure of Prestatyn Community Hospital 18 signatures to develop Blaenau Ffestiniog Memorial Hospital as a ‘hub’ hospital. 24. The petitions are clearly important and BCUHB will treat them very seriously, but the Board should also note that petitions can exaggerate public sentiments and fail to take account of the needs of the whole Betsi Cadwaladr area.
Towards Conclusions
Introduction 25. It would be a brave author who claimed to derive unambiguous conclusions from the various consultation elements reported here, but without hubris it is possible to identify some signposts to assist the Board and others in their deliberations.
Reviewing the Evidence 26. The submissions made during the consultation are clearly very important and they fall into two distinct groups: those from professional bodies, which mainly broadly support BCUHB’s proposals while raising issues about the implementation of ‘community care’, and those from residents and community organisations, which typically object strongly to any centralisation at the expense of local access to services. 27. The conclusions the Board reaches about the issues will depend partly on how its members weigh the inevitably smaller number of professional bodies’ submissions alongside the greater numbers from community groups and residents. This is a critical issue. For example, some professionals groups believe BCUHB has been too conservative in its review, whereas many community groups and residents would radically disagree with greater centralisation of specialised services – so the tension between safety, specialisation and resilience, on the one hand, and local access on the other, defines the dilemma for the Board. 28. The Board will also wish to consider the focus groups, in which randomly selected people reflected relatively dispassionately about the proposals – and, though they did not welcome some of the changes, many could accept them in the light of the Board’s key considerations. In Flint, though, feelings were particularly high – and some were even reluctant to attend the meetings following local publicity. 29. The considerable and detailed quantitative data are important for the Board to consider. As we have said, the Household Survey findings are much more representative of the general population than the Open Questionnaire data – in which Denbighshire, and also people aged 55-74, are over-represented compared with Wrexham and other areas, and those under-35, who are under-represented. 30. Of course, the responses to the Open Questionnaire reflect the strength of feeling of many people in Denbighshire – and in particular Prestatyn: that is democracy in action; and it is good that people organise to promote their ideas and protect their interests; but the BCUHB has to make public policy choices on the basis of the safety, quality and sustainability of services, as well as accessibility, for the whole of its area. 31. The views expressed in the 48 public meetings, and also in the petitions, are also important and need to be weighed by the Board alongside all the other material.
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Overall Conclusions
Introduction 32. As we have said, there can be no ‘definitive’ interpretation of this complex material and the diverse opinions expressed through so many consultation routes; and ORS does not presume to tell the Board what to think. Nonetheless, part of our role is to highlight what we consider to be the key conclusions that can reasonably be derived from all the material in this report – and these follow, under headings for each of the key proposals.
Healthcare Services Where You Live – the principles 33. There was clearly strong support for the Health Board’s three key priorities for healthcare, which was evident across all elements of the consultation. 34. There was also support for the principles that resources should be focused into fewer hospitals and that the same healthcare services should be available within 40 minutes’ drive for as many people as possible. The Household Survey showed that an absolute majority of residents support both principles. Very few submissions question the principle of ‘hub hospitals’, and some of those who do are more concerned about the choice of locations rather than with the very principle. However, whilst the Open Questionnaire supported the same services being available for as many as possible, there was clear disagreement with the principle of fewer hospitals. 35. Despite this support, responses about these priorities and principles raised concerns about the interlinked problems of transport (particularly for those without cars) and access to community or acute hospitals. These issues were highlighted in questionnaire responses as well as many submissions, with a number promoting a holistic approach to encompass transport planning as well as healthcare issues. 36. The consultation also highlighted doubts about the deliverability of enhanced care in the community – in relation to: the readiness or capacity of GPs; whether funding will be available; whether there is a secure business case; whether the staff and community facilities will cope in practice with the demands for care; and whether health and social services staff will develop effective partnerships. Across all elements of the consultation, it was argued strongly that existing facilities and services should not be removed until alternative community-based services are successfully in place.
Healthcare Services Where You Live – the specific proposals 37. There was less consensus about the specific ‘Hub Hospitals’ proposed. Views differed by location, with particular disagreement in those areas where the proposals mean that services would no longer be provided at the local hospital. The proposed locations for hubs were fiercely debated at the public meetings, and many submissions (especially those from local residents) raised concerns. Opinion was clearly divided about the specific proposals in the Open Questionnaire: 43% agreed, 49% disagreed; but it was evident that disagreement increased in proportion to the additional distance to the nearest proposed hub. Nevertheless, the Household Survey showed strong support from the general population for the ten hospitals proposed: three quarters (74%) agreed while only 17% disagreed. 38. In the Household Survey there was majority support for the principle and proposals for Minor Injuries Services and X-Ray Services, but in the Open Questionnaire there was an absolute majority in opposition. Many had general concerns about the specific locations for the ‘Hub Hospitals’ and about travel and transport.
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39. With regard to specific local services, the consultation showed majority support for the proposals to develop facilities and expand primary care in local areas; but there was strong localised opposition to moving community inpatient beds evident across all elements of the consultation. In particular, many written submissions were received from organisations and local residents were critical of the proposed changes and numerous petitions were presented about specific local proposals.
Older People’s Mental Health 40. The consultation showed strong support for the proposals for older people’s mental health, though there were some anxieties over the additional local proposals – particularly those in Gwynedd and Anglesey, where opinion was divided. 41. However, the public meetings and focus groups showed concerns and some scepticism about the implementation – in relation to: the recognition of projected demand (especially with respect to dementia) and implications for services; the need for a preventative ‘at home’ care service especially for older people living alone; the pressure on families and the levels of respite care available; the need for effective out-of- hours services; and issues surrounding staff recruitment and retention. Once again, it was felt that proper community services must be in place prior to the removal of inpatient beds from hospitals.
Neonatal Intensive Care 42. There was widespread opposition to the proposals for providing long-term neonatal intensive care services from Arrowe Park Hospital (although feedback from the consultation showed that there may be some misunderstanding about the proposal only affecting those babies needing long-term complex care, and the small numbers involved). In some cases, disquiet about Arrowe Park was based on its capacity and standards rather than on the principle of outsourcing; but in others it is based on both. 43. Opinion was divided in the Household Survey (37% agree, 47% disagree) but there was more disagreement in the Open Questionnaire, with seven in ten (71%) disagreeing and only a fifth (22%) in agreement. Majorities at some focus groups felt they could support the proposal once the issues had been discussed, but only if the Health Board could guarantee that: there would be no service inequality based on nationality; lower-level neonatal intensive care would be maintained at the North Wales acute hospitals; and after-care was still provided closer to home. However, some focus groups continued to oppose the proposals even after an informed discussion. The proposal was also keenly debated at all of the public meetings, where there was no consensus on the issue of local services versus excellence. 44. Nevertheless, it is notable that most of the submissions from professional bodies support (or do not oppose) the proposals for intensive care neonatal services, though some oppose them particularly strongly. 45. One alternative provider of neonatal services challenges BCUHB’s choice of Arrowe Park while offering standards of care that could well reassure those with doubts about Arrowe Park’s capacity.
Vascular Services 46. Overall, there was strong support to centralise vascular services. There was widespread support at the focus groups (providing that before- and after-care was provided at local hospitals) and people attending the public meetings were also broadly in favour. Both the Household Survey and Open Questionnaire showed that absolute majorities agree with the proposal (68% and 50% respectively), although more than two fifths (42%) did disagree with the proposal in the Open Questionnaire. Similarly, whilst most of the submissions support (or certainly do not oppose) the proposals for vascular services, there are some submissions that are strongly opposed.
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47. There was clear support for Glan Clwyd Hospital being the overall preferred location due to its central location in the BCUHB area. This was evident in the Household Survey (48% support for Glan Clwyd), the Open Questionnaire (69% support for Glan Clwyd) and also at the focus groups. There was no consensus on location from the public meetings, but people urged BCUHB to consider this carefully as it was argued that the recruitment of specialist staff would be dependent on this.
Scope of BCUHB’s Review 48. Finally, we should draw attention to submissions from the National Clinical Forum and the Royal College of Surgeons that say that BCUHB’s review has been too conservative in proposing to continue emergency general surgery on all three acute hospital sites and/or in not examining the sustainability of other specialist services. They believe that the scope of BCUHB’s review should have been wider and more critical in examining the sustainability of current arrangements for emergency general surgery and other specialised services (see the National Clinical Forum and the Royal College of Surgeons Professional Affairs Board in Wales).
The Board’s Dilemmas 49. The comments by the professional bodies highlight the pressures on the Board in the context of the overall consultation outcomes. In its proposals, the Board seems to have tried to steer a middle way between clinical imperatives towards greater centralisation, on the one hand, and urgent community demands for accessible and familiar facilities, on the other; at the same time it faces demanding financial pressures and also the expectations of clinicians, who understandably want to protect their services and establishments. 50. On the evidence of the consultation programme, the challenge for the Board is to maintain both public and professional body confidence in the safety, resilience and accessibility of its healthcare services while also demonstrating that it can successfully deliver the changes it proposes in community care. 51. We trust that this report will make at least some contribution to that endeavour.
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Healthcare in North Wales is Changing
Betsi Cadwaladr University
Health Board’s Consultation on Healthcare Services
Assessing the Evidence: Report of the Consultation Outcomes
Opinion Research Services January 2013
Opinion Research Services | The Strand • Swansea • SA1 1AF | 01792 535300 | www.ors.org.uk | [email protected]
Healthcare in North Wales is Changing
Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services
Assessing the Evidence: Report of the Consultation Outcomes by Opinion Research Services
Opinion Research Services
The Strand Swansea SA1 1AF 01792 535300 | www.ors.org.uk | [email protected]
As with all our studies, findings from this survey are subject to Opinion Research Services’ Standard Terms and Conditions of Contract.
Any press release or publication of the findings of this survey requires the advance approval of ORS. Such approval will only be refused on the grounds of inaccuracy or misrepresentation
© Copyright January 2013
Opinion Research Services | The Strand • Swansea • SA1 1AF | 01792 535300 | www.ors.org.uk | [email protected]
Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Contents
Executive Summary and Conclusions ...... 9 Public Consultation ...... 9 Need for Interpretation ...... 10 Accountability...... 11 Executive Summary and Full Report ...... 11 Key findings: Healthcare Services Where You Live ...... 12 Healthcare Priorities ...... 12 Hospitals in our Communities ...... 12 Hospital ‘Hubs’ ...... 13 Minor Injuries Services ...... 13 X-Ray Services ...... 14 Local Services in Blaenau Ffestiniog ...... 15 Local Services in North Denbighshire - Rhyl and Prestatyn ...... 16 Local Services in Llangollen ...... 17 Local Services in Flint ...... 18 Older People’s Mental Health ...... 19 Neonatal Intensive Care ...... 20 Vascular Services ...... 22 Submissions ...... 23 Introduction ...... 23 Selected Abstracts ...... 23 Petitions...... 28 Towards Conclusions ...... 29 Introduction ...... 29 Reviewing the Evidence ...... 29 Overall Conclusions ...... 30 Introduction ...... 30 Healthcare Services Where You Live – the principles ...... 30 Healthcare Services Where You Live – the specific proposals ...... 30 Older People’s Mental Health ...... 31 Neonatal Intensive Care ...... 31 Vascular Services ...... 31 Scope of BCUHB’s Review ...... 32 The Board’s Dilemmas ...... 32
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
1. Introduction ...... 33 An overview of the formal consultation 33 Challenges and Changes ...... 33 Assessing the Evidence ...... 34
2. Quantitative Consultation...... 36 Household Survey and Open Questionnaire compared 36 Overview ...... 36 Open Questionnaire ...... 37 Questionnaire Responses ...... 37 Duplicate and Co-ordinated Responses ...... 38 Household Survey ...... 39 Questionnaire Responses ...... 39 Respondent Profile ...... 40 Questionnaire Profiling Information ...... 42 Interpretation of the Data ...... 45 Summary of Key Findings ...... 46 Healthcare Services Where You Live ...... 46 Older People’s Mental Health ...... 50 Neonatal Intensive Care ...... 50 Vascular Services ...... 51 Healthcare Services Where You Live ...... 52 Priorities for delivering healthcare in North Wales ...... 52 Providing healthcare services at fewer hospitals ...... 53 Providing the same healthcare services within 40 minutes’ drive ...... 54 Hospital ‘Hubs’ ...... 57 Minor Injuries Services – Services concentrated in fewer places ...... 59 X-Ray Services – Services concentrated in fewer places ...... 61 Local Services in Blaenau Ffestiniog ...... 63 Local Services in North Denbighshire – Rhyl and Prestatyn ...... 65 Local Services in Llangollen ...... 66 Local Services in Flint ...... 67 Healthcare Services Where You Live – Further Comments ...... 68 Older People’s Mental Health ...... 70 General Proposals ...... 70 Additional Proposals for Older People’s Mental Health: Conwy and Denbighshire ...... 72 Additional Proposals for Older People’s Mental Health: Gwynedd and Anglesey ...... 73 Older People’s Mental Health – Further Comments ...... 73 Neonatal Intensive Care Services ...... 75 Neonatal Intensive Care Services – Further Comments ...... 78 Vascular Services ...... 79 Proposals for Vascular Services at One Specialist Centre ...... 79
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Preferred Location of Specialist Centre for Vascular Services ...... 80 Vascular Services – Further Comments...... 82 Further Comments ...... 83
3. Deliberative Findings ...... 84 Feedback from focus groups with members of the public 84 Anglesey (held in Llangefni) ...... 85 Conwy (held in Llanrwst) ...... 89 Denbighshire (held in Rhyl) ...... 95 Flintshire (held in Flint) ...... 104 Gwynedd (held in Dolgellau) ...... 115 Wrexham (held in Chirk) ...... 120
4. Public Meetings ...... 124 Main issues and themes from the public meetings 124 Summary of Main Findings ...... 124 Hospitals in Our Communities ...... 124 Older People’s Mental Health ...... 126 Neonatal Intensive Care Services ...... 126 Vascular Services ...... 127 Local Service Changes involving Closures ...... 127 Overall Themes ...... 128 Findings in More Detail ...... 133 Hospitals in our Communities ...... 133 Community Healthcare ‘Hubs’ ...... 136 Minor Injuries Services ...... 139 X-Ray Services ...... 140 Local Services in Blaenau Ffestiniog ...... 143 Local Services in Rhyl and Prestatyn ...... 144 Local Services in Llangollen ...... 145 Local Services in Flint ...... 147 Older People’s Mental Health ...... 148 Neonatal Intensive Care Services ...... 152 Vascular Services ...... 156 Other Feedback ...... 158 Equality and Diversity ...... 158 Views on the Consultation Process ...... 159 Management of the Public Meetings ...... 161 Overview of the Public Meetings ...... 162 Organisations and Interest Groups attending Sessions ...... 163 Media Attendance ...... 164 Key Issues presented at each Consultation by BCUHB ...... 164
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
5. Written Submissions ...... 167 Analysis of stakeholder responses to the proposals 167 Summaries of Key Submissions ...... 170 Key Submissions from Professional Bodies and NHS Organisations ...... 170 Key Submissions from Local Authorities and Statutory Bodies ...... 190 Key Submissions from BCUHB Staff ...... 202 Key Submissions from Special Interest, Voluntary and Community Groups ...... 206 Key Submissions from Assembly Members and Members of Parliament ...... 216 Analysis of Other Submissions ...... 226 Submissions from Special Interest Groups (inc. Voluntary/Community Groups) ...... 226 Submissions from GPs and Other Health Professionals ...... 229 Submissions from BCUHB staff ...... 230 Submissions from County Councillors ...... 232 Submissions from Town and Community Councils/Councillors ...... 234 Submissions from Residents ...... 235 Consultation Questionnaire: Responses from Organisations ...... 238 Healthcare Services Where You Live ...... 239 Older People’s Health ...... 245 Neonatal Intensive Care Services ...... 246 Vascular Services ...... 247
6. Petitions ...... 248 Overview of petitions objecting to the proposals 248 Summary of Petitions ...... 248 Chirk Community Hospital ...... 248 Mold Community Hospital ...... 248 Neonatal Intensive Care Services ...... 249 Tywyn Community Hospital ...... 249 Llangollen Community Hospital ...... 249 Colwyn Bay Community Hospital ...... 250 Ruthin Community Hospital ...... 250 Prestatyn Community Hospital ...... 250 Blaenau Ffestiniog Memorial Hospital ...... 251 Healthcare Services in North Wales ...... 251 Consultation: Public Meetings ...... 252 Need for Interpretation ...... 252
Table of Figures ...... 253
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
The ORS Project Team
Project design, management Fieldwork management and reporting Kirsty Millbank Dale Hall Leanne Hurlow Jonathan Lee Kester Holmes Data analysis Kelly Lock Richard Harris David Harrison Joe Marchant Claire Thomas Hugo Marchant Hannah Champion Anna Shakeshaft Kathryn Middleton
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Acknowledgements
Opinion Research Services (ORS) is pleased to have worked with Betsi Cadwaladr University Health Board (BCUHB) on the important consultation regarding the future of health services in North Wales, as reported here.
We hope this report of the consultations will contribute to the Health Board’s thinking; and we hope the ORS contribution is been constructive and instrumental in ensuring that the views of the people of North Wales are captured and considered as part of the overall review process.
We are grateful to BCUHB’s managers for their helpful and positive liaison throughout the detailed preparation and management of the consultation. ORS’ status as an independent social research organisation was respected throughout.
We also thank the members of the public who took part in the consultation by a wide range of routes; participants shared their views and took a full part in the process.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Executive Summary and Conclusions
Public Consultation
1. ‘Together for Health’ was published by the Minister for Health and Social Services in November 2011 to offer a five-year vision in the context of the challenges facing the health service in Wales. The document declares that Health Boards need to change to provide the very best quality of services for their population in the future. In this context, Betsi Cadwaladr University Health Board (BCUHB) embarked on a major review of its services to clarify both general principles and particular proposals for changes to services. The formal consultation on the proposals ran from 20th August to 28th October, and included an extensive programme of engagement with staff, stakeholders and the public. 2. BCUHB conducted a wide range of consultation activities with staff, stakeholders and the public and it has taken all of them into account and responded to many contacts from interested parties. This report concentrates on some particularly important elements of the consultation process in order to provide an independent report and interpretation of the outcomes. The elements included in this report are:
ORS activities Open Consultation Questionnaire (both on-line and paper versions) – widely distributed by BCUHB and with responses from 1,899 residents and organisations Household Survey of Residents (by post) – with responses from 683 (14%) of the 5,000 randomly selected households Eight focus groups with members of the public
BCUHB activity 48 public meetings over 16 days (three sessions per day) – attended by a total of more than 1,300 people
Other activities Written submissions from stakeholders Petitions. 3. As a research practice with wide-ranging experience of controversial statutory consultations across the UK, ORS is able to certify that the formal consultation processes undertaken by BCUHB has been both intensive and extensive. Overall, there is no doubt that the exercise has been conscientious, competent and comprehensive in eliciting the opinions of stakeholders and many members of the public. 4. In the submissions and elsewhere, there has been some understandable criticism of the way in which the 48 public meeting sessions were organised; but BCUHB took independent advice on the conduct of these meetings from the Consultation Institute and the decision to hold 48 separate sessions with a team of senior managers present at each was certainly scrupulous – so those who believe there were shortcomings should take heart from the conscientiousness and scale of the of consultation programme taken as a whole.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Need for Interpretation 5. Proper interpretation of BCUHB’s consultation programme should distinguish the findings of the various elements – for example, to compare the results of the Open Questionnaire with the more representative random sample Household Survey, while also comparing the quantitative outcomes generally with the qualitative deliberative focus groups, the public meetings, the submissions and the petitions. 6. The Open Questionnaire elicited nearly three times as many responses (1,899) as the Household Survey (683) – but, as an important and accessible consultation route open to everyone, it was distributed unsystematically and in many cases circulated at public meetings and other events, and by groups. Therefore, it is unsurprising, but important, that the Open Questionnaire achieved responses that are less representative of Betsi Cadwaladr’s population than the Household Survey. Because the former’s larger size does not compensate for the fact that its respondent profile is an imperfect reflection of the Betsi Cadwaladr population, the results of the Open Questionnaire have to be interpreted carefully and compared throughout with the Household Survey findings. 7. For example, in the Open Questionnaire data, Denbighshire is very over-represented due to its high response rate (42% of responses but only 14% of the Betsi Cadwaladr population) whereas Wrexham is under-represented (5% of the responses compared with its 19% proportion of the total population). Similarly, older people (aged 55 to 74) are highly over-represented compared with those aged under-35 who are very under-represented. 8. Crucially, this does not mean that the Open Questionnaire findings should be discounted: they are analysed in detail in this report and should definitely be taken into account as a demonstration of the strength of feeling of residents who were motivated to put forward their concerns. For example, a Prestatyn-based pressure group successfully co-ordinated Open Questionnaire responses from 418 residents with the same views – amounting to more than a fifth (22%) of the 1,899 responses from the whole of Betsi Cadwaladr! As a consequence, though, the Open Questionnaire results cannot plausibly be interpreted as representative of the views of the total population. 9. Of course, neither the Open Questionnaire nor the Household Survey achieved fully random samples; but the point of the Household Survey was to contact the general population, and questionnaires went to 5,000 randomly selected households across the whole of the BCUHB area and got a ‘reasonable’ 14% response. In contrast to the Open Questionnaire, the achieved Household Survey sample, though smaller, is broadly representative of the population overall and within each county. In other words, it is a more plausible basis for considering the likely views of the general population; and given the need for BCUHB to consider the interests of the whole of the Betsi Cadwaladr area, the representativeness of the Household Survey means its findings should carry more weight than the less representative Open Questionnaire results. 10. In any case, influencing public policy through consultation is not simply a ‘numbers game’ or ‘popularity contest’ in which the loudest voices or the greatest numbers automatically win the argument! Instead, consultation is to inform authorities of issues or arguments, implications they might have overlooked; or to contribute to the re-evaluation of matters already known; or to reassess priorities and principles critically. However popular proposals might be, that does not itself mean they are feasible, safe, sustainable, reasonable and value-for-money; and unpopularity does not mean the reverse. The allegedly Confucian statement, When all applaud: verify; when all condemn: verify! summarises the approach we should take when confronted by the big battalions of numbers.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
11. Of course, the responses to the Open Questionnaire reflect the strength of feeling of many people in Denbighshire (particularly Prestatyn) – which is democracy in action; but the BCUHB has to make public policy choices on the basis of the safety, quality, sustainability and accessibility of services across the whole of Betsi Cadwaladr. 12. All of this means that interpreting the overall meaning of the consultation outcomes is neither straightforward nor just ‘numerical’, for the different consultation methods have not only to be respected and recognised, but also evaluated or assessed: they cannot be simply summated. In this context, ORS attaches particular weight to findings that are representative of the general population (the Household survey and focus groups) and/or deliberative (based upon thoughtful reflective discussion in non-emotive forums, focus groups or public meetings) and/or based on professional expertise (submissions from professional bodies, staff and other informed groups); but, of course, all the other consultation elements are important and should be recognised and taken into account as well. 13. While ORS makes the above assessments, there is no single ‘right interpretation’ of all the consultation elements, for professional and political judgement is needed. Ultimately, an overall interpretation of the consultation will depend upon the executive and non-executive members of the Health Board itself: they will consider all elements and determine which seem the most telling – above all, by considering the relative merits of the various opinions as the basis for public policy.
Accountability 14. The Board consults the public and stakeholders because it is accountable – but, in this context, accountability means giving an account of its ideas and then taking into account public and stakeholder views: it does not mean that the opinions of the largest majority should automatically decide public policy. After all, consultations are not referenda: they should inform, but not displace, professional and political judgements, which (above all) should assess the cogency of the views expressed.
Executive Summary and Full Report 15. Although the submissions are dealt with separately (due to their length, complexity and scope), in this executive summary, as far as possible, the outcomes of consultations are integrated under headings for the main proposals; but in the full report the results of each consultation method are reported in separate chapters. 16. We trust that this executive summary is a sound guide to the consultation outcomes and how they might be interpreted, but readers are encouraged to read the full document for more detailed insights. Whereas this summary travels towards overall conclusions fairly quickly, the full report traverses public, professional and stakeholder opinions and feelings in considerable detail to achieve a more comprehensive understanding – and it is the journey, as well as the destination, that will matter to those wishing to understand the assumptions, arguments, conclusions and feelings about current and future healthcare services in Betsi Cadwaladr. We trust that both the summary and full reports will be helpful to all concerned.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Key findings: Healthcare Services Where You Live
Healthcare Priorities
Open Questionnaire and Household Survey In the Household Survey in relation to the three key priorities for healthcare – targeted prevention, enhanced care at home and moving care from acute hospitals to the community – the absolute majorities in favour were respectively 86%, 80% and 56%. The only priority with which more than a quarter disagreed was moving care from hospitals into the community (27% disagreed, but more than twice as many agreed). In the Open Questionnaire the majorities in favour of these key priorities were only very slightly smaller (82%, 67% and 55% respectively). More than seven in ten of the organisations completing the Open Questionnaire also agreed with the three priorities.
Public Focus Groups There was general approval for the principle of providing ‘care closer to home’ – but many worried about its deliverability in practice. There was also general support for moving services out of hospitals and into the community, providing community services are properly resourced. The main concerns were: the need for greatly increased resources to ensure it is done properly (and the costs associated with this); that some frail older people may be better cared for in hospital; that it may lead to isolation insofar as it is promoting people to stay in their houses and never come out; and that it may result in a greater burden on patients’ families and friends.
Hospitals in our Communities
Open Questionnaire and Household Survey – Providing healthcare services at fewer hospitals In the Household Survey an absolute majority (54%) agreed with the principle that resources should be focused into fewer hospitals, while 38% disagreed. There was more disagreement, though, in the Open Questionnaire – with just under two-thirds disagreeing (64%) strongly and only three in ten agreeing. Analysis showed that, if (as a result of all the proposals) respondents would no longer be able to use their local hospital, then their disagreement increased in direct proportion to their additional distance of travel to the nearest hub. In the Open Questionnaire more than half of the organisations responding agreed with the principle of providing reliable healthcare at fewer hospitals; more than two fifths disagreed.
Public Meetings - Providing healthcare services at fewer hospitals Although people recognised the need to address existing service pressures, many concerns were expressed about the transport costs to patients in accessing health services in fewer locations across North Wales.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Open Questionnaire and Household Survey – Same healthcare services within 40 minutes In the Household Survey there was overwhelming support (80%) for the principle that the same healthcare services should be available within 40 minutes’ drive for as many people as possible, whereas only one in six disagreed with this approach. Support was less pronounced in the Open Questionnaire – but there was still absolute majority support (57%, with 37% disagreeing).
Hospital ‘Hubs’
Open Questionnaire and Household Survey In the Household Survey three quarters (74%) agreed that the ten hospitals proposed by BCUHB are the most appropriate hospitals as ‘hubs’, while only 17% disagreed. However, in the Open Questionnaire opinion was divided: 43% agreed and 49% disagreed. Analysis showed that, if (as a result of all the proposals) respondents would no longer be able to use their local hospital, then their disagreement increased in proportion to their additional distance of travel to the nearest hub. Disagreement was more pronounced for those who would have to travel an extra 10km or more. Organisations completing the Open Questionnaire were divided in their opinions on the ten ‘hubs’: 48% agreed and 42% disagreed.
Public Meetings Hospital hubs were fiercely debated at most of the public meetings, where the main queries, issues and concerns raised were: Earlier reviews and alleged broken promises by BCUHB, resulting in a lack of confidence in current proposals The chosen locations (with various alternatives proposed) – and whether projected population changes have been accounted for in making these choices The potentially high costs involved in accessing ‘hub’ services, which may mean more pressure on local GPs BCUHB’s plans for redundant assets no longer required when ‘hubs’ are developed Whether BCUHB has undertaken a Health and Equalities Impact Assessment on the ‘hub’ proposal.
Minor Injuries Services
Open Questionnaire and Household Survey In the Household Survey absolute majorities agreed with the proposals for Minor Injuries Services: 56% agreed with the principle that Minor Injuries Services should be provided at fewer hospitals and 54% agreed with the Health Board’s specific proposals. Around a third (35% and 33% respectively) disagreed with the principle and with the proposals. In the Open Questionnaire there was more disagreement with the proposals for Minor Injuries Services, with six in ten (61%, (44% strongly)) disagreeing with both the principle and proposals.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Further analysis showed that if (as a result of all the proposals) respondents would no longer be able to use their local hospital, then their disagreement increased in direct proportion to their additional distance of travel to the nearest hub. In the Open Questionnaire the organisations responding were divided in their opinions on the proposals for Minor Injuries Services.
Public Focus Groups At Chirk, a majority of more than two-to-one agreed that centralising minor injuries services is reasonable in principle – but the group also opposed the closure of the Minor Injuries Unit (MIU) at Chirk Community Hospital by the same majority, mainly because people would have to travel further to Wrexham. The proposed closure of the MIU at Colwyn Bay was not controversial for the Conwy group. In fact, many were not aware of its existence and, of those who were, most tend to use Llandudno due to the greater range of services there. There was, however, some concern about the distance to Llandudno or Glan Clwyd for those without their own transport, and the potential extra demand on ‘hub’ hospitals – especially Glan Clwyd. At Ruthin, it was said that the MIU is not well-used because local people are unaware it exists. Indeed, there was considerable concern about the impact of its proposed closure on demand at Ysbyty Glan Clwyd – and it was suggested that better promotion of the Unit would increase usage and lessen demand on the acute hospital. If the MIU is closed, participants strongly desired the provision of routine appointments (e.g. dressing changes) locally.
Public Meetings The issue of Minor Injuries Services was keenly debated in many meetings, where the main areas of discussion were: BCUHB’s decision-making process, particularly with regard to how decisions on where to locate the hospital ‘hubs’ were made The need for more detail on current and projected service usage – as well as on the cost savings from individual (local closures) and collective changes (full service review) Transport and travel difficulties (particularly using public transport in rural North Wales) The implications of the proposed changes for GP services.
X-Ray Services
Open Questionnaire and Household Survey In the Household Survey absolute majorities agreed with the principle of X-Ray services being concentrated in fewer places (56%) and with the specific proposals for X-Ray services (55%). Around a third disagreed with the principle (36%) and the proposals (30%). However, in the Open Questionnaire the majority of respondents opposed both the principle (53% (37% strongly)) and the proposals (54% (36% strongly)) for X-Ray services. In the Open Questionnaire the majority of the organisations (52%) responding agreed with the principle of concentrating X-Ray services in fewer places, whereas their opinion was divided on the proposals.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Public Focus Groups Mold residents were greatly concerned about the proposed closure of the X-Ray department (and indeed the MIU) at Mold Community Hospital. These were considered to be well-used services that are very much needed by Mold’s growing population, as well as the large number of schools in the area that rely on them. The Mold Community Hospital League of Friends has apparently offered to buy a new X-Ray machine in a bid to retain the service – an offer that it was considered prudent for BCUHB to accept.
Public Meetings There was little or no discussion about BCUHB’s proposals for X-Ray services at most meetings, but there was debate at Tywyn, Ruthin, Pwllheli, Caernarfon and Mold. The main areas of discussion were: BCUHB’s decision-making process, particularly with regard to how decisions to focus X-Ray services at chosen ‘hubs’ were made Whether people’s views will influence decisions on ‘hub’ locations The need for more information on the evidence (financial and statistical) that led to BCUHB’s proposals The cost/benefit of various service location options Travel costs for patients and the reliability of public transport Whether staff recruitment issues influenced the location of the proposed ‘hubs’ The risk of closure for remaining services after the ‘hubs’ are developed.
Local Services in Blaenau Ffestiniog
Open Questionnaire and Household Survey In the Household Survey absolute majorities supported the proposals for a new facility (58%) and the expansion of primary care services (58%) at Ffestiniog Memorial Hospital. However, there was less support for the proposal to remove community inpatient beds from Ffestiniog to Ysbyty Alltwen, with only three in ten (29%) agreeing with this proposal. Most residents (43%) neither agreed nor disagreed with removing beds. In the Open Questionnaire there was support for developing a new facility (45% agreed and 28% disagreed) and expanding primary care services (57% agreed and 14% disagreed) at Ffestiniog. However, there was opposition to the proposal to move community inpatient beds (49% disagreed and 23% agreed). Analysis showed that opposition levels to all proposals were higher from respondents living within 10km of Ffestiniog Memorial Hospital, particularly with regard to the proposal to relocate community inpatient beds. In the Open Questionnaire the majority of organisations agreed with the proposals to develop a new facility and expand primary care services at Ffestiniog; however, more than half disagreed with the proposal to move community inpatient beds.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Public Focus Groups There was a great deal of concern at the Gwynedd group about the loss of inpatient beds from Blaenau Ffestiniog Memorial Hospital (and Dolgellau Community Hospital), mainly due to the reduction in local respite and convalescent services and the potential for increased pressure on general wards and patients’ families. There was significant support for retaining Blaenau Ffestiniog Memorial Hospital where, it was thought, excellent care is provide in an adequate setting. People’s main concern was the distance and journey time to Ysbyty Gwynedd and Ysbyty Alltwen – but they were also worried (a concern that has apparently been fuelled by the local press) that the hospital will be used for drug rehabilitation in future. The development of a full A&E service at Alltwen Hospital was strongly advocated.
Public Meetings The public meetings at Blaenau Ffestiniog were preceded by a protest meeting of circa 150 protestors. In the meetings, participants expressed concern about the consultation process and how seriously it will be considered – and worried that their questions and responses to BCUHB had received no response. They also sought reassurance that the petition gathered in the area would be taken into account.
Local Services in North Denbighshire - Rhyl and Prestatyn
Open Questionnaire and Household Survey In the Household Survey an absolute majority (62%) agreed with the proposal to develop a new hospital on the Royal Alexandra Hospital site to replace other health service facilities in the area. Further analysis showed that the majority of residents supported the proposal regardless of their distance from Royal Alexandra Hospital. In the Open Questionnaire there was more opposition to the proposal - with more than half disagreeing (55%). However, it should be noted that responses from a Prestatyn pressure group substantially influenced the overall balance of opinion in the Open Questionnaire – partly because all of them strongly disagreed with the proposal, compared with only a third of other respondents who disagreed. Further analysis of the Open Questionnaire showed that opposition was highest amongst respondents living within 5km of Prestatyn Community Hospital, and within 10km of Royal Alexandra Hospital. In other words, the opposition is intensely local on this issue. In the Open Questionnaire almost two thirds (65%) of organisations supported the proposal to develop a new hospital on the Royal Alexandra site.
Public Focus Groups The Royal Alexandra Hospital (Rhyl) and Prestatyn Community Hospital were typically considered expensive to run and unsuitable as modern healthcare facilities. The Denbighshire focus group generally welcomed the proposed new integrated facility, with the strong caveat that it is in place prior to the removal of existing facilities. There was also some interest in how the Royal Alexandra building will be redeveloped given that it is Grade II listed and thus subject to restrictions.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Public Meetings The most significant concerns at the public meetings related to Prestatyn Community Hospital. People sought reassurance on the future use of the building (and questioned whether BCUHB will dispose of it) – and were concerned that current services will cease before new services are launched. There were also concerns about the risks to local older people with mental health problems as a result of the proposals.
Local Services in Llangollen
Open Questionnaire and Household Survey In the Household Survey there was absolute majority (57%) agreement with the proposal for an extended primary care centre in Llangollen. However, in the same survey, opinion was broadly divided on moving community inpatient beds from Llangollen Community Hospital to local care homes or Chirk Community Hospital – with 35% agreeing, 35% neither agreeing nor disagreeing and 29% disagreeing. In the Open Questionnaire the majority (52%) in favour of an extended primary care centre in Llangollen was only slightly smaller than in the Household Survey. However, unlike the Household Survey, a majority (50%) disagreed with removing community inpatient beds. Further analysis showed that those who live within 10km of Llangollen Community Hospital were much more likely than average to disagree with removing beds. In the Open Questionnaire more than two thirds of organisations responding agreed with the proposal for an extended primary care centre; but more than three fifths disagreed with removing community inpatient beds.
Public Focus Groups There was little concern in the Wrexham Focus Group (held in Chirk) about the proposed changes to Llangollen Community Hospital - even among the participants from Llangollen itself. The group was unanimous that it is reasonable on the basis of the evidence, and commented that the hospital is an old, unsuitable building and that some services (such as the MIU) are unavailable much of the time.
Public Meetings The proposed closure of Llangollen Community Hospital was discussed at both Llangollen and Wrexham. There were more significant concerns at the former – particularly in relation to the loss of inpatient beds. People’s other main concerns were: Travel distances, the cost of transport and overall access to other hospitals The potential for current services to cease before new services are in place Whether the proposed new primary care centre (and local GPs) will be able to cope with future demand increases Whether funding has been secured for the new service.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Local Services in Flint
Open Questionnaire and Household Survey In the Household Survey there was absolute majority (62%) agreement with the proposal for an extended primary care centre in Flint. However, in the same survey, there was a broad division in opinion on the proposal to move community inpatient beds from Flint Community Hospital to Holywell Community Hospital – with 36% agreeing, 25% disagreeing and many residents (40%) neither agreeing nor disagreeing. In the Open Questionnaire a similar majority (57%) were also in favour of an extended primary care centre in Flint; but nearly half (48%) opposed moving community inpatient beds. Further analysis in both surveys showed that those who live within 10km of Flint Community Hospital were much more likely than average to disagree with both proposals, but moreso with moving community inpatient beds. In the Open Questionnaire the organisations responding were broadly divided in their opinions on an extended primary care centre in Flint. However, more than half disagreed with moving community inpatient beds.
Public Focus Groups Three public focus groups were held in Flint due to the strength of feeling locally about the proposed closure of Flint Community Hospital. The first group discussed the full range of BCUHB proposals and the remaining two focused only on those for Flint. All participants across the three groups were initially strongly against the proposal for the following reasons: It is a community resource that has ‘always been there and always should be’ It provides well-used, efficient, flexible services The distance to Hollywell is too great (and the hospital is not easily accessible via public transport) Flint’s large and expanding population warrants a community hospital The potential for increased demand on other hospitals and the Ambulance Service An emotional attachment to the hospital due to personal experience or the experience of loved ones It allows terminally ill people to die close to home (and family and friends). After discussion, while still inherently opposed to the closure of their local hospital, participants at two of the three groups softened their stance somewhat after considering the proposed new Primary Care Resource Centre (which some people were wholly unaware of). However, they wished to reserve their judgement until they knew what will be in this new centre, when it will be built and where exactly it will be – and also felt they could only accept it if the community hospital remains open until it is complete and that it provides Minor Injuries and Phlebotomy services. Some people in these two groups did not consider it reasonable that the town should have to wait until 2016 for the new facility – and would thus prefer to see BCUHB developing the existing hospital to house the Resource Centre. Participants in the third group remained wholly opposed to the closure of Flint Community Hospital and the development of a new Primary Care Resource Centre at the end of the session.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Public Meetings There was considerable opposition at Flint to the proposed closure of the town’s Community Hospital (and reference was made to the ongoing campaign to save it). In relation to the proposed new Primary Care Resource Centre, people at Flint were mainly concerned about: Whether it will adequately serve the community Whether the predicted costs for its development are accurate Whether the required funding is sufficient and secure.
Older People’s Mental Health
Open Questionnaire and Household Survey
Older People’s Mental Health In the Household Survey there was overwhelming support (91%) for the proposals for older people’s mental health. Further analysis showed support for the proposals regardless of which District General Hospital residents lived nearest to. In the Open Questionnaire the majority (64%) also agreed with these proposals, though more than a quarter (27%) disagreed. In the Open Questionnaire more than three quarters of the organisations responding agreed with the proposals for older people’s mental health.
Additional Proposals for Conwy and Denbighshire In the Household Survey an absolute majority (64%) agreed with the additional proposals for Conwy and Denbighshire. However, in the Open questionnaire there was majority opposition to the additional proposals for Conwy and Denbighshire: just over a third (35%) agreed with the proposals, whereas one in two (47%) disagreed. In the Open Questionnaire almost half of the organisations responding agreed with the additional proposals for Conwy and Denbighshire.
Additional Proposals for Gwynedd and Anglesey In the Household Survey there was a balance in favour of the additional proposals for Gwynedd and Anglesey – 40% agreed and 30% disagreed. However, in the Open Questionnaire the majority (52%) opposed the proposals. In the Open Questionnaire more than three fifths of the organisations disagreed with the proposals; almost half strongly disagreed.
Public Focus Groups Although there was a great deal of support for the proposal to provide more community-based care for older people with mental health issues, there was also considerable scepticism about its implementation. People’s main concerns were that: The change will place pressure on families to care for their elderly relatives (which could lead to more patients being placed in care homes)
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
It may not be safest or most practicable option for many BCUHB will be unable to recruit enough staff to provide a sufficiently decent standard of care Patients could end up in inappropriate care settings to make room on acute wards. If implemented, it was felt that proper community services must be in place prior to the removal of inpatient beds from hospitals. The Llangefni group strongly desired the retention of inpatient beds at Cefni Hospital to provide respite care for elderly patients with mental health issues. In fact, this group was concerned generally about the reduction in the number of inpatient beds at their local hospital, especially with respect to: the loss of local convalescence facilities; the potential for bed-blocking in acute hospitals; and the possible additional pressure on Ysbyty Gwynedd and Ysbyty Penrhos Stanley and on patients’ families, neighbours and friends.
Public Meetings Older People’s Mental Health was a topic of considerable concern to attendees, particularly with respect to: The recognition of projected demand (especially with respect to dementia) and the implications for services Older people living alone and the need for a preventative ‘at home’ care service Levels of respite care provision for carers The need for an effective out of hours service for older people The quality and range of private nursing homes The recruitment and retention of specialist staff Travel and transport (and the particular challenge of rural North Wales).
Neonatal Intensive Care
Open Questionnaire and Household Survey In the Household Survey the majority (47%) disagreed with the proposal to provide long term Neonatal Intensive Care Services from Arrowe Park Hospital, while 37% agreed. There was more disagreement in the Open Questionnaire - with seven in ten (71%) disagreeing and only a fifth (22%) agreeing. However, it should be noted that responses from a Prestatyn pressure group substantially influenced the balance of opinion in the Open Questionnaire – partly because all of them strongly disagreed with the proposal, compared with three fifths (60%) of other respondents who disagreed. Further analysis showed that there was general disagreement with the proposal across all of North Wales. However, the Household Survey showed that residents whose nearest District General Hospitals are Bronglais and Ysbyty Glan Clwyd were more likely than average to disagree. In the Open Questionnaire more than half of organisations responding disagreed with providing long term Neonatal Intensive Care Services from Arrowe Park Hospital. We should note, though, that it seems likely that the Open Questionnaire and Household Survey were both influenced by the wording of the question in this case – which said “all intensive care
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neonatal services” when, in fact, the proposal was for only long-term intensive care (affecting about 36 babies a year).
Public Focus Groups Majorities at Anglesey, Conwy, Flintshire and Gwynedd felt they could support the proposal to provide Neonatal Intensive Care Services from Arrowe Park, given the small number of babies involved and BCUHB’s recruitment issues in this area. However, people sought reassurances that: There will be no service inequality based on nationality Special Care Baby Units (or at least some specialist neonatal equipment) will be maintained at the North Wales acute hospitals After-care can be provided closer to home. There was also some concern that the proposal will worsen recruitment, as the Welsh centres will be seen as ‘second best’ and will struggle to attract good quality staff. All at the Denbighshire group and five of 11 at Wrexham opposed the proposal. They felt services should be developed in North Wales for the following reasons: The distance to Arrowe Park (especially from western areas) – and the impact of this on babies, their parents and their siblings Arrowe Park’s capacity to care for North Wales babies The lack of Welsh language provision at Arrowe Park The issue of nationality (i.e. ‘Welsh’ children being born in a different country) The potential for Welsh patients to be treated with less urgency The possible worsening of recruitment issues (as above). It should also be noted that all groups had difficulty distinguishing between long-term complex and ‘routine’ short-term neonatal intensive care; and were unaware of the small numbers involved with respect to the former.
Public Meetings The provision of Neonatal Intensive Care Services from Arrowe Park was discussed keenly in all sessions. There was no overall consensus on the issue of local services versus excellence. There was, however, a great deal of regret about the loss of specialist neonatal skills from North Wales – and people sought reassurance that Arrowe Park has the capacity to take the affected North Wales babies and can meet BAPM standards. Other issues raised were: the potential difficulties involved in transferring serious cases and the impact of this on affected babies; the need to provide a bi-lingual, professional service at a difficult time for parents; the need for the service level agreement between BCHUB and Arrowe Park to be comprehensive, able to cope with future demand, and deliver on quality and cost; and the implications of Welsh money being spent in England, and ‘Welsh’ babies being born in a different country.
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Vascular Services
Open Questionnaire and Household Survey In the Household Survey an absolute majority (68%) agreed with the proposal to provide vascular services at one specialist centre in North Wales, though one in five (19%) disagreed. In the Open Questionnaire a majority (50%) also agreed with providing vascular services at one specialist centre in North Wales, although more than two fifths (42%) disagreed. Once more, responses from a Prestatyn pressure group substantially influenced the balance of opinion in the Open Questionnaire – partly because all but one of them strongly disagreed with the proposal, compared with less than a third (31%) of other respondents who disagreed. In the Household Survey the majority (48%) favoured Glan Clwyd Hospital as the location for a specialist centre for vascular services, followed by Wrexham Maelor Hospital (33%) and Ysbyty Gwynedd (19%). In the Open Questionnaire there was even stronger support for Glan Clwyd Hospital as the preferred location for the specialist centre (69%). There was proportionally less support for Wrexham Maelor Hospital (17%) and Ysbyty Gwynedd (13%). In the Open Questionnaire around three fifths of the organisations responding supported the proposal to provide vascular services at one specialist centre in North Wales. Half of organisations identified Glan Clwyd Hospital as the preferred location for the centre.
Public Focus Groups There was widespread support for centralising complex vascular services, with before- and after- care being provided at local hospitals. People’s main reasons for offering their support were: the small numbers of patients involved; that most people would be prepared to travel for specialist care; and that the change will improve patient outcomes (if BCUHB can attract and retain sufficient specialist staff). There were a couple of main concerns, however – namely the increased travelling distances for some patients; and the pressure on a single centre in terms of having single points of failure. Opinions were divided on whether there should be one specialist vascular centre or two. If BCUHB decides on one, there was an overall preference for Glan Clwyd as it is more central and the fairest location for the North Wales Community.
Public Meetings The proposals for Vascular Services were discussed in most meetings where people were broadly in favour of them. There were, however, some concerns about the implications of having just one specialist centre, particularly in relation to transport (and the risks of travelling) for very ill patients. People were also worried about how the proposed service would cope with emergency cases. There was no clear consensus in terms of location, but it was clear that people in the west of North Wales feared having to travel furthest. People urged BCUHB to consider carefully the issue of location, as it was argued that the recruitment of specialist staff will be dependent on this.
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Submissions
Introduction 17. During the formal consultation process 779 written submissions were received from professional, political, interest, voluntary and community groups as well as from many residents and staff. The full report contains a detailed tabulated analysis of the points made by the various organisations and people making submissions. 18. In addition, as well as identifying the important general themes and topics in the tabulated analysis, a selected range of the submissions (which were often very long) has been summarised in detail by ORS in the main report, in order to make them more accessible to interested readers. It was neither practical nor necessary to summarise all the submissions in the same manner (for their general content is tabulated), but we trust we have chosen a fairly wide range of important submissions for illustration. Our summaries cannot do full justice to the arguments and evidence of the many detailed and lengthy submissions, but they at least make them accessible and capture important arguments. If readers wish to go into further detail, they are encouraged to refer to the submissions documents available from BCUHB.
Selected Abstracts 19. As a guide to the content of the important submissions selected for summary in the full report, key abstracts are given immediately below. The submissions selected for detailed summary were chosen on the basis of the nature and importance of the organisations/individuals concerned and/or their relative prominence in public debate of the issues. 20. Many of those below are broadly positive about BCUHB’s proposals, but there is also important and forthright criticism from some community groups, staff and organisations. The overall impression these submissions make on readers will depend primarily on the relative weights that readers give to the sources of the submissions and to their respective arguments and reasoning. For example, readers must decide how to balance the judgements of key professional bodies compared with community and other organisations’ views. Key abstracts of the selected submissions are as follows.
Professional Bodies and NHS Organisations Royal College of Surgeons Professional Affairs Board in Wales (RCSPABW): disagrees with BCUHB’s proposal to continue emergency general surgical services on all three main sites because it is unsustainable and not in the interests of standards, staff and patients. The review is too limited insofar as unscheduled general surgery was not included; but the RCSPABW supports the proposal to centralise vascular surgical services onto a single site. Royal College of Midwives Wales: main concern is that neonatal intensive care services should be safe, sustainable and as accessible as possible; it does not oppose the Arrowe Park proposal. Royal College of Paediatrics and Child Health and Paediatric and Child Health National Advisory Group: the reconfiguration of paediatric services should be determined by the needs of the local population and the resources available; and BCUHB and the Welsh Government are best placed to make the difficult decisions. The guiding criteria should be the quality and safety of care, rather than simply access.
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Royal College of Nursing in Wales (RCNW): supports BCUHB’s case for change, but opposes outsourcing neonatal intensive care services to Arrowe Park. It does not oppose the other main proposals, but says that better financial and general planning is required for their successful implementation. Royal College of Psychiatrists in Wales (RCPW): supports the move towards community rather than inpatient care, but wants to know how sustainable 24-hour emergency mental health care will be provided. [This submission is the same as the one from the National Specialist Advisory Group: Mental Health]. Wales Deanery (WD): The WD says it is important for BCUHB and the Deanery to work together. National Clinical Forum (NCF): supports the proposals since they will aid the development of quality, sustainable services for North Wales. The review should have been wider in also including an examination of the sustainability of other specialist services. The NCF supports as much care in the community as possible; but it is crucial to develop community services before reducing inpatient care. Chartered Society of Physiotherapists (CSP): supports care closer to home and sees opportunities for physiotherapists and other health professionals to make a greater contribution within ‘extended primary care teams’; but says that transport is a key issue to get right. Hywel Dda Health Board (HDdHB): recognises the need for the modernisation of healthcare services and wishes to work in collaboration with adjoining health boards. Powys Teaching Health Board (PTHB): supports BCUHB’s direction of travel and believes the boards should work with Hywel Dda to enhance joint planning and delivery of healthcare across rural Wales. Wales Abdominal Aortic Aneurysm Screening Programme (WAAASP): recommends that BCUHB should have a single inpatient arterial site in order to meet professional and training standards. Public Health Wales (PHW): supports BCUHB’s approach while recognising that further work is required on some issues. British Medical Association: Clwyd North Division (BMACND): the status quo is unsustainable; but the Arrowe Park proposal should be reconsidered in favour of keeping level three services at Glan Clwyd. It supports centralising vascular emergency surgery, also at Glan Clwyd, but is concerned about the loss of community beds and believes some of BCUHB’s planning has been too vague. Welsh Ambulance Services NHS Trust (WAST): BCUHB’s general strategy is correct, but wants to see more detailed service models and information on funding to meet additional costs. Older People’s Commissioner for Wales (OPCW): expresses some concern about the consultation process. Community Pharmacy Wales North Regional Committee (CPWNRC): does not comment directly on BCUHB’s proposals, but supports the transfer of more care into the community and urges a bigger and more positive role for community pharmacies as “healthy living centres.” Liverpool Women’s NHS Foundation Trust (LWFT): makes a formal objection to BCUHB’s proposal to commission services from Arrowe Park without considering LWFT as an alternative provider. LWFT has a superior neonatal unit that already provides important services to BCUHB, would not involve significantly different travel times from North Wales, and could provide the services more cost-effectively.
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Unison Wales: agrees with BCUHB’s mission statement but urges that changes to services should not be implemented before alternative provision is in place.
Local Authorities and Statutory Bodies Conwy County Borough Council (CCBC): supports the centralisation of some specialist services, including vascular services at Glan Clwyd, but questions the Arrowe Park proposal. Is particularly concerned that services at Colwyn Bay hospital should be retained in full and that community services should be well established before current services are withdrawn. Is not confident that enhanced community care can be successfully delivered. Denbighshire County Council (DCC): pleased that three DGH sites are being maintained while accepting the need for specialised services to be concentrated on fewer sites, including vascular services at Glan Clwyd; but it doubts the need for outsourcing to Arrowe Park. It broadly supports most of the proposals for community hospitals, but emphasises that existing facilities should not close until new services are properly in place. Gwynedd County Council (GCC): recognises the need for change and welcomes the change of emphasis from acute hospitals to community care, but the new approach will need improved joint working with local authorities and the third sector. Finds strengths and weaknesses in proposals for local hospitals, and stresses that changes should not be implemented until new services are in place. Flintshire County Council (FCC): broadly supports the Arrowe Park and vascular services plans, but urges BCUHB to withdraw all its proposals because, although strategically sound, they lack proper planning. Isle of Anglesey County Council (ACC): wants to strengthen Welsh language provision and move more services into the community to reduce pressure on acute hospitals and provide accessible care. Accepts the centralisation of some services, including long-term specialist neonatal care at Arrowe Park, but accommodation should be provided there for patients’ families. The best use should be made of Cefni and Penrhos Stanley community hospitals, and sufficient resources should be available to strengthen mental health care and other community services. Wrexham County Borough Council (WCBC): asks questions about neonatal intensive care, vascular services and older people’s mental health, but does not oppose the proposals. Raises questions about how enhanced 24/7 community care will be delivered. North Wales Fire and Rescue Service (NWFRS): recognises the need for healthcare changes and says that BCUHB’s plans balance local access against requirements for specialist services. Does not comment on specific proposals but wishes to develop the current partnership in the context of community care. North Wales Police - Chief Constable (CCNWP): does not comment on the individual proposals, but makes observations on delayed ambulance responses and access to services for those with mental health problems.
Betsi Cadwaladr University Health Board Staff Cardiology Department (Glan Clwyd): Glan Clwyd’s accreditation for the catheter laboratory’s interventional cardiac procedures requires the availability of on-site vascular surgery – and this interdependency should be taken into account when vascular services are reorganised.
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Two Consultant General and Vascular Surgeons (Wrexham): concentrating major arterial surgery on a single site would make routine vascular services unviable at the remaining two acute hospitals without improving overall patient safety; so a two-site model is more reasonable. North Wales Advanced Neonatal Nurse Practitioners (Glan Clwyd) (NWANNPs): the dangers of post-natal transfers to Arrowe Park have been under-estimated while the merits of care there have been exaggerated. There are risks and inconvenience associated with transfers to the Wirral.
Special Interest, Voluntary and Community Groups Mold Labour Party (MLP): Mold needs small injuries and X-Ray services because it is a natural hub to a sizeable community. Dwyfor Labour Party (DLP): BCUHB should rethink its proposals radically in order to meet the health needs of rural communities in upland areas of North Wales. The Board should not close community hospitals, but make better use of them with step-up-step-down facilities while also developing level three intensive care neonatal service in North Wales. Wrexham Plaid Cymru (WPC): all neonatal intensive care services should be retained in North Wales because of deficiencies at Arrowe Park and access difficulties. Blaenau Ffestiniog Hospital Defence Committee (BFHDC): Very strongly opposes the proposed closure of the Memorial Hospital: it should retain its 12 inpatient beds and five (already removed) should be reinstated, as well as the minor injuries service. Community Hospitals Association (CHA): the proposals for community hospitals, minor injuries units, X-Ray facilities and hub hospitals jeopardise healthcare by reducing both access and community capacity, leading to a greater not lesser reliance on specialist acute services. National Specialist Advisory Group Mental Health: supports the move towards community rather than inpatient care, but wants to know how sustainable 24-hour emergency mental health care will be provided. [This submission is the same as the one from the Royal College of Psychiatrists in Wales]. North Wales Social Services Improvement Collaboration (NWSSIC): supports the strategic changes that BCUHB is making and accepts the proposals for vascular and intensive neonatal care services; but objects to closing/downgrading community hospitals. Accepts the principle of hubs, but questions the choices made. There should be a more detailed business case with costs, timetables and continuity of care during organisational change. There should be clarity and joint planning about the impact of health service changes on social services.
Assembly Members and Members of Parliament Rebecca Evans AM (RE): questions aspects of the consultation process and raises a number of issues about the data used to justify the outcomes of BCUHB’s planning process. Janet Finch-Saunders, AM for Aberconwy and Shadow Minister for Local Government (JFS): funding cuts are jeopardising patients by leading to undue centralisation of services and undesirable outsourcing of level three neonatal services. Mental health and other services should achieve a balance between care in the community and access to local inpatient beds; and Llandudno hospital should continue as a major facility.
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Llyr Gruffydd, AM (LG): objects strongly to the proposals for neonatal intensive care and community hospital services: both proposals will worsen standards and access for patients. Also encloses a range of anonymous submissions. David Hanson MP (DH): passes on the concerns of Flint Town Council about the closure of Flint Community Hospital and also asks questions about Mold Hospital. Ann Jones AM (AJ): passes on the objections of “Cuddles” about the outsourcing of level three neonatal services to Arrowe Park. Elfyn Llwyd, MP (EL): Tywyn’s services should be protected due to its remoteness and visitor numbers. Sandy Mewies AM (SM): passes on residents’ objections to the proposals for Flint hospital and Mold minor injuries and X-Ray services. There is no objection in principle to hubs, but their location is important. Darren Millar AM (DM): accepts the proposal for vascular services, but criticises plans for neonatal services while also objecting to proposals for minor injuries and X-Ray services at Colwyn Bay and Ruthin. Aled Rhys Roberts AM (ARR): accepts the need to reform healthcare, but more evidence and implementation planning is required before changes can be justified in practice. Chris Ruane, MP (CR): expresses concerns about the conduct of the consultation. Antoinette Sandbach AM (AS): the distribution of information about the consultation proposals has not been effective in all cases and so the response timetable should be extended. Level three neonatal services should be retained at Glan Clwyd, not outsourced to Arrowe Park, and community hospitals should not be closed on the basis of current evidence. Ken Skates AM (KS): supports health service reform and the new health centre in Llangollen, but seeks information to set the record straight and to ensure that all avenues are explored before changes are implemented at Chirk and Llangollen. Joyce Watson AM (JW): objects to the closure of Blaenau Ffestiniog hospital, which will lead to considerable access problems for local people. 21. All of the above submissions were selected for detailed summary in the full report on the basis of the nature and importance of the organisations/individuals concerned or their relative prominence in public debate of the issues. 22. It should be recognised, though, that there was a total of 779 submissions, with 535 from individual residents. Whereas many of the professional bodies and others cited above are relatively favourable to BCUHB’s proposals, the submissions from residents and other organisations were almost uniformly critical. Their concerns are clearly detailed in the main report and should not be overlooked because they deal with important local issues. Briefly, the main issues and themes raised in the majority of submissions were as follows: Opposition to the proposed closure of local hospitals or departments Distance, travel and transport considerations Increased pressure on acute and other proposed ‘hub’ hospitals – as well as the Ambulance Service Loss of local rehabilitation, convalescence and respite facilities
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Needed to cater for growing and ageing populations Lack of information about proposed replacements (i.e. Primary Care Resource Centres). Opposition to the provision of Neonatal Intensive Care Services from Arrowe Park Distance, travel and transport considerations Practical and emotional strain on parents and families Nationality issues (i.e. ‘Welsh’ babies born in a different country and the need for Welsh language provision at Arrowe Park) BAPM standards not met at Arrowe Park More cots and a better staff/child ratio at North Wales hospitals currently De-skilling of North Wales staff – and a negative effect on future recruitment to North Wales services. Support for more community-based care in principle, but concerns about its practical implementation – and a strong desire for good community provision to be in place prior to removal of existing services. Most support for (although also some opposition to) proposals for Vascular Services.
Petitions
23. During the formal consultation the total number of signatures on petitions received was 12,068, but a petition with 3,891 names from Blaenau Ffestiniog is also relevant despite being submitted during the summer (before the consultation period began). The petitions were as follows: 3,457 signatures to save the MIU at Chirk Community Hospital from closure 2,403 signatures to oppose the closure of the MIU and X-Ray service at Mold Community Hospital – and to urge BCUHB to make Mold the ‘hub’ for the area (since Deeside Hospital has no MIU currently) 42 signatures to oppose the closure of the Minor Injuries and X-Ray Units at Mold Community Hospital 1,990 signatures (organised by the organisation Cuddles) to oppose the provision of Neonatal Intensive Care Services from Arrowe Park 1,249 signatures against the closure of the X-Ray service and reduced MIU hours at Tywyn Community Hospital 1,240 signatures against the proposed closure of Llangollen Community Hospital 1027 signed template letters to oppose the closure of the MIU at Colwyn Bay Community Hospital 76 signatures (collected by the Colwyn Bay Action Group) against the closure of the Minor Injuries Unit at Colwyn Bay Community Hospital 228 signatures to protest against the need to pre-book spaces at BCUHB’s public meetings 168 signatures on an e-petition (organised by Mike Parry) entitled ‘medical emergency - preventing the introduction of a poorer Health Service for North Wales’ 92 signatures calling on BCUHB to improve services at Ruthin Community Hospital
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78 Signatures (petition organised by Clwb-y-Ffrith in Prestatyn) against the proposed closure of Prestatyn Community Hospital 18 signatures to develop Blaenau Ffestiniog Memorial Hospital as a ‘hub’ hospital. 24. The petitions are clearly important and BCUHB will treat them very seriously, but the Board should also note that petitions can exaggerate public sentiments and fail to take account of the needs of the whole Betsi Cadwaladr area.
Towards Conclusions
Introduction 25. It would be a brave author who claimed to derive unambiguous conclusions from the various consultation elements reported here, but without hubris it is possible to identify some signposts to assist the Board and others in their deliberations.
Reviewing the Evidence 26. The submissions made during the consultation are clearly very important and they fall into two distinct groups: those from professional bodies, which mainly broadly support BCUHB’s proposals while raising issues about the implementation of ‘community care’, and those from residents and community organisations, which typically object strongly to any centralisation at the expense of local access to services. 27. The conclusions the Board reaches about the issues will depend partly on how its members weigh the inevitably smaller number of professional bodies’ submissions alongside the greater numbers from community groups and residents. This is a critical issue. For example, some professionals groups believe BCUHB has been too conservative in its review, whereas many community groups and residents would radically disagree with greater centralisation of specialised services – so the tension between safety, specialisation and resilience, on the one hand, and local access on the other, defines the dilemma for the Board. 28. The Board will also wish to consider the focus groups, in which randomly selected people reflected relatively dispassionately about the proposals – and, though they did not welcome some of the changes, many could accept them in the light of the Board’s key considerations. In Flint, though, feelings were particularly high – and some were even reluctant to attend the meetings following local publicity. 29. The considerable and detailed quantitative data are important for the Board to consider. As we have said, the Household Survey findings are much more representative of the general population than the Open Questionnaire data – in which Denbighshire, and also people aged 55-74, are over-represented compared with Wrexham and other areas, and those under-35, who are under-represented. 30. Of course, the responses to the Open Questionnaire reflect the strength of feeling of many people in Denbighshire – and in particular Prestatyn: that is democracy in action; and it is good that people organise to promote their ideas and protect their interests; but the BCUHB has to make public policy choices on the basis of the safety, quality and sustainability of services, as well as accessibility, for the whole of its area. 31. The views expressed in the 48 public meetings, and also in the petitions, are also important and need to be weighed by the Board alongside all the other material.
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Overall Conclusions
Introduction 32. As we have said, there can be no ‘definitive’ interpretation of this complex material and the diverse opinions expressed through so many consultation routes; and ORS does not presume to tell the Board what to think. Nonetheless, part of our role is to highlight what we consider to be the key conclusions that can reasonably be derived from all the material in this report – and these follow, under headings for each of the key proposals.
Healthcare Services Where You Live – the principles 33. There was clearly strong support for the Health Board’s three key priorities for healthcare, which was evident across all elements of the consultation. 34. There was also support for the principles that resources should be focused into fewer hospitals and that the same healthcare services should be available within 40 minutes’ drive for as many people as possible. The Household Survey showed that an absolute majority of residents support both principles. Very few submissions question the principle of ‘hub hospitals’, and some of those who do are more concerned about the choice of locations rather than with the very principle. However, whilst the Open Questionnaire supported the same services being available for as many as possible, there was clear disagreement with the principle of fewer hospitals. 35. Despite this support, responses about these priorities and principles raised concerns about the interlinked problems of transport (particularly for those without cars) and access to community or acute hospitals. These issues were highlighted in questionnaire responses as well as many submissions, with a number promoting a holistic approach to encompass transport planning as well as healthcare issues. 36. The consultation also highlighted doubts about the deliverability of enhanced care in the community – in relation to: the readiness or capacity of GPs; whether funding will be available; whether there is a secure business case; whether the staff and community facilities will cope in practice with the demands for care; and whether health and social services staff will develop effective partnerships. Across all elements of the consultation, it was argued strongly that existing facilities and services should not be removed until alternative community-based services are successfully in place.
Healthcare Services Where You Live – the specific proposals 37. There was less consensus about the specific ‘Hub Hospitals’ proposed. Views differed by location, with particular disagreement in those areas where the proposals mean that services would no longer be provided at the local hospital. The proposed locations for hubs were fiercely debated at the public meetings, and many submissions (especially those from local residents) raised concerns. Opinion was clearly divided about the specific proposals in the Open Questionnaire: 43% agreed, 49% disagreed; but it was evident that disagreement increased in proportion to the additional distance to the nearest proposed hub. Nevertheless, the Household Survey showed strong support from the general population for the ten hospitals proposed: three quarters (74%) agreed while only 17% disagreed. 38. In the Household Survey there was majority support for the principle and proposals for Minor Injuries Services and X-Ray Services, but in the Open Questionnaire there was an absolute majority in opposition. Many had general concerns about the specific locations for the ‘Hub Hospitals’ and about travel and transport.
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39. With regard to specific local services, the consultation showed majority support for the proposals to develop facilities and expand primary care in local areas; but there was strong localised opposition to moving community inpatient beds evident across all elements of the consultation. In particular, many written submissions were received from organisations and local residents were critical of the proposed changes and numerous petitions were presented about specific local proposals.
Older People’s Mental Health 40. The consultation showed strong support for the proposals for older people’s mental health, though there were some anxieties over the additional local proposals – particularly those in Gwynedd and Anglesey, where opinion was divided. 41. However, the public meetings and focus groups showed concerns and some scepticism about the implementation – in relation to: the recognition of projected demand (especially with respect to dementia) and implications for services; the need for a preventative ‘at home’ care service especially for older people living alone; the pressure on families and the levels of respite care available; the need for effective out-of- hours services; and issues surrounding staff recruitment and retention. Once again, it was felt that proper community services must be in place prior to the removal of inpatient beds from hospitals.
Neonatal Intensive Care 42. There was widespread opposition to the proposals for providing long-term neonatal intensive care services from Arrowe Park Hospital (although feedback from the consultation showed that there may be some misunderstanding about the proposal only affecting those babies needing long-term complex care, and the small numbers involved). In some cases, disquiet about Arrowe Park was based on its capacity and standards rather than on the principle of outsourcing; but in others it is based on both. 43. Opinion was divided in the Household Survey (37% agree, 47% disagree) but there was more disagreement in the Open Questionnaire, with seven in ten (71%) disagreeing and only a fifth (22%) in agreement. Majorities at some focus groups felt they could support the proposal once the issues had been discussed, but only if the Health Board could guarantee that: there would be no service inequality based on nationality; lower-level neonatal intensive care would be maintained at the North Wales acute hospitals; and after-care was still provided closer to home. However, some focus groups continued to oppose the proposals even after an informed discussion. The proposal was also keenly debated at all of the public meetings, where there was no consensus on the issue of local services versus excellence. 44. Nevertheless, it is notable that most of the submissions from professional bodies support (or do not oppose) the proposals for intensive care neonatal services, though some oppose them particularly strongly. 45. One alternative provider of neonatal services challenges BCUHB’s choice of Arrowe Park while offering standards of care that could well reassure those with doubts about Arrowe Park’s capacity.
Vascular Services 46. Overall, there was strong support to centralise vascular services. There was widespread support at the focus groups (providing that before- and after-care was provided at local hospitals) and people attending the public meetings were also broadly in favour. Both the Household Survey and Open Questionnaire showed that absolute majorities agree with the proposal (68% and 50% respectively), although more than two fifths (42%) did disagree with the proposal in the Open Questionnaire. Similarly, whilst most of the submissions support (or certainly do not oppose) the proposals for vascular services, there are some submissions that are strongly opposed.
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47. There was clear support for Glan Clwyd Hospital being the overall preferred location due to its central location in the BCUHB area. This was evident in the Household Survey (48% support for Glan Clwyd), the Open Questionnaire (69% support for Glan Clwyd) and also at the focus groups. There was no consensus on location from the public meetings, but people urged BCUHB to consider this carefully as it was argued that the recruitment of specialist staff would be dependent on this.
Scope of BCUHB’s Review 48. Finally, we should draw attention to submissions from the National Clinical Forum and the Royal College of Surgeons that say that BCUHB’s review has been too conservative in proposing to continue emergency general surgery on all three acute hospital sites and/or in not examining the sustainability of other specialist services. They believe that the scope of BCUHB’s review should have been wider and more critical in examining the sustainability of current arrangements for emergency general surgery and other specialised services (see the National Clinical Forum and the Royal College of Surgeons Professional Affairs Board in Wales).
The Board’s Dilemmas 49. The comments by the professional bodies highlight the pressures on the Board in the context of the overall consultation outcomes. In its proposals, the Board seems to have tried to steer a middle way between clinical imperatives towards greater centralisation, on the one hand, and urgent community demands for accessible and familiar facilities, on the other; at the same time it faces demanding financial pressures and also the expectations of clinicians, who understandably want to protect their services and establishments. 50. On the evidence of the consultation programme, the challenge for the Board is to maintain both public and professional body confidence in the safety, resilience and accessibility of its healthcare services while also demonstrating that it can successfully deliver the changes it proposes in community care. 51. We trust that this report will make at least some contribution to that endeavour.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
1. Introduction An overview of the formal consultation
Challenges and Changes
1.1 ‘Together for Health’ was published by the Minister for Health and Social Services in November 2011 to offer a five-year vision in the context of the challenges facing the health service in Wales. The document declares that Health Boards need to change to provide the very best quality of services for their population in the future, while also recognising the challenges they face. Betsi Cadwaladr University Health Board (BCUHB) faces particular challenges in running four district general hospitals across a large rural area with a population of about 678,000 people. The specific issues it faces include: an aging population; health inequalities; difficulties in recruiting and retaining sufficient well qualified clinical staff; sustaining excellent and safe medical care across a large rural area with dispersed communities; and managing services effectively within a limited budget. 1.2 Facing these issues, BCUHB undertook a major review of its services and sought to clarify the principles that would eventually inform proposals for changes to services. As a result of that process, BCUHB began an extensive and intensive formal consultation programme about its proposals, which lasted from 20 August to 28 October 2012. BCUHB conducted a wide range of consultation activities with staff, stakeholders and the public and it has taken all them into account and responded to many contacts from interested parties. This report concentrates on some particularly important elements of the consultation process in order to provide and independent report and interpretation of the outcomes. The elements included in this report are:
ORS activities Open Consultation Questionnaire (both on-line and paper versions) – widely distributed by BCUHB and with responses from 1,899 residents and organisations Household Survey of Residents (by post) – with responses from 683 (14%) of the 5,000 randomly selected households Eight focus groups with members of the public
BCUHB activity 16 days of public meetings, with three sessions per day – attended by a total of more than 1,300 people
Other activity Written submissions from stakeholders Petitions. 1.3 As a research practice with wide-ranging experience of controversial statutory consultations across the UK, ORS is able to certify that the formal consultation processes undertaken by BCUHB has been both
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
intensive and extensive. Overall, there is no doubt that the exercise has been conscientious, competent and comprehensive in eliciting the opinions of stakeholders and many members of the public. There has been some understandable criticism that people had to pre-register for the 48 public meeting sessions and that attendance was limited; but even though who disagree with this approach should acknowledge that BCUHB took independent advice accepted the recommendations of the Consultation Institute about the conduct of these meetings. In any case, holding 48 separate public sessions with senior managers present at each was certainly conscientious. Overall, any objections to the style of the public meetings do not negate the overall rigour and scale of the of consultation programme taken as a whole.
Assessing the Evidence
1.4 Proper interpretation of BCUHB’s consultation programme should distinguish the findings of the various elements – for example, to compare the results of the Open Questionnaire with the more representative random sample Household Survey, while also comparing the quantitative outcomes generally with the qualitative, deliberative, focus groups, public meetings, submissions and petitions. To facilitate such comparisons, in the full report (as distinct from the executive summary) ORS has reported the different consultation elements separately. 1.5 Interpreting the outcomes of the consultation is neither straightforward nor just a ‘technical’ matter (as, for example, assessing survey error margins is a technical issue). For there is no unambiguous calculus through which the different elements of the consultation listed above can be ‘reduced’ or ‘condensed’ into a single homogeneous ‘output’ or ‘finding’. For example, qualitative and quantitative data cannot be simply combined – for the different methodologies have to be respected and recognised in any proper report; and likewise, submissions, petitions and deliberative events are different in kind and cannot be simply summated. In fact, these different outputs are incommensurable and their differences of kind need to be recognised. 1.6 ORS attaches particular weight to findings that are representative of the general population (the Household Survey) and/or deliberative (based upon thoughtful reflective discussion in non-emotive focus groups) and/or based on professional expertise (submissions from professional bodies, members of staff and some important stakeholder submissions); but, of course, all the other consultation elements have to be recognised and interpreted as well. 1.7 While ORS makes the above judgements, the process of assessing the overall outcomes of different kinds of consultation is not capable of ‘objective proof’, but requires professional and political judgements. Ultimately, an overall interpretation of the consultation will depend upon the executive and non-executive members of the Health Board itself: they will consider all elements and determine which seem the most telling – above all, by considering the relative merits of the various opinions as the basis for public policy. 1.8 The Board consults the public and stakeholders because it is accountable – but, in this context, accountability means giving an account of its ideas and then taking into account public and stakeholder views: it does not mean that the opinions of the largest majority should automatically decide public policy. After all, consultations are not referenda: they should inform, but not displace, professional and political judgements, which (above all) should assess the cogency of the views expressed. Influencing public policy through consultation is not primarily a ‘numbers game’ or ‘popularity contest’ in which the loudest voices or greatest numbers automatically win the argument; it is more a matter of informing
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
authorities about things they might have overlooked or contributing to the re-evaluation of things already known. Popularity does not itself mean that proposals are feasible, safe, sustainable, reasonable and value for money – and unpopularity does not mean the reverse. The allegedly Confucian aphorism, When all applaud: verify; when all condemn: verify! summarises the approach the Board will no doubt wish to take. 1.9 In the report that follows, the results of each consultation method are reported in separate chapters. Whereas the earlier summary report reaches overall conclusions quickly, the full report traverses public, professional and stakeholder opinions and feelings in detail – because the journey is necessary for those wishing to understand views about current and future healthcare services in Betsi Cadwaladr.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
2. Quantitative Consultation Household Survey and Open Questionnaire compared
Overview
2.1 As part of the Reconfiguration of Services consultation, a consultation document covering the health Board’s proposed changes was produced and made available to residents and organisations on request. A consultation questionnaire was developed that included questions on the following key topics, and included alongside the consultation document: » Healthcare Services Where You Live – Hospitals in Our Communities – Hospital “Hubs” – Minor Injuries Services – X-Ray Services – Local Services in Blaenau Ffestiniog – Local Services in North Denbighshire - Rhyl and Prestatyn – Local Services in Llangollen – Local Services in Flint » Older People’s Mental Health – Additional Proposals for Conwy and Denbighshire – Additional Proposals for Gwynedd and Anglesey » Neonatal Intensive Care Services » Vascular Services 2.2 Given the complexity of some of the Health Board’s proposals, the questionnaire development was very careful and conscientious. This process sought to ensure that the questions asked were clear and unambiguous and that respondents were given the necessary information to give an informed response. The consultation questionnaire was available on request, and the questionnaire was also typically enclosed with the consultation document. It was also available to be completed online. Feedback from respondents that completed these questionnaires is reported in this chapter as results to the “Open Questionnaire”. 2.3 The questionnaire was also distributed with a summary of the Health Board’s proposals to 5,000 randomly selected households from across the whole Health Board area. This sample survey ensured that residents less likely to be engaged with the wider consultation were included and encouraged to give their views about the proposals. The results from this survey are reported separately in this chapter as the “Household Survey”.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Open Questionnaire
2.4 The Open Questionnaire was available online throughout the consultation period, from 20 August 2012 until 28 October 2012. 2.5 BCUHB published an online resource centre on their website www.bcuhbjointhedebate.wales.nhs.uk and this was launched through a press release. The link to the online resource centre was publicised throughout the consultation period on the BCUHBB website and on numerous other websites, as well as being widely promoted through the local press. Paper copies of the questionnaire were available from libraries and GP surgeries across the area, and BCUHB also provided paper copies to residents on request. Completed paper questionnaires were returned directly by post to ORS, and all questionnaires received by 28 October 2012 were included in the analysis.
Questionnaire Responses 2.6 A total of 873 questionnaires were completed online and 1,026 paper questionnaires were returned – yielding a total sample of 1,899 completed questionnaire. Figure 1 shows the distribution of Open Questionnaire responses received for those questionnaires where a postcode was provided. The map shows the number of questionnaires received in each area relative to the number of usual residents aged 16+ identified by the UK Census of Population 2011.
Figure 1: Open Questionnaire responses per 1,000 residents aged 16+ by Lower Super Output Area (LSOA) – All individual respondents that provided a postcode
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
2.7 It is clear that responses were generally higher in a number of locations – in particular the areas surrounding Prestatyn Community Hospital, Ffestiniog Memorial Hospital, Tywyn Memorial Hospital, Llangollen Community Hospital, Ruthin Community Hospital, Mold Community Hospital and Deeside Community Hospital. Response rates were also generally higher in Denbighshire. 2.8 Of the 1,899 responses received, a total of 55 responses were representing the views of organisations with 1,699 individual responses (145 respondents did not answer this question). This chapter considers all responses collectively, but responses from groups have also been reported alongside other submissions.
Duplicate and Co-ordinated Responses 2.9 It is important that consultation questionnaires are open and accessible to all, while being alert to the possibility of multiple completions (by the same people) distorting the analysis. Therefore, while making it easy to complete the survey online, ORS monitors the IP addresses through which surveys are completed. On this occasion, the monitoring showed that there were 5 IP addresses which each generated more than one response. 2.10 A total of 132 completed questionnaires were submitted from three IP registered to the Welsh Assembly Government, which we understand to be associated with the wales.nhs.uk domain. As a major employer, it is not surprising that many submissions originated from the NHS Wales network. These responses provided a range of different views and ORS therefore consider it appropriate that all of the submissions are individually counted in our analysis. 2.11 A further 4 IPs which were registered to County Borough Councils generated a total of 20 completed questionnaires. After careful study of these responses, in which we looked at cookies, date stamps as well as the nature of the answers; none were considered to be identical responses or appeared to be attempting to skew the results, so (given that more than one person at an IP address might want to complete the questionnaire) we have not excluded any online submissions due to malicious intent. 2.12 A total of 160 completed questionnaires were submitted from two IP registered to BT; we understand that these respondents are part of a Prestatyn based pressure group. The paper questionnaires were subject to similar scrutiny, and 258 paper questionnaires were also returned from the Prestatyn Pressure group. 2.13 The group’s responses show that they mainly disagreed with: » The proposals about the main Health Services Where You Live (around a third answered these questions); » The proposal for a new hospital to be developed on the Royal Alexandra Hospital (all respondents but one answered this question); » The main proposals and additional proposals for Conwy and Denbighshire in terms of Older People’s Mental Health (around half answered these questions); » The Neonatal Intensive Care proposal to provide all services from Arrowe Park Hospital (almost all respondents answered this question); and » The Vascular Services proposal to provide complicated and emergency services at one specialist centre. The group also showed support for the services to be located at Glan Clwyd Hospital (around half answered these questions).
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
2.14 Whilst these responses were clearly co-ordinated, they did appear to have been provided by individual residents that subscribed to a common view. Given that the Open Questionnaire is intended to provide everyone with the opportunity to share their views it is important to recognise that the results will not necessarily provide a representative cross-section of views; therefore ORS has decided that all of the responses from this group should be included within the analysis. 2.15 Nevertheless, these questionnaires do constitute a significant proportion of all responses received (418 out of 1,899 = 22%) so they sometimes systematically distort responses provided by other respondents. In this context, where the Open Questionnaire results are notably different with and without the responses from this pressure group, in addition to presenting the overall results we have also separated out the results from other respondents to show how views differ.
Household Survey
2.16 Questionnaires for the Household Survey were distributed in the week commencing 8 October 2012 to 5,000 addresses that had been selected at random from across the Betsi Cadwaladr University Health Board area. The sample was selected from the Royal Mail Postcode Address File based on a simple random selection process. 2.17 Paper questionnaires that had been pre-printed with a unique reference number were distributed to every selected address, together with a copy of the summary version of the Health Board’s consultation document and a Freepost return envelope. Respondents were also able to participate online by using their unique reference number.
Questionnaire Responses 2.18 Of the 5,000 questionnaires that were distributed, a total of 683 were completed and returned by the survey closing date (28 October 2012), including 663 postal returns and 20 questionnaires completed online. A further 25 questionnaires were returned by the Royal Mail as having failed addresses, thereby reducing the effective sample to 4,975 and yielding a 14% response rate. 2.19 Figure 2 shows the distribution of the completed questionnaires. It is clear that responses have been received from across all of the Health Board area.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Figure 2: Household Survey responses mapped by area – All individual respondents that provided a postcode
Respondent Profile 2.20 The extent to which results can be generalised from a sample depends on how well the sample represents the population from which it is drawn. Although a random sample of addresses was selected, different types of people in different places may have been more or less likely to take part. This is known as response bias, and can be corrected for through a process of statistical weighting. 2.21 It is also necessary to compensate for a bias introduced by sample design. Whilst the survey is representative of all residents aged 16+, the sample involved randomly selected addresses – so people living in larger households had less chance to take part than single people living on their own. For example, a single person household has the same chance of being selected as a couple household (as both have one address on the Postal Address File) – but in the couple household, each person only has a 1-in-2 chance to participate. Statistical weights are therefore also derived to compensate for this. 2.22 For the Household Survey, the survey data was weighted by the number of people aged 16+ in the household (to compensate for sample design); and subsequently weighted by age, gender, working status and local authority area (to compensate for response bias).
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Figure 3: Household Survey responses (unweighted and weighted) and Resident Population by Age, Gender and Local Authority Area (Note: Figures may not sum due to rounding)
Unweighted Unweighted Weighted Resident Characteristic Count Valid % Valid % Population % BY AGE Under 35 37 6% 14% 26% 35-44 39 6% 17% 16% 45-54 100 16% 16% 17% 55-64 158 25% 19% 16% 65-74 181 28% 17% 13% 75+ 129 20% 16% 11% Total valid responses 644 100% 100% 100% Not known 39 - - - BY GENDER Male 233 37% 44% 49% Female 401 63% 56% 51% Total valid responses 634 100% 100% 100%
Not known 49 - - - BY LOCAL AUTHORITY AREA Conwy 131 19% 16% 17% Denbighshire 117 17% 14% 14% Flintshire 136 20% 22% 22% Gwynedd 136 20% 18% 18% Isle of Anglesey 59 9% 9% 10% Wrexham 103 15% 22% 19% Total valid responses 682 100% 100% 100%
Not known 1 - - -
2.23 Following the weighting process, survey results based on the weighted data will be broadly representative of the entire population across the Betsi Cadwaladr University Health Board area. After taking account of the weighting process and sample design effect, we can be 95% confident that the Household Survey results will be within ±5% points of the views of the population that the sample represents. Therefore, if everyone in the population had given their views, then 19-times-out-of-20 the results would be within 5% points of the survey estimate. 2.24 Given this context, when the report refers to results based on the weighted data the results are given as the proportion of “residents”. Any results based on unweighted data (including the results from the Open Questionnaire) refer specifically to the proportion of “respondents”.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Questionnaire Profiling Information 2.25 Figure 4 to Figure 7 compare the profile for the Household Survey with respondents from the Open Questionnaire.
Figure 4: Response by Age. Comparison between Household Survey, Open Questionnaire and general population
Resident Population Household survey Open questionnaire 30% 26 26 25% 24
20% 19 17 17 17 17 16 16 16 16 14 15% 13 13 12 11 10% 7 5%
0% Under 35 35-44 45-54 55-64 65-74 75 +
Figure 5: Comparison of socio-demographic characteristics for the Household Survey and Open Questionnaire (Note: Figures based on valid responses. Figures may not sum due to rounding)
Household Survey Open Characteristic (weighted) Questionnaire BY GENDER Male 44% 41% Female 56% 59% BY EMPLOYMENT STATUS Working full-time 35% - Working part-time 16% - Not working 49% - BY NHS EMPLOYEE NHS employee 5% 17% Not an NHS employee 95% 83% BY LIMITING LONG-TERM ILLNESS OR DISABILITY Limited a lot 13% 10% Limited a little 13% 18% No limiting long-term illness/disability 74% 72% BY CARER STATUS Carer 10% - Not a carer 90% - BY HOUSEHOLD TYPE With children 25% - Without children 75% -
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Figure 6: Response by Local Authority. Comparison between Household Survey, Open Questionnaire and general population Resident Population Household survey Open questionnaire 45% 42 40% 35% 30% 25% 22 22 23 22 18 18 19 20% 17 16 14 14 15 15% 11 10 9 10% 4 5 5% 0% Conwy Denbighshire Flintshire Gwynedd Isle of Anglesey Wrexham
Figure 7: Comparison of location characteristics for the Household Survey and Open Questionnaire (Note: Figures based on valid responses where a postcode was provided. Figures may not sum due to rounding)
Household Survey Open Characteristic (weighted) Questionnaire BY URBAN/RURAL Urban 47% 54% Rural 53% 46% BY NEAREST DISTICT GENERAL HOSPITAL Glan Clwyd Hospital, Rhyl 34% 62% Wrexham Maelor Hospital 38% 19% Ysbyty Gwynedd, Bangor 24% 14% Bronglais Hospital 4% 5% BY DISTANCE TO NEAREST DISTICT GENERAL HOSPITAL Less than 5km 17% 8% 5km but less than 10km 22% 34% 10km but less than 15km 15% 15% 15km but less than 20km 20% 15% Over 20km 25% 29% BY NEAREST HUB HOSPITAL Ysbyty Penrhos Stanley, Holyhead 4% 1% Ysbyty Gwynedd, Bangor 10% 6% Ysbyty Alltwen, Tremadog 7% 7% Dolgellau and Barmouth District Hospital 5% 5% Llandudno Hospital 12% 8% Glan Clwyd Hospital, Rhyl 14% 35% Holywell Community Hospital 5% 12% Deeside Community Hospital 15% 11% Wrexham Maelor Hospital 24% 8% Denbigh Infirmary/Community Hospital 4% 7%
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Household Survey Open Characteristic (weighted) Questionnaire BY DISTANCE TO NEAREST HUB HOSPITAL Less than 2km 11% 8% 2km but less than 4km 15% 9% 4km but less than 6km 19% 12% 6km but less than 8km 17% 18% 8km but less than 10km 12% 28% 10km but less than 15km 15% 14% Over 15 km 11% 11% BY NEAREST LOCAL HOSPITAL Ffestiniog Memorial Hospital 2% 3% Flint Community Hospital 3% 9% Llangollen Community Hospital 2% 3% Prestatyn Community Hospital 6% 29% Mold Community Hospital 8% 8% Royal Alexandra Community Hospital 4% 4% Chirk Community Hospital 5% 1% Ruthin Community Hospital 2% 4% Cefni, Llangefni, Gwynedd 3% 2% Eryri Community Hospital, Caernarfon 4% 1% Bryn Beryl Community Hospital, Pwllheli 3% 2% Colwyn Bay Community Hospital 6% 4% Tywyn Memorial Hospital 2% 3% Ysbyty Penrhos Stanley, Holyhead 3% 1% Ysbyty Gwynedd, Bangor 5% 3% Ysbyty Alltwen, Tremadog 2% 1% Dolgellau and Barmouth District Hospital 2% 2% Hospital 6% 4% Glan Clwyd Hospital, Rhyl 4% 3% Holywell Community Hospital 3% 2% Deeside Community Hospital 7% 3% Wrexham Maelor Hospital 17% 5% Denbigh Infirmary/Community Hospital 2% 3% BY DISTANCE TO NEAREST LOCAL HOSPITAL Under 1km 11% 36% 1km but less than 2 km 19% 22% 2km but less than 4 km 29% 20% 4km but less than 6km 16% 8% 6km but less than 10km 14% 7% Over 10km 11% 6%
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
2.26 It is apparent that the Open Questionnaire has a proportionately higher response from respondents aged 55 to 74 (half of all respondents, compared with only 29% of the resident population) and, as previously noted, those living in Denbighshire – so it is clear that the Open Questionnaire is not representative of the resident population. The Household Survey is broadly representative overall, so for those questions where the two results significantly differ, more emphasis should typically be placed on the Household Survey.
Interpretation of the Data
2.27 The results for the Household Survey and Open Questionnaire are presented in a largely graphical format. 2.28 Graphics are used extensively in this report to make it as user friendly as possible. The pie charts and other graphics show the proportions (percentages) of respondents making relevant responses. Where possible, the colours of the charts have been standardised with a ‘traffic light’ system in which: » Green shades represent positive responses » Beige and purple/blue shades represent neither positive nor negative responses » Red shades represent negative responses » The bolder shades are used to highlight responses at the ‘extremes’, for example, very satisfied or very dissatisfied. 2.29 Where percentages do not sum to 100, this may be due to computer rounding, the exclusion of “don’t know” categories, or multiple answers. Throughout the volume an asterisk (*) denotes any value less than half of one per cent. In some cases figures of 2% or below have been excluded from graphs. 2.30 When considering responses between different groups within the population, differences have been analysed using appropriate statistical means to check for statistical significance (i.e. not happened ‘by chance’). Differences that are not said to be ‘significant’ or ‘statistically significant’ are indicative only. Statistical significance is at a 95% level of confidence.
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Summary of Key Findings
2.31 The following section summarises the questionnaire results
Healthcare Services Where You Live 2.32 The following summary table shows significant levels of agreement with two of the three priorities for delivering healthcare in North Wales: Targeted Prevention and Enhanced Care at Home. Around one in two agree with the priority of Moving Care from Acute Hospital to the Community. There are higher levels of disagreement in the Open Questionnaire.
KEY PRINCIPLE 1 KEY PRINCIPLE 2 KEY PRINCIPLE 3 Targeted Prevention Enhanced Care at Home Moving Care from Taking action to promote Acute Hospitals to the good health and prevent Community illness
Household Survey 86% 9% 6% 80% 10% 10% 56% 18% 27% Agree Neither Disagree Agree Neither Disagree Agree Neither Disagree
Open Questionnaire 82% 5% 14% 67% 10% 23% 55% 11% 34% Agree Neither Disagree Agree Neither Disagree Agree Neither Disagree 2.33 In general, the following summary table shows notable levels of disagreement with the fourth key principle, and a majority agreement with the fifth key principle. 2.34 Levels of disagreement for both Key Principles are higher in the Open Questionnaire.
KEY PRINCIPLE 4 KEY PRINCIPLE 5 We should focus our The same healthcare resources on providing services with the same reliable healthcare services opening times should be at fewer hospitals to make provided within 40 sure that the services minutes’ drive for as many provided are consistently people as possible in available North Wales
Household Survey 54% 8% 38% 80% 6% 14% Agree Neither Disagree Agree Neither Disagree
Open Questionnaire 31% 6% 64% 57% 6% 37% Agree Neither Disagree Agree Neither Disagree
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Proposed Hospital “Hubs” 2.35 In general, Household Survey residents agree that the ten hospitals proposed by BCUHB are the most appropriate hospitals to act as “hubs” for healthcare services across North Wales, whereas almost half of Open Questionnaire respondents disagree.
The ten hospitals proposed by the Health Board are the most appropriate hospitals to act as “hubs” for healthcare services across North Wales?
Household Survey 74% 9% 17% Agree Neither Disagree
Open Questionnaire 43% 8% 49% Agree Neither Disagree
Minor Injury Services and X-Ray Services 2.36 In general, the results show that the majority of Household Survey residents agree with the proposals for Minor Injuries and X-ray Services, whereas the majority of Open Questionnaire respondents disagree with the proposals.
Minor Injury Services In principle, should Do you agree or disagree services be provided at with the Health Board’s fewer hospitals specific proposals
Household Survey 56% 9% 35% 54% 13% 33% Agree Neither Disagree Agree Neither Disagree
Open Questionnaire 34% 5% 61% 31% 8% 61% Agree Neither Disagree Agree Neither Disagree
X-Ray Services In principle, should Do you agree or disagree services be concentrated with the Health Board’s in fewer places specific proposals
Household Survey 56% 8% 36% 55% 15% 30% Agree Neither Disagree Agree Neither Disagree
Open Questionnaire 41% 6% 53% 38% 8% 54% Agree Neither Disagree Agree Neither Disagree
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Local Services in Blaenau Ffestiniog 2.37 There is general agreement for the proposals regarding the development of a new facility and the expansion of primary care services at Ffestiniog Memorial Hospital. However, the majority do not agree with the proposal to move community inpatient beds from Ffestiniog Memorial Hospital to Ysbyty Alltwen. 2.38 Disagreement levels are higher in the Open Questionnaire.
Do you agree or disagree with the proposal(s)…?
That a new facility should That community inpatient That primary care services be developed at Ffestiniog beds should be moved should be expanded at Memorial Hospital as a from Ffestiniog Memorial Ffestiniog Memorial base for better community Hospital to Ysbyty Hospital? services? Alltwen?
Household 58% 31% 12% 58% 36% 7% 29% 43% 28% Survey Agree Neither Disagree Agree Neither Disagree Agree Neither Disagree 39% answered the question 38% answered the question 37% answered the question
Open 45% 26% 28% 57% 29% 14% 23% 28% 49% Questionnaire Agree Neither Disagree Agree Neither Disagree Agree Neither Disagree 38% answered the question 37% answered the question 36% answered the question
Local Services in North Denbighshire - Rhyl and Prestatyn 2.39 Results show that Household Survey residents agree with the proposal for Local Services in North Denbighshire, whereas the majority of Open Questionnaire respondents do not agree with the proposal (in particular respondents from the Prestatyn Pressure Group).
Do you agree or disagree with the proposal…?
That a new hospital should be developed on the Royal Alexandra Hospital site which would replace other health service facilities in the area?
Household 62% 23% 15% Survey Agree Neither Disagree 51% answered the question
Open 32% 13% 55% Questionnaire Agree Neither Disagree 70% answered the question
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Local Services in Llangollen 2.40 Whereas there is general agreement with the proposal for an extended primary care centre in Llangollen, the majority do not agree with the proposal that Community inpatient beds should be moved from Llangollen Community Hospital to local care homes or Chirk Community Hospital. 2.41 Disagreement levels are higher in the Open Questionnaire.
Do you agree or disagree with the proposal(s)…?
Community inpatient beds should be moved from That an extended primary Llangollen Community care centre should be Hospital to local care developed in Llangollen? homes or Chirk Community Hospital?
Household 57% 30% 12% 35% 35% 29% Survey Agree Neither Disagree Agree Neither Disagree 38% answered the question 37% answered the question
Open 52% 24% 23% 27% 23% 50% Questionnaire Agree Neither Disagree Agree Neither Disagree 35% answered the question 35% answered the question
Local Services in Flint 2.42 Whereas there is general agreement with the proposal for an extended primary care centre in Flint, the majority do not agree with the proposal that Community inpatient beds should be moved from Flint Community Hospital to Holywell Community Hospital. 2.43 Disagreement levels are higher in the Open Questionnaire.
Do you agree or disagree with the proposal(s)…? Community inpatient beds An extended primary care should be moved from centre should be Flint Community Hospital developed in Flint? to Holywell Community Hospital?
Household 62% 27% 10% 36% 40% 25% Survey Agree Neither Disagree Agree Neither Disagree 41% answered the question 41% answered the question
Open 57% 19% 25% 33% 19% 48% Questionnaire Agree Neither Disagree Agree Neither Disagree 39% answered the question 39% answered the question
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Older People’s Mental Health 2.44 The following summary table shows high levels of agreement with the proposals for older people’s mental health, although there are higher levels of disagreement from Open Questionnaire respondents (in particular respondents from the Prestatyn Pressure Group). 2.45 Results show that Household Survey residents agree with the additional proposals for Conwy and Denbighshire, whereas Open Questionnaire respondents are less likely to agree with them. The majority of respondents do not agree with the additional proposals for Gwynedd and Anglesey.
Do you agree or disagree with the proposal(s)…?
For older people’s mental Additional proposals for Additional proposals for health Conway and Denbighshire Gwynedd and Anglesey
Household 91% 5% 4% 64% 25% 12% 40% 30% 30% Survey Agree Neither Disagree Agree Neither Disagree Agree Neither Disagree 90% answered the question 56% answered the question 51% answered the question
Open 64% 9% 27% 35% 18% 47% 26% 22% 52% Questionnaire Agree Neither Disagree Agree Neither Disagree Agree Neither Disagree 78% answered the question 56% answered the question 40% answered the question
Neonatal Intensive Care 2.46 The majority of Household Survey residents and Open Questionnaire respondents disagree with the proposal to provide all Neonatal Intensive Care Services from Arrowe Park Hospital – with higher levels of disagreement in the Open Questionnaire (in particular respondents from the Prestatyn Pressure Group).
Do you agree or disagree with the proposal…? To provide all Neonatal Intensive Care Services from Arrowe Park Hospital
Household 37% 15% 47% Survey Agree Neither Disagree 66% answered the question
Open 22% 7% 71% Questionnaire Agree Neither Disagree 83% answered the question
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Vascular Services 2.47 The majority of Household Survey residents and Open Questionnaire respondents agree with the proposal to provide Vascular Services at one specialist centre in North Wales – with higher levels of disagreement in the Open Questionnaire. 2.48 In general, Glan Clwyd Hospital is the preferred location for a specialist centre for Vascular Services.
Do you agree or disagree with the proposal to At which hospital do you think that this provide Vascular Services should this be located? at one specialist centre in North Wales?
Household Survey 68% 13% 19% 19% 48% 33% Agree Neither Disagree Ysbyty Gwynedd Glan Clwyd Hospital Wrexham Maelor
Open Questionnaire 50% 8% 42% 13% 69% 17% Agree Neither Disagree Ysbyty Gwynedd Glan Clwyd Hospital Wrexham Maelor
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Opinion Research Services | Betsi Cadwaladr University Health Board’s Consultation on Healthcare Services: Summary Report January 2013
Healthcare Services Where You Live
Priorities for delivering healthcare in North Wales
Figure 8: Consultation Questionnaire responses to proposals for delivering healthcare in North Wales
To what extent do you agree or disagree with the following priorities for delivering healthcare in North Wales?
Household Survey
Open Questionnaire
Base: All respondents (Number of respondents shown in brackets)
2.49 The Consultation Questionnaire shows significant levels of agreement with the targeted prevention and enhanced care at home proposals. A slightly smaller proportion agree with moving care from acute hospitals to the community, however, the majority are still in favour with this proposal. 2.50 There is little difference in response between the Household Survey and Open Questionnaire; more than four fifths of all residents/respondents agree with taking action to promote good health and prevent illness, while more than half (55%)agree with moving care to the community. 2.51 However, a higher proportion of Open Questionnaire respondents disagree (23%) with enhanced care at home than Household Survey residents (10%).
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Providing healthcare services at fewer hospitals
Figure 9: Consultation Questionnaire responses to proposals for providing healthcare services at fewer hospitals
In principle, do you agree or disagree that we should focus our resources on providing reliable healthcare services at fewer hospitals to make sure that the services provided are consistently available?
Household Survey Open Questionnaire
Base: All Respondents (637) Base: All respondents (1,527) 93% of respondents answered the question 80% of respondents answered the question
2.52 The Household Survey shows that the majority of residents (54%) agree with the proposal, while around two fifths (38%) disagree. Conversely, the majority of respondents to the Open Questionnaire disagree (64%), including 46% that strongly disagree with this proposal, and only around 3 in 10 (31%) agree. 2.53 The graphs overleaf consider the responses in terms of the extra distance residents’ would need to travel if they could no longer use their local hospital for certain services. Both the Household Survey and the Open Questionnaire show that in general, the longer the extra distance respondents would have to travel, the higher the level of disagreement.
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Figure 10: Consultation Questionnaire responses to proposals for providing healthcare services at fewer hospitals by the distance between local and hub hospital
Household Survey
Open Questionnaire
Base: All respondents (Number of respondents shown in brackets)
Providing the same healthcare services within 40 minutes’ drive
Figure 11: Consultation Questionnaire responses to proposals for the same healthcare services being provided within 40 minutes’ drive for as many people as possible
In principle, do you agree or disagree that the same healthcare services with the same opening times should be provided within 40 minutes’ drive for as many people as possible in North Wales?
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Household Survey Open Questionnaire
Base: All Respondents (643) Base: All respondents (1,445) 94% of respondents answered the question 76% of respondents answered the question
2.54 The Consultation Questionnaire also shows that the majority agree that in principle, the same healthcare services with the same opening times should be provided within 40 minutes’ drive for as many people as possible. 2.55 Agreement is strongest in the Household Survey, where four fifths (80%) of respondents agree with the proposal, including 51% that strongly agree. The Open Questionnaire shows that around three fifths (57%) of residents agree with the proposal, including 35% that strongly agree. However, it is worth noting that almost two fifths (37%) of Open Questionnaire respondents disagree with this proposal. 2.56 The graphs overleaf consider the responses in terms of the extra distance residents’ would need to travel if they could no longer use their local hospital for certain services. The Household Survey shows little difference in levels of agreement and disagreement, but those respondents to the Open Questionnaire who have an extra travelling distance of 5km or more show much higher levels of disagreement.
Figure 12: Consultation Questionnaire responses to proposals for the same healthcare services being provided within 40 minutes’ drive for as many people as possible by the distance between local and hub hospital
Household Survey
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Open Questionnaire
Base: All respondents (Number of respondents shown in brackets)
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Hospital ‘Hubs’
Figure 13: Consultation Questionnaire responses to proposals for the ten hospitals to act as ‘hubs’
Do you agree or disagree that the ten hospitals proposed by the Health Board are the most appropriate hospitals to act as “hubs” for healthcare services across North Wales?
Household Survey
Base: All Respondents (621) 91% of respondents answered the question
Open Questionnaire – all respondents Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All Respondents (1,395) Base: All respondents (1,259) 73% of respondents answered the question 85% of respondents answered the question
2.57 The Household Survey shows significant levels of agreement that the ten hospitals proposed by the Health Board are the most appropriate hospitals to act as “hubs” for healthcare services across North Wales, while the Open Questionnaire shows that opinion is split. 2.58 Three quarters (74%) of Household Survey residents agree with this proposal, while conversely, half (49%) of Open Questionnaire respondents disagree with this proposal. However, it is worth noting that when excluding the Prestatyn Pressure Group responses from the Open Questionnaire results, the
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proportion who disagree decreases to 43% and in turn the proportion who agree increases from 44% to 47%. 2.59 When we consider the responses in terms of the extra distance residents’ would need to travel if they could no longer use their local hospital for certain services, both consultation questionnaires show that the longer the extra distance to travel is, the higher the level of disagreement.
Figure 14: Consultation Questionnaire responses to proposals for the ten hospitals to act as ‘hubs’ by the distance between local and hub hospital
Household Survey
Open Questionnaire
Base: All respondents (Number of respondents shown in brackets)
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Minor Injuries Services – Services concentrated in fewer places
Figure 15: Consultation Questionnaire responses to proposals for focusing resources on providing minor injuries services at fewer hospitals
In principle, do you agree or disagree that we should focus our resources on providing reliable Minor Injuries Services at fewer hospitals to make sure services are consistently available?
Household Survey Open Questionnaire
Base: All Respondents (647) Base: All respondents (1,443) 95% of respondents answered the question 76% of respondents answered the question
2.60 The Household Survey shows the majority (56%) of residents agree that resources should be focussed on providing reliable Minor Injuries Services at fewer hospitals, although more than a third (35%) disagree. In contrast, the Open Questionnaire shows that a significant proportion of respondents (61%) disagree with this proposal, while 34% agree.
Figure 16: Consultation Questionnaire responses to the specific proposals for minor injuries services
Do you agree or disagree with the Health Board’s specific proposals for Minor Injury Services?
Household Survey Open Questionnaire
Base: All Respondents (639) Base: All respondents (1,417) 94% of respondents answered the question 75% of respondents answered the question
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2.61 While the Household Survey shows that more than half (54%) of residents agree with the Health Board’s specific proposals for Minor Injuries Services, the Open Questionnaire shows that the majority (61%) disagree. 2.62 When we consider the responses in terms of the extra distance residents’ would need to travel if they could no longer use their local hospital for minor injuries services, both consultation questionnaires show that the longer the extra distance to travel is, the higher the level of disagreement. However, this pattern is more predominant in the Open Questionnaire.
Figure 17: Consultation Questionnaire responses to the specific proposals for minor injuries services by the distance between local and hub hospital
Household Survey
Open Questionnaire
Base: All respondents (Number of respondents shown in brackets)
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X-Ray Services – Services concentrated in fewer places
Figure 18: Consultation Questionnaire responses to proposals for services to be concentrated in fewer places
In principle, do you agree or disagree that X-ray Services should be concentrated in fewer places to ensure reliable services?
Household Survey Open Questionnaire
Base: All Respondents (653) Base: All respondents (1,440) 96% of respondents answered the question 76% of respondents answered the question
2.63 The Household Survey shows that more than half (56%) of residents agree that x-ray services should be concentrated in fewer places, while more than a third (36%) disagree. Conversely, the Open Questionnaire shows lower levels of agreement (41%), while around half (53%) disagree with this proposal.
Figure 19: Consultation Questionnaire responses to the specific proposals for X-ray services
Do you agree or disagree with the Health Board’s specific proposals for X-ray Services?
Household Survey Open Questionnaire
Base: All Respondents (644) Base: All respondents (1,415) 94% of respondents answered the question 75% of respondents answered the question
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2.64 The Household Survey shows fairly high levels of agreement (54%) with the Health Board’s specific proposals for x-ray services, with a third (30%) stating disagreement. On the other hand, The Open Questionnaire shows that the majority (54%) disagree, including 36% that strongly disagree. 2.65 When we consider the responses in terms of the extra distance residents’ would need to travel if needed to go to their nearest ‘hub’ hospital for services, both consultation questionnaires show that the longer the extra distance to travel is, the higher the level of disagreement. This is particularly the case for residents to the Household Survey who would have an extra travelling distance of 10km or more and for respondents to the Open Questionnaire who would have an extra travelling distance of 5km or more.
Figure 20: Consultation Questionnaire responses to the specific proposals for X-ray services by the distance between local and hub hospital
Household Survey
Open Questionnaire
Base: All respondents (Number of respondents shown in brackets)
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Local Services in Blaenau Ffestiniog
Figure 21: Consultation Questionnaire responses to proposals for a new facility being developed at Ffestiniog Memorial Hospital
Do you agree or disagree that a new facility should be developed at Ffestiniog Memorial Hospital as a base for better community services?
Household Survey Open Questionnaire
Base: All Respondents (265) Base: All respondents (698) 39% of respondents answered the question 38% of respondents answered the question
Do you agree or disagree that primary care services should be expanded at Ffestiniog Memorial Hospital?
Household Survey Open Questionnaire
Base: All Respondents (260) Base: All respondents (677) 38% of respondents answered the question 37% of respondents answered the question
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Do you agree or disagree that community inpatient beds should be moved from Ffestiniog Memorial Hospital to Ysbyty Alltwen?
Household Survey Open Questionnaire
Base: All Respondents (252) Base: All respondents (654) 37% of respondents answered the question 36% of respondents answered the question
2.66 The Consultation Questionnaire shows significant levels of agreement with the proposals to develop a new facility and expand primary care services at Ffestiniog Memorial Hospital. 2.67 However, the Household Survey shows that a high proportion neither agree nor disagree with the proposal to move inpatient beds from at Ffestiniog Memorial Hospital to Ysbyty Alltwen, and the remainder are split between agreement and disagreement. Conversely, the Open Questionnaire shows that the majority disagree with this proposal. 2.68 The highest levels of disagreement with all the proposals concerning Blaenau Ffestiniog are by residents who live within 10km for Ffestiniog Memorial Hospital – in particular with regards to the proposal for relocating inpatient beds.
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Local Services in North Denbighshire – Rhyl and Prestatyn
Figure 22: Consultation Questionnaire responses to proposals for a new hospital to be developed on the Royal Alexandra Hospital site
Do you agree or disagree that a new hospital should be developed on the Royal Alexandra Hospital site which would replace other health service facilities in the area?
Household Survey
Base: All Respondents (345) 51% of respondents answered the question
Open Questionnaire – all respondents Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All Respondents (1,275) Base: All Respondents (858) 70% of respondents answered the question 58% of respondents answered the question
2.69 The Household Survey shows significant levels (62%) of agreement with the proposal for a new hospital to be developed on the Royal Alexandra Hospital site. Although the Open Questionnaire shows that the majority (55%) disagree with this proposal, when the Prestatyn Pressure Group responses are excluded from the results, around half (48%) actually agree and only a third (33%) disagree. 2.70 When we consider the responses in terms of residents’ distance from Royal Alexandra Hospital, the Household Survey shows general agreement with the proposal regardless of the distance they live from the hospital. The Open Questionnaire (excluding Prestatyn Pressure Group responses) shows that those
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who live 20km or more away from the hospital show higher levels of neither agreement nor disagreement.
Local Services in Llangollen
Figure 23: Consultation Questionnaire responses to proposals for an extended primary care centre to be developed in Llangollen
Do you agree or disagree that an extended primary care centre should be developed in Llangollen?
Household Survey Open Questionnaire
Base: All Respondents (262) Base: All respondents (638) 38% of respondents answered the question 35% of respondents answered the question
Do you agree or disagree that community inpatient beds should be moved from Llangollen Community Hospital to local care homes or Chirk Community Hospital?
Household Survey Open Questionnaire
Base: All Respondents (256) Base: All respondents (643) 37% of respondents answered the question 35% of respondents answered the question
2.71 The Consultation Questionnaire shows significant levels of agreement with the proposal for developing an extended primary care centre in Llangollen; both the Household Survey (57%) and Open Questionnaire (52%) show similar levels of agreement.
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2.72 In contrast, the Household Survey shows that opinion is split with regards to the proposal for inpatient beds to be moved from Llangollen Community Hospital to local homes or Chirk Community Hospital, where around a third (35%) neither agree nor disagree. The Open Questionnaire shows that the majority (50%) disagree with this proposal. 2.73 When we consider the responses in terms of residents’ distance from Llangollen Community Hospital, the Household Survey shows that a significantly lower proportion of residents who live within 10km of the hospital agree with the proposal for an extended primary care centre. The Open Questionnaire shoes that a significantly higher proportion of residents who live within 10km of the hospital disagree with proposal to move inpatient beds.
Local Services in Flint
Figure 24: Consultation Questionnaire responses to proposals for an extended primary care centre to be developed in Flint
Do you agree or disagree that an extended primary care centre should be developed in Flint?
Household Survey Open Questionnaire
Base: All Respondents (278) Base: All respondents (719) 41% of respondents answered the question 39% of respondents answered the question
Do you agree or disagree that community inpatient beds should be moved from Flint Community Hospital to Holywell Community Hospital??
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Household Survey Open Questionnaire
Base: All Respondents (278) Base: All respondents (714) 41% of respondents answered the question 39% of respondents answered the question
2.74 The Consultation Questionnaire shows high levels of agreement with the proposal for developing an extended primary care centre in Flint, however, a low proportion agree with the proposal to move inpatient beds from Flint Community Hospital to Holywell Community Hospital. 2.75 The Household Survey shows that a similar proportion of residents either agree (36%) or neither (40%) with moving inpatient beds, while a quarter (25%) disagree. Conversely, the Open Questionnaire show that around half (48%) of respondents disagree with this proposal, although a similar proportion to the Household Survey (33%) agree. 2.76 When we consider the responses in terms of residents’ distance from Flint Community Hospital, the Household Survey shows that those who live within 10km of the hospital show the highest levels of disagreement with both proposals - in particular the relocation of inpatient beds
Healthcare Services Where You Live – Further Comments 2.77 Respondents were given the opportunity to make further comments with regards to all of the proposals relating to ‘Healthcare services where you live’. Around a quarter (27%) of Household Survey residents made any further comments, in comparison to more than two fifths (45%) of Open Questionnaire respondents. 2.78 The table below shows the top main comments that were made by both sets of respondents.
Figure 25: Further comments about the proposals for healthcare services where you live?
Number of Responses
Main further comments Household Open Survey Questionnaire (179) (861)
Concerns over travel: - distance - cost 75 321 - poor road network/concerns over public transport - concerns about family not being able to visit - travelling further will have a negative impact on people living in rural areas
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Against idea of hospital hubs for Minor Injury and X-ray Services: - don’t close smaller hospitals 29 164 - proposals are not cost effective - proposals will lead to a worse level of service
Excellent care already provided at Mold Hospital; 18 66 keep/develop current level of service
Concerns about resources and increased demand: - X-Ray & minor injuries services will need to be more accessible with open longer hours - GPs wont cope with increased demand 16 66 - GPs will need more staff/equipment/better facilities to act as Minor Injury/X-ray units - GPs and NPs will need to play more of a role in treating minor injuries
Proposals will have a negative impact on the elderly 15 60
Base: All respondents who made a further comment(s) (Number of respondents in brackets)
2.79 The table below shows other comments which were mainly made by Open Questionnaire respondents, but by very few Household Survey residents.
Figure 26: Further comments mainly made by Open Questionnaire respondents about the proposals for healthcare services where you live?
Number of Responses
Further comments mainly made by Open Questionnaire respondents Household Open Survey Questionnaire (179) (861)
Excellent care already provided at Flint Hospital; 7 93 keep/develop current level of service
More beds are needed not less 3 78
Excellent care already provided at Prestatyn Community Hospital; 2 63 keep/develop current level of service here
Agree with proposals as long as alternatives have been put in place before any 2 57 closures
Base: Number of respondents who made a further comment for each questionnaire in brackets)
2.80 The following groups of respondents to the Open Questionnaire were significantly more likely to have made further comments about concerns over travel: » Respondents who would have an extra travelling distance of 10 km or more to get to their nearest Hub Hospital » Disagree with moving inpatient beds from Ffestiniog Memorial Hospital » Nearest local Hospital is Llangollen Community Hospital or Flint Community Hospital
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Older People’s Mental Health
General Proposals
Figure 27: Consultation Questionnaire responses to proposals for older people’s mental health
Do you agree or disagree with these proposals for older people’s mental health?
Household Survey
Base: All Respondents (616) 90% of respondents answered the question
Open Questionnaire – all respondents Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All Respondents (1,419) Base: All respondents (1,216) 75% of respondents answered the question 82% of respondents answered the question
2.81 The Consultation Questionnaire shows significant levels of agreement with the proposals for older people’s mental health; the vast majority of residents (91%) to the Household Survey agree, while more than three fifths (64%) of respondents to the Open Questionnaire agree with this proposal. Furthermore, when the Prestatyn Pressure Group responses are excluded from the Open Questionnaire results, an even higher proportion (75%) agree. 2.82 When we consider the geographic spread of responses for this proposal (Figure 28) it is evident that there are high levels of agreement regardless of which main general hospital residents are nearest to. However, it is worth noting that residents whose nearest general hospital is Bronglais how slight lower levels of disagreement.
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Figure 28: Household Survey responses mapped by area, with shaded zones depicting 5km, 10km, 25km and over 25km from named General Hospital – All individual respondents that provided a postcode
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Additional Proposals for Older People’s Mental Health: Conwy and Denbighshire
Figure 29: Consultation Questionnaire responses to proposals for Conwy and Denbighshire
Do you agree or disagree with the mental Health proposals for Conwy and Denbighshire?
Household Survey
Base: All Respondents (303) 44% of respondents answered the question
Open Questionnaire – all respondents Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All Respondents (1,015) Base: All respondents (802) 53% of respondents answered the question 54% of respondents answered the question
2.83 The Household Survey shows that the majority (64%) of residents agree with the proposals for Conwy and Denbighshire, and a low proportion (12%) disagree. The Open Questionnaire shows that almost half (47%) disagree, while more than a third (35%) agree. However, when the Prestatyn Pressure Group responses are excluded from the Open Questionnaire results, 45% agree and 32% disagree.
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Additional Proposals for Older People’s Mental Health: Gwynedd and Anglesey
Figure 30: Consultation Questionnaire responses to proposals for Gwynedd and Anglesey
Do you agree or disagree with the mental Health proposals for Gwynedd and Anglesey?
Household Survey Open Questionnaire
Base: All Respondents (350) Base: All respondents (729) 51% of respondents answered the question 38% of respondents answered the question
2.84 The Household Survey shows that opinion is split with regards to the proposals for Gwynydd and Anglesey, with 40% in agreement and 30% in disagreement. However, the Open Questionnaire shoes that the majority (52%) disagree with the proposals, and only a quarter (26%) agree.
Older People’s Mental Health – Further Comments 2.85 Respondents were given the opportunity to make further comments about the Health Board’s proposals for older people’s mental health. Only around 1-in-8 (12%) of Household Survey residents made any further comments, in comparison to around a fifth (19%) of Open Questionnaire respondents. The table below shows the top main comments that were made by both sets of respondents.
Figure 31: Further comments about the proposals for older people’s mental health?
Number of Responses
Main further comments Household Open Survey Questionnaire (85) (370)
Concerns over travel: - distance - cost 25 117 - poor road network/concerns over public transport - concerns about family not being able to visit - keep care local
Need more trained staff (such as district nurses) to deal with 16 29 older people/mental health issues before changes are made
Community care is not able to provide the 24-hour/appropriate levels of care 13 23 that hospitals can
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Base: All respondents who made a further comment(s) (Number of respondents in brackets)
2.86 The table below shows other comments which were mainly made by Open Questionnaire respondents, but by very few Household Survey residents.
Figure 32: Further comments mainly made by Open Questionnaire respondents about the proposals for older people’s mental health?
Number of Responses
Further comments mainly made by Open Questionnaire respondents Household Open Survey Questionnaire (85) (370)
EMI units must be kept open 1 34
Agree with proposals but there needs to be an increase number of carers and more 5 29 support/funding before anything is put into place
More beds needed for the growing ageing population 9 28
Concerns that care in the home will place stress on the family/the family might be 3 25 expected to act as a carer
Focus should be on earlier and prompt diagnosis/dedicated assessment centres 4 25
Against permanent closure of beds at Uned Hafan (Bryn Beryl Community Hospital) 8 21 and Uned Merion (Dolgellau and Barmouth Hospital)
Base: All respondents who made a further comment(s) (Number of respondents in brackets)
2.87 Open Questionnaire respondents who would have to travel an extra 10km or more to their nearest hub hospital were significantly more likely to have made further comments with regards to: concern over travel; community care not being able to provide the level of care that hospitals are; and EMI units being kept open. 2.88 Open Questionnaire respondents whose nearest local hospitals are: Bryn Beryl Community Hospital; Tywyn Memorial Hospital; and Dolgellau and Barmouth District Hospital were significantly more likely to make further comments about concerns over travel.
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Neonatal Intensive Care Services
Figure 33: Consultation Questionnaire responses to the proposal for providing all services from Arrowe Park
Do you agree or disagree with these proposals for Gwynedd and Anglesey?
Household Survey
Base: All Respondents (453) 66% of respondents answered the question
Open Questionnaire – all respondents Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All Respondents (1,518) Base: All respondents (1,105) 83% of respondents answered the question 75% of respondents answered the question
2.89 The Consultation Questionnaire shows high levels of disagreement with the proposal to provide all Neonatal Intensive Care Services from Arrowe Park Hospital; disagreement is strongest in the Open Questionnaire, with 7 in 10 (71%) stating that they disagree – of which 62% strongly disagree. However, when the Prestatyn Pressure Group responses are removed from the Open Questionnaire results, this proportion decreases to 60%. 2.90 When we consider the geographic spread of responses (Figure 34), it is evident that residents whose nearest district general hospitals are Bronglais and Ysbyty Glan Clwyd show higher levels of disagreement than residents who live nearest too Wrexham Maelor Hospital and Ysbyty Gwynedd.
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Figure 34: Household Survey responses mapped by area, with shaded zones depicting 5km, 10km, 25km and over 25km from named General Hospital – All individual respondents that provided a postcode
Arrowe Park Hospital
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2.91 When we consider responses by residents’ distance to Arrowe Park Hospital, both the Household Survey and the Open Questionnaire show that those respondents who live closest to the hospital (within 30km) indicate higher levels of disagreement than those who live further away, although this pattern is strongest in the Open Questionnaire.
Figure 35: Consultation Questionnaire responses to the proposal to provide all Neonatal Intensive Care Services from Arrowe Park Hospital
Household Survey
Open Questionnaire – all respondents
Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All respondents (Number of respondents shown in brackets)
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Neonatal Intensive Care Services – Further Comments 2.92 Respondents were given the opportunity to make further comments about the Health Board’s proposals for Neonatal Intensive Care Services. Only a quarter (24%) of Household Survey residents made any further comments, in comparison to around a third (30%) of Open Questionnaire respondents. The table below shows the top main comments that were made by both sets of respondents.
Figure 36: Further comments about the proposals for Neonatal Intensive Care Services?
Number of Responses
Main further comments Household Open Survey Questionnaire (147) (563)
Concerns over travel: - distance - cost - poor road network/concerns over public transport 91 290 - concerns about family not being able to visit - keep care local - extra distance to travel will cause more deaths
One intensive neonatal unit needs to be kept in North Wales 40 178
Keep long term intensive neonatal unit/develop unit to meet national standard at 25 108 Glan Clwyd Hospital
Base: All respondents who made a further comment(s) (Number of respondents in brackets)
2.93 The table below shows other comments which were mainly made by Open Questionnaire respondents, but by very few Household Survey residents.
Figure 37: Further comments mainly made by Open Questionnaire respondents about the proposals for Neonatal Intensive Care Services?
Number of Responses
Further comments mainly made by Open Questionnaire respondents Household Open Survey Questionnaire (147) (563)
Arrowe Park Hospital is not suitable: - run down - lack of facilities/parking 7 53 - concerns about bacteria outbreak - does not meet national standard for intensive neonatal care unit - it would cost more to provide the service in Arrowe Park
Keep services in North Wales to maintain specialties and train new doctors/keep 0 37 current doctors’ skills
Support using Arrowe Park Hospital - only a small proportion of babies will be 3 32 affected/happy to travel for best care
Base: All respondents who made a further comment(s) (Number of respondents in brackets)
2.94 Open Questionnaire respondents who disagree with the proposal to provide all Neonatal Care Services from Arrowe Park Hospital are significantly more likely to make further comments about: concerns over
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travel; support for keeping a long-term neonatal unit at Glan Clwyd Hospital; and support for keeping one intensive neonatal unit in North Wales.
Vascular Services
Proposals for Vascular Services at One Specialist Centre
Figure 38: Consultation Questionnaire responses to proposals for providing services at a specialist centre in North Wales
Do you agree or disagree with the proposal to provide complicated and emergency Vascular Services at one specialist centre in North Wales?
Household Survey
Base: All Respondents (632) 92% of respondents answered the question
Open Questionnaire – all respondents Open Questionnaire – all respondents NOT from the Prestatyn Pressure Group
Base: All Respondents (1,501) Base: All respondents (1,256) 82% of respondents answered the question 85% of respondents answered the question
2.95 The Consultation Questionnaire shows that the majority agree with the proposal to provide complicated and emergency Vascular Services at one specialist centre in North Wales; The Household
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Survey shows that around 7 in 10 (68%) residents are in agreement and the Open Question shows that half are in agreement (which increases to 59% when excluding the Prestatyn Pressure group responses). 2.96 Although disagreement is higher for the Open Questionnaire, when the Prestatyn Pressure group responses are excluded from the results, this proportion decreases from 42% to 31%.
Preferred Location of Specialist Centre for Vascular Services
Figure 39: Consultation Questionnaire responses to proposals for the location of the specialist centre to be at the one of the following hospitals
If a specialist centre for complicated and emergency Vascular Services was established, at which hospital do you think that this should this be located?
Household Survey Open Questionnaire
Base: All Respondents (582) Base: All respondents (1,375) 85% of respondents answered the question 72% of respondents answered the question
2.97 The Consultation Questionnaire shows a significant level of support for a specialist centre for complicated and emergency Vascular Services to be established at Glan Clwyd Hospital. 2.98 The Household Survey shows that almost half (48%) of residents think that the specialist centre should be located at Glan Clwyd, closely followed by Wrexham Maelor Hospital. In comparison, the Open Questionnaire shows that support for Glan Clwyd Hospital is even stronger, with 7 in 10 (69%) showing preference for this hospital, and only small proportions choosing the remaining two hospitals. 2.99 When we consider the geographic spread of responses (Figure 40), it is evident that there is little difference in agreement/disagreement with this proposal in terms of residents’ nearest district general hospital. It is also evident that residents have mainly shown preference for the specialist centre to be located at their nearest district general hospital. However, the majority of residents who nearest hospital is Bronglais would chose as their preferred location, and furthermore, more than quarter of residents whose nearest hospital is Ysbyty Gwynedd would also chose Ysbyty Glan Clwyd. Therefore the support for Ysbyty Glan Clwyd is not only concentrated near the boundaries of the area surrounding the hospital.
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Figure 40: Household Survey responses mapped by area, with shaded zones depicting 5km, 10km, 25km and over 25km from named General Hospital – All individual respondents that provided a postcode
Support for Glan Clwyd is not only concentrated near “boundaries” “Support Glan Clwyd as it is central”
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Vascular Services – Further Comments 2.100 Respondents were given the opportunity to make further comments about the Health Board’s proposals for Vascular Services. Only around 1 in 10 (15%) of Household Survey residents made any further comments, in comparison to a fifth (21%) of Open Questionnaire respondents. 2.101 The table below shows the top main comments that were made by both sets of respondents.
Figure 41: Further comments about the proposals for Vascular Services?
Number of Responses
Main further comments Household Open Survey Questionnaire (88) (401)
Concerns over travel: - distance - cost 24 100 - poor road network/concerns over public transport - concerns about family not being able to visit - keep care local
Support Glan Clwyd Hospital as it is central 19 70
Base: All respondents who made a further comment(s) (Number of respondents in brackets)
2.102 The table below shows other comments which were mainly made by Open Questionnaire respondents, but by very few Household Survey residents.
Figure 42: Further comments mainly made by Open Questionnaire respondents about the proposals for older people’s mental health?
Number of Responses
Further comments mainly made by Open Questionnaire respondents Household Open Survey Questionnaire (88) (401)
More than one specialist centre is needed to cover the geographical catchment area 8 54 centres of population/one centre could not cope with the demand of three
Distance to travel in emergency cases may/will cause deaths 3 39
Excellent care/keep current level of service/develop service at Glan Clwyd 1 37
Base: All respondents who made a further comment(s) (Number of respondents in brackets)
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Further Comments
2.103 Respondents were given the opportunity to make further comments about any of the proposals mentioned in the consultation questionnaire. Around 1-in-8 (12%) of Household Survey residents made any further comments, in comparison to almost a quarter (23%) of Open Questionnaire respondents. These mainly included: Main comments made by both Household Survey and Open Questionnaire responses » Keep care local - concerns with distance to travel and that road infrastructure cannot cope » Spend money on patient care and services and not admin/cut back on admin and management staff » The patient should be the priority, not cutting costs » Changes are being made without listening to public opinion: – the public need to be consulted more – BCUHB has already made decisions – Health Board staff are not attending public meetings Main comments made mainly by Open Questionnaire respondents » General negative comments about politicians/ministers/senior health figures/BCUHB » Recruitment needs to be improved in order to minimize closures: – need more well trained staff – BCUHB needs to invest in recruiting specialists – doubts that BCUHB can hire all the staff needed to implement proposals » Against the centralisation of services because: reduces availability of local care/increases travel/overworks staff » Public transport needs to be improved in order for proposals to work
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3. Deliberative Findings Feedback from focus groups with members of the public
3.1 In order to provide thoughtful consideration of the issues by a wide range of ‘ordinary’ members of the public, ORS recruited and facilitated eight focus groups across the BCUHB area during October 2012. Overall, the meetings were well attended and broadly representative: they were: Inclusive (encompassing a wide range of people); Not self-selecting (randomly recruited); Relatively well-informed (following an initial presentation of the key issues and policy options); and Fairly conducted (through careful facilitation by ORS). 3.2 In total, there were 70 diverse participants at the eight sessions. The meetings, attendance level and demographics by members of the public were as follows:
Figure 43: Profile of focus group participants
Number of Characteristic Participants Area Anglesey 7 Conwy 12 Denbighshire 10 Flint (3 groups) 23 Gwynedd 7 Wrexham 11 Gender Male 36 Female 34 Age 18 to 34 14 35 to 54 26 55 or over 30 Social Grade AB 13 C1 24 C2 16 DE 17 Limiting Long-term Illness or Disability 14
3.3 There was a considerable contrast between the tone of these thoughtful and considered meetings, on the one hand, and the more confrontational atmosphere that BCUHB encountered in some of its public meetings, on the other. 3.4 This report concisely reviews the sentiments and judgements of participants about BCUHB’s Review of Healthcare Services in North Wales. Verbatim quotations are used, in indented italics, not because we
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agree or disagree with them – but for their vividness in capturing recurrent points of view. ORS does not endorse the opinions in question, but seeks only to portray them accurately and clearly. While quotations are used, the report is obviously not a verbatim transcript of the sessions, but an interpretative summary of the issues raised by participants in free-ranging discussions.
Anglesey (held in Llangefni)
Awareness of Consultation and Proposals 3.5 Some participants had heard about possible ward closures at Cefni and Penrhos Stanley Hospitals, but were not aware of any specific proposals. Others had heard that specialist Neonatal Services would be unavailable in North Wales - but were again unsure as to how or where they had received this information. 3.6 Awareness of the formal consultation process was limited; no-one recalled having seen or received any formal publications from BCUHB. In fact, most people commented that they would have liked to have seen the materials about the proposals before the discussion had taken place so that they could comment in a more considered and informed way. They were, however, satisfied that the presentation given during the sessions had provided a comprehensive overview of the proposals.
Neonatal Intensive Care Services 3.7 In relation to Neonatal Intensive Care being provided at Arrowe Park, participants sought assurances that there will not be inequality of NHS services depending on postcode or nationality – and that Welsh patients will be treated in exactly the same way as those from the hospital’s catchment area. There was also concern about the trend toward specialist services moving further afield and outside the jurisdiction of BCUHB and the Welsh Government: Does this then mean that Welsh patients are given less priority if specialist Neonatal Services are only available across the border? It’s not so much travelling for quality of care that’s the issue, it’s whether or not we’ll get treated the same as local patients and tax payers. Will it be a two-tier system in Wales and England? 3.8 One participant, who had recently had a child, expressed concerns about the current level of specialist knowledge at Ysbyty Gwynedd. They called for improvement in maternity and new-born services at this hospital as a minimum. Others felt that there should be at least some specialist baby care equipment in the region - albeit not a Centre of Excellence: When my girlfriend went in with bleeding on a Sunday, there were no doctors there! We waited in a room on our own while nurses watched the TV When children are concerned, then I don’t think that we’d complain about travelling for the best possible care but it would be nice to think that Wales would have some specialist baby care provision.
Vascular Services 3.9 Participants urged the provision of Vascular Services as close to patients as possible given that vascular illnesses tend to be sudden and very urgent. For example, they stated that strokes and thrombosis can
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strike at any time and cause death or long-lasting affects very quickly; therefore speed of treatment is of the essence. Participants wanted quick and effective treatment within a reasonable travel time and, while accepting that having three hospitals providing the highest level of care is unrealistic, a central location for this would be the safest option for patients. 3.10 Rationalising and centralising skills and resources in fewer acute hospitals was supported by participants – but they also sought tangible evidence that patient outcomes will improve (and costs for administration and patient travel will reduce) under these plans. Moreover, participants generally agreed that centralising services does not guarantee an improved service unless BCUHB is able to attract and retain specialist skills and the best quality staff: A better funded and equipped service alone is not a guarantee of improved service; you need the best staff to be recruited and not just bring the staff you have together into one place - there’s a big difference I think the public will need to see things like waiting lists reduce and less need for unnecessary appointments before we’d say this is a success. 3.11 Overall, participants agreed that travelling for specialist services is acceptable. However, they also wanted to see IT being used more smartly to facilitate specialist aftercare or routine appointments closer to home. Indeed, better use of Skype and video calls to assess and monitor patients would, it was felt, reduce the need for unnecessary hospital appointments and could streamline clinical pathways - making it quicker and more efficient for patients and staff. In all cases, where online or video consultation is used, the group stressed the need to ensure there is a clinician at each side of the video link to facilitate the assessment: Travelling for specialist care isn’t the issue; it is having to go back and forth sometimes for years or even for life after you’ve had the treatment. There has to be a better way for patients A GP or hospital doctor needs to be to represent the patient during video and Skype appointments to make sure the patient and the other doctor knows all the facts.
Older People’s Mental Health Services 3.12 For participants, the older people’s mental health plans appear to emphasise the role of (and place more pressure on) families to care for their elderly relatives. Indeed, people felt that the proposals reflect the NHS passing responsibility for care back to families once more: People with long term needs should be cared for closer to home because it’s less upheaval for them, and more so when their old. But a lack of support and respite will make it really tough for patients and their carers Being a carer is a full-time job which takes a lot of sacrifice - it’s not fair to assume that everyone can and will be able to do this for their loved ones. 3.13 As a consequence, respondents called for a re-think of the proposed reduction in inpatient beds at Cefni Hospital because the need for care close to home should include some respite care near to families who are caring for elderly patients with mental health issues, Alzheimer’s and Dementia.
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One ward at Cefni (Llangefni Hospital) is currently used for elderly people’s care and is proposed to close under these plans, so there will be no respite care services available for families. 3.14 Another participant expressed concern about the plans, suggesting that the ageing population and the demographic trend toward elderly migration into North Wales make this proposed care model more complex and expensive to deliver in the long-term: Many elderly patients in the area have migrated to Wales and may or may not have a support network around them required to support this model of care. If the ageing population is getting bigger and more and more people are retiring into north Wales, then surely it makes more sense to provide these services in community hospitals? 3.15 Other participants feared that under the proposals, elderly patients with mental health issues would too often end up in the wrong care setting as a consequence of either inadequate care at home, or most likely, being fast-tracked into inappropriate care or accommodation to make room on acute wards. Some also feared that older patients with mental health problems would be put into care as an easy option – and be heavily medicated to make them manageable: The care homes are already half full with drugged-up elderly people who have Dementia and Alzheimer’s; there just aren’t enough places to meet the demand that this policy is going to create Patients whose families who can’t cope, or who have no family will end up in care rather than at home.
Community Services and Primary Care 3.16 Participants agreed with the broad aims of the proposals – that is, that reducing unnecessary hospital appointments and admissions through better care close to home would be better for patients. For this to be successful and safe, however, participants stressed the need for investment in IT, GP services, community trained nurses and support staff. Without more investment (and detailed financial planning) in community health services, participants regard this proposed model as merely a way to devolve more responsibility for healthcare back to individuals and their families, while saving money for the NHS: Where is the money going to come from, as I take it this is about saving money? These plans will cost more but passing the buck back to the patients and their families is a good way to save money I’d like to see how the costs would be worked out. There’s nothing in the proposals that shows how these savings have been broken down. 3.17 In addition, participants suggested that the local community model will also require GP contracts to be re-negotiated or re-written because, in their view, GPs would not be willing to undertake the extra work under current contractual agreements. More community nurses with relevant skills will also be needed and therefore there will need to be a short-term but very high level of investment to make it work: The Health Board are going to have a battle with GPs to bring these changes in. Doctors are too busy earning hundreds a day working as locums in A&E
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They say they can’t recruit doctors and nurses at the moment so where are the nurses going to come from to travel around the place? These plans are looking more and more expensive than the current system which they say is already too expensive.
Community Hospitals 3.18 Reductions in community hospital services - and particularly the proposed reduction of inpatient beds at Llangefni – will, it was felt, have an impact on local people being able to convalesce closer to home. Respondents also suggested that the proposals will lead to bed-blocking because patients will have nowhere to go once discharged from acute or specialist hospitals. This could then place additional pressure on: Ysbyty Gwynedd’s wards; Penrhos Stanley Hospital in Holyhead; and patients’ family, neighbours and friends: Cefni hospital has a convalescence ward at the moment, but with that going there’s nowhere for patients to stay close to home. They’ll either be discharged home or further away to Holyhead My worry is that they’ll be forced to stay longer than necessary on a general ward or be sent home to fend for themselves. 3.19 In much the same way as they questioned the care closer to home strategy, participants desired evidence that there is a cost saving to be had in replacing services at community hospitals with staff travelling to patients’ homes. Some doubted it is cost-effective, or even possible, to operate a community-based health service (with the emphasis on professionals visiting patients) in such a rural area: Does the NHS have the finances in reality to employ these staff? Where are the figures that support these proposals? It will be cheaper to maintain the community hospital model than to move to more home based care. 3.20 Some participants also feared that low-paid support staff will be relied upon to perform tasks traditionally fulfilled by professional staff: They’ll just use low paid care staff, so standards will drop and so will the care. This will be community healthcare done on the cheap! 3.21 In terms of logistics, it was suggested that GPs and nurses are already over-stretched in covering such a large rural area – and so participants questioned whether the proposed model will work in practice, or might it simply compound an already strained community healthcare service: This will, if not paid for properly, just make the existing services even worse Doctors and nurses don’t have any time with patients as it is, and things like Home Help are only there for 20 minutes max. People are going to be left on their own more and more God help you if you don’t have family to check up on you!
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3.22 As for other hospital-based issues, having primary care, and particularly emergency services, available to all within a safe distance was a significant priority for this group. However, A&E was less of an issue for participants in comparison with other areas because of their proximity to a full general service at Ysbyty Gwynedd. Participants suggest that the A&E, triage and out-of-hours services based there are very good:
I think we’re quite lucky to have a major hospital nearby, so we haven’t got a great deal to complain about There is a triage service at Ysbyty Gwynedd and ‘Meddygon Menai’ is there to treat non- urgent cases or MIU cases. This helps to reduce clogging of A&E.
Conwy (held in Llanrwst)
Awareness of Consultation and Proposals 3.23 Conwy-based participants demonstrated very little awareness of both BCUHB’s proposals and its formal consultation process (no-one, for example, had seen the consultation document). Indeed, any knowledge people had seemed to have been gathered from informal channels such as local media and employment networks: I have heard there are closures of hospitals and some services, not a lot more than that really. I’ve heard from the local papers and things I’ve been to a meeting as part of my job and I have got some information from there. 3.24 The participant who had heard of the proposals via their job works in Denbighshire and claimed that awareness and consultation activity is far higher there - presumably (they felt) as it is, as a county, more affected by the proposals than Conwy: Denbighshire is quite active; I have been asked to go to meeting and answer questionnaires and things. 3.25 The general sense was that the level of awareness is not high in the area…the Health Board doesn’t seem to have been pro-active in providing information.
Neonatal Intensive Care Services 3.26 Participants at Llanrwst could see the logic behind the proposal to provide Neonatal Intensive Care Services for North Wales from Arrowe Park and most were prepared to support it, albeit somewhat reluctantly in some cases. The general sense was that, although it would be preferable to develop services locally, if the best care can be provided at Arrowe Park then parents will be prepared to travel there. This support did, however, come with the caveat that a Special Care Baby Unit is retained in each of the three acute hospitals in North Wales: I don’t agree really with the Paediatric side of things but I can see why it makes sense I wouldn’t care about where it was, I would just want them to have the best service If you think this is the best thing for my child, you would travel. I’m sure the 36 parents would do everything to get the best care
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There needs to be a SCBU in every hospital here. 3.27 There was, however, some support for developing good quality specialist Neonatal Services in the West of the BCUHB area given the distance from there to Arrowe Park: It’s all in the east, what about people in the west? I think they should have one at Bangor…people living in places like Anglesey will have so far to travel. 3.28 There was also some concern that the loss of Level 3 Neonatal Services from North Wales will perpetuate BCUHB’s paediatric recruitment issues. That is, it was argued that losing specialist services from the area will deter career-minded doctors and consultants from locating there, which could then lead to the loss of further specialist services – a ‘vicious circle’ if you like: If staff hear that in Wales they are providing a poor quality service it’s another reason why people aren’t going to work here. It’s a vicious circle isn’t it? Is this the beginning of us just having very ordinary services in North Wales? 3.29 It was, however, acknowledged that North Wales has some Centres of Excellence that attract doctors from all over the world, which may offset the loss of specialist services in other fields of medicine: The cancer services in Glan Clwyd are attracting people from all over the world. The cancer centre there is one of the best in the UK…there are lots of things happening that we are not aware of There are lots of other services in North Wales that are making it a worthwhile place to be as well. 3.30 A couple of participants were of the view that Neonatal Services should be developed in North Wales on a matter of principle - and so that good quality doctors and nurses are attracted to the area: Why can’t North Wales have the Arrowe Park facilities? It’s a Welsh Health board I thought the whole idea was that we weren’t having to go into England anymore We need to get equipment into Wales so all the doctors and nurses will come into Wales to work.
Vascular Services 3.31 Participants at Llanrwst supported the proposed centralisation of major arterial surgery in one location. They agreed that locating specialists in one Centre of Excellence will improve patient outcomes and felt that people would be prepared to travel for the best possible care. It was also recognised that this will affect a relatively small number of people per year: With more specialists in one area there will be better care If you know the best team is in a certain hospital, you are going to go there. If you are in that category you would want to go wherever the doctors are. So when it comes down to it I don’t think that it is that much of an issue Its only 300, it’s not massive is it…all three hospitals will do the minor routine stuff.
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3.32 The group was also pleased that before- and after-care would be provided from local hospitals: I know you would have to travel for the surgery, but I assume there would be further period in your own hospital The follow up care is available in three satellite hospitals that are around so once you have had it you can come back. It makes sense. 3.33 In terms of location, most agreed that Glan Clwyd would be most appropriate given its relative centrality in North Wales – although there was some concern about the hospital’s capacity to expand further: It should go to Glan Clwyd; it’s more central to everybody I’m thinking myself which hospital, because surely at Glan Clwyd they can’t cram anything else in there? They have a huge cancer centre there, a massive heart specialist centre there that used to be in Manchester…and parking is an absolute nightmare. 3.34 There was little support for either Ysbyty Gwynedd or Wrexham Maelor: It shouldn’t be put in Wrexham because a) It is furthest away from the mountains where emergencies might happen b) the majority of people are not near there and you are putting the services so far away from everybody If you had it in Bangor you would have to have another one somewhere else because of where it is.
Older People’s Mental Health Services 3.35 Participants were surprised, and indeed horrified, by the projected 68% increase in people with dementia over the next 20 years: I’d like to know where they have got the 68% increase in dementia. I can’t get that out of my head It is quite terrifying. 3.36 Although there was considerable support for community services to support older people with mental health issues, there was also considerable scepticism about how they will be provided ‘on the ground’ without a large increase in staffing levels: I have worked with Community Liaison Teams and they were stretched as it was. I was getting phone calls all the time from family members at the end of their tether and people in the community worried about their neighbours There needs to be a lot more in place… there needs to something more robust in the community for the patients and their families. 3.37 In relation to the final quotation above, the group was disappointed at the lack of reference to providing support for carers and families within the consultation document. This, it was strongly, felt, is essential – especially if some community hospitals are closed and are no longer able to offer respite care: You have got to think of the pressure on those families
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My closest friend died of Alzheimer’s a few years ago and the effect it had on the family was absolutely horrendous It is an absolutely huge thing for the family and if the patients are staying at home or with family, the family need that respite support. So closing some community hospitals means there is no respite there at all which is crucial. It really does scare me that these smaller hospitals are closing with a 68% increase. 3.38 There was a great deal of concern about the stated longer-term aim of moving all inpatient services from Ysbyty Cefni to Ysbyty Gwynedd. Participants argued that this would be especially detrimental for dementia sufferers who need a large degree of familiarity in their lives – and for their families who must have regular contact to provide that familiarity and will have to travel large distances to do so: It’s not good to be away from your home when you’re ill and confused It adds to the confusion It’s taking them away from the community that they live in and know. A lot of people with dementia…their short-term memory goes first and their long-term memory stays. Taking them away completely throws them What about going to visit them in hospital. It will be a long way for some people and it’s hard to take time off work… 3.39 On a more positive note, people were very supportive of strengthening Memory Services to support early diagnosis: I like the idea of the memory service; I think that is a positive step. Again, I do know that there are things that can be done at an early stage so I think I would definitely support more money going into early diagnosis.
Community Services and Primary Care 3.40 Again, people were very supportive of the idea of care closer to home in principle, but were unconvinced about its achievability in practice (a view in some cases driven by experience). Participants were particularly sceptical about the costs involved in providing such care properly – and questioned how BCUHB can afford it: The reality is that care 24/7 is not really possible. Both my parents have recently died of cancer and they were at home...trying to get the care 24/7 was not happening. Marie Curie was great but they could only come over three nights a week. And the nurses only come for a short time, 20 minutes to one hour tops for two people, twice a day. In the end they needed to go to a hospice because they needed 24-hour care That looks good, but reality is completely different 24-hour patient care at home, how on earth are you going to finance it? It’s not so much how much is it going to cost, its where are they going to get the money from to do that? 3.41 One person described their father’s experience of dying at home, with apparently excellent community ‘end of life’ support. Their mother, on the other hand, had little support when in the same situation. The lack of consistency of care was certainly an issue for several people:
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My dad died at home and it seemed to work for him because he had an awful lot of care and support. And my mum died six months before and was almost left to her own devices. It’s a bit of a hit or miss. 3.42 As with the proposals for Older People’s Mental Health, participants argued that care closer to home may not be the safest or most practicable option in practice for a lot of people – and also that the proposals will place more of burden on patients’ families and friends: Everything sounds good on paper but how are they going to have more people at home? Yes you might have a nurse calling but it isn’t always better, it depends on the person concerned and their condition Someone I know who had a hip operation was sent home and she was only entitled to a couple of hours a day of care and they couldn’t do this and they couldn’t do that. If she hadn’t of had me, doing the shopping, cleaning and general things, she would have been in an awful mess. 3.43 More positively, participants were supportive about moving care from hospitals to the community: I’m diabetic so I have tests done and I go to my doctors and then I have to go to the hospital to have blood taken there. It would be great if they could take the bloods there and then? 3.44 On a separate note, a couple of people mentioned the First Responders in their areas – and the difficulties they have experienced in maintaining their service: We had a good team of First Responders here; we had 19. Because of hiccups in administration, which caused a lot of us to drop out, we are now down to four. We are saying we can’t cope with it anymore and we can’t do it. We are just out of date with our training and assessments. It’s not regulated by the NHS and I would have thought it would have been. It has been three years now We have got in Llanrwst here from what I gather are First Respondents…one girl was saying there was problem for funding and that she would have to raise the money herself to get it. She was willing to do the work and give her time. It seems to be again lack of funding, which is a shame when people are ready to give their time and services. There was a definite sense that this service - which performs an important function, especially in rural areas, should be better supported.
Community Hospitals 3.45 Although people could see the logic behind concentrating services in hospital hubs, there was some concern about losing the ‘personal’ service provided in the local community hospitals. Even the larger community hospitals themselves were thought to have expanded to such an extent that services no longer work together as smoothly as previously: When you are going so big like this it’s like you are going into a factory I’ve worked in Llandudno hospital and I can see the difference when I was there to now; it’s massive. What I did find when I worked there, everything was together and people worked together really well. Whereas now it’s too big and it’s not working. An example of this was my Dad collapsed Christmas time last year and he couldn’t breathe and they found huge
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tumour in his throat. But they operated on him, sent the sample off and it took seven days to come back. 3.46 Also, when looking at the map of the hub hospitals, people were concerned about the geographical ‘gaps’ – especially on the Llyn Peninsula, in South Conwy and South Denbighshire: I can see the sense; I just think there are some big gaps there. The poor people who live right on the edge, where do they go? 3.47 The group was pleased that Llandudno Hospital is proposed to be a hub hospital, but they were worried that A&E services are not available there 24 hours. This was considered especially difficult for those in the rural south of Conwy county who are 40 minutes away from both Ysbyty Glan Clwyd and Ysbyty Gwynedd: Smaller hospitals are essential, especially here because we are 40 minutes away from Bangor, 40 minutes away from Glan Clwyd and we are closing the A&E in the evening in Llandudno which is only 20 minutes away. That’s the difference between life and death when you are living in a rural community The fact that Llandudno is not open 24-hours is very worrying, especially in a rural area like this. 3.48 Given that participants (even those from Colwyn Bay) would tend to use Llandudno Community Hospital for minor injuries rather than Colwyn Bay Hospital, the proposed closure of the MIU at the latter was not controversial – especially so given that many participants were not even aware of its existence. The main reason for their preference for Llandudno is that the range of services provided there is greater than at Colwyn Bay – and thus there is less of a chance of being sent to Glan Clwyd for treatment: I broke my wrist playing football and went to Llandudno rather than Colwyn Bay I go to Llandudno because services at Colwyn Bay aren’t as big as those at Llandudno My son was punched after school…we went to Colwyn Bay and they just sent us up to Glan Clwyd When I went there I got sent to Glan Clwyd anyway. I didn’t even know Colwyn Bay had one! 3.49 This is not to say that there were no concerns about the proposal. The impact of the closure on those without transportation was a worry (although this, it was felt, could be mitigated by GPs offering minor injuries services) – as was the potential for extra demand to be placed on the hub hospitals – especially Ysbyty Glan Clwyd: The Minor Injuries Unit closing in Colwyn Bay for me personally is not a problem because I have got a car. But lots of people don’t have cars If GPs had extended services, could one of them have the responsibility to do minor injuries? It’s also affecting other places with pressure If the Minor Injuries Service are say only 10 hours, then the hub hospitals are the only ones here you can get out of hours for injuries
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It puts the service out of the way really. And puts the pressure on those three hubs. Even at Glan Clwyd the number of doctors goes down overnight. The wait will then be huge. 3.50 Indeed, many comments were made about the pressure Glan Clwyd is under currently – even before the proposed closures of community hospitals, MIUs and X-Ray departments are considered. This is so much of an issue for a couple of participants that they would prefer to travel the slightly longer distance to Ysbyty Gwynedd for treatment: It seems to be Glan Clwyd that is busiest. My friend is an ambulance driver and he says there are eight to ten ambulances in a weekend there. It’s continuous. They are waiting in pain. There seems to be an awful lot of people coming to A&E and they are waiting and suffering for hours on end and they shouldn’t have to be When I was there last week with my daughter the doctors didn’t know what was going on. Then in the bed next to her this poor girl had been waiting for six hours with her mum with no name written on the bed. Nurses didn’t know what was going on. And this was a very small area with skeleton staff on… If you are not in hospital a lot you wouldn’t know, but when you are there it’s like ‘oh crikey’. There are massive staff shortages and a lack of communication My son had an ear infection so we travelled to Glan Clwyd and we waited about two hours and they said it wasn’t an emergency because there was no pus coming out of his ears. He was six months and screaming. We then went to Bangor and they saw us within twenty to thirty minutes. 3.51 On a final note, people felt that the general public should be provided with more information about the services available at each hospital so that they are able to choose appropriately which to attend: We need more information as to what to expect from each hospital. You don’t think…when things happen you just go to the hospital It could be a good idea to have video screens in GPs giving us more information. Some people don’t want to pick up a leaflet, but if you’re sat there in the waiting room this information can be played so that people know where to go.
Denbighshire (held in Rhyl)
Awareness of Consultation and Proposals 3.52 One person at the Denbighshire group had been to a public meeting in Prestatyn, which they had heard about via emails from their local Assembly Member (to which they appear to have subscribed on a generic basis): I was aware because I had general emails from the AM member. He does send out a couple of emails a week saying what he’s doing and what’s going on and he mentioned these public meetings. He was also banging on quite a lot about this process.
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3.53 However, they acknowledged that few people of their acquaintance were aware of the meeting – or indeed the wider consultation process: A lot of people I know didn’t know about that meeting or the process. 3.54 This view was supported by the remainder of the group, most of whom were not aware of a public meeting (or any other consultation) having taken place. Even those who did know about it were not sufficiently motivated to attend: I did not know about the consultations, the only thing I knew was what I read in the newspaper after the event. There are articles in the paper and stuff about individual cases of changes but I don’t know of any overall strategy or plan… I remember seeing something in the newspaper and I didn’t do anything about it. 3.55 As for people’s knowledge and understanding of BCUHB’s proposals, this was again generally low – although some had a vague idea of the ideas under consideration and one was very familiar with the proposal for Neonatal Services: I have no idea really what is intended or why. Presumably it’s to save money. But is it to improve services? I’m sure they are saying this but I have no idea what they are going to do except from the baby unit and the Ruthin changes Not specifically, I have heard about them closing one or two hospitals but that is about it I’m sure there is one proposal of moving the mother and baby unit over into England isn’t there? I have heard that they are thinking of closing the Minor Injuries Unit and the X-Ray Department. 3.56 No-one at the group had read BCUHB’s consultation document – but several commented on what they perceived to be the inadequacy of the consultation programme, especially in relation to the number of people spoken to as part of the process and the fact that there are no options ‘on the table’: They do not seem to be pursuing a proper consultation process with the public It only says you are going to speak to 200 people overall, which is a very small percentage of the population It does seem they are composing it as a done deal rather than putting options on the table, they are proposing one thing. It seems as if they have made a decision and this is what we want to do.
Neonatal Services 3.57 As aforementioned, one participant was fully aware of the proposal for Neonatal Services and they (and indeed others at the group) had strong reservations about it – particularly in relation to: The distance to Arrowe Park – especially from the western areas of North Wales The distance from somewhere like the Lleyn Peninsula to Arrowe Park…it’s huge The main issue for me is the distance; further West it is a real issue The proposal is saying they want care as close to home as possible and they are taking it away!
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The impact of the travelling distance on the affected babies’ parents – especially those who have other children to care for: It’s quite worrying because my wife is pregnant at the moment. I wouldn’t be happy with her staying at the Wirral. I wouldn’t be able to have that much time off work so I wouldn’t be able to stay there with her. If I was doing a full day of teaching I wouldn’t really want to travel all the way there and all the way home If you have a very sick baby obviously you want the best care. But what happens if you have young school-age children and you don’t have local family support to help you get those children to school if your child will be in hospital for a long time? Arrowe Park’s capacity to care for the additional babies from North Wales What happens if Arrowe Park doesn’t have the capacity to take these children on? What happens if we can’t provide the facility? A lack of service improvement At Glan Clwyd and Wrexham they do one-to-one intensive care and at Arrowe Park it will be two-to-one. So it’s not an improved service at all A lack of Welsh-language provision at Arrowe Park There is also the issue of people being able to speak the language of their choice The question of ‘nationality’ There’s also the nationality issue…wanting your child to be born in Wales is an important issue for some people. The potential for the Service Level Agreement between BCUHB and Arrowe Park to be amended in future, with higher costs for the former The price may go up even more next year and the year after and it’ll be costing us in North Wales more and more. 3.58 A further concern that should be addressed (and this applies to all cross-border services) is that Welsh patients will be treated with less urgency than those from within the hospital’s catchment area. Indeed, one participant cited personal experience of this – although they did acknowledge that this was some time ago and hoped that the situation had now changed for the better: I was waiting for heart surgery and I went to see the surgeon in Manchester Royal Infirmary and he said we can do it within 6 weeks. I spoke to the Sister and she said ‘where do you live?’ I said North Wales and she said well it won’t be within six weeks, it will be 12 to 15 weeks. This is history and I hope that has changed now but this is the type of thing that is going on This was a particular issue not only in respect to the availability of beds, but also of ambulances. That is, people questioned whether, during an ambulance shortage, priority would be given to ‘local’ patients over the babies needing transfer from North Wales: How are they going to guarantee the ambulance coming from Arrowe Park? Will we be put on the bottom of list because we are North Wales. They don’t want to know…I think Arrowe Park will service their own needs first
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3.59 The issue of recruitment was also raised at the group, with one participant arguing that BCUHB has not made sufficient efforts to recruit specialist staff to North Wales: There is no money being spent here to recruit nurses and doctors. I think they are not working hard enough to recruit. They have just thought ‘we can’t provide it so we will ship it out’ This participant was particularly concerned about the Wales Deanery’s apparent position of not sending Paediatricians-in-training to areas with no Level 3 neonatal provision – which would, of course, be the situation in the BCUHB area should this proposal be approved: Cardiff has said if we don’t have Level 3 Services they won’t send Paediatricians up here for training so that’s another knock-on effect…there will be a brain drain as well. 3.60 Overall, most of the group was opposed to the proposal to provide all long-term neonatal intensive care from Arrowe Park and felt that the service should be developed in North Wales (preferably, in terms of accessibility, at Glan Clwyd): South Wales have three intensive care services and there is not one in North Wales. It’s a vital service They have got three centres here, have they not considered enlarging one of those? Paediatricians and clinicians want it in Glan Clwyd. It would make more sense to have once centre here and, in North Wales, Glan Clwyd is more equidistant to more people. 3.61 Only one participant supported the proposal on the premise that they would be prepared to travel to access the best possible care for their child (but even they felt that, in an ideal world, services should be developed in North Wales): I agree with having the best care and I will travel. People who live near me commute to Manchester every day to go to work but then they moan if they have to go more than two miles to see a doctor. I would rather go to the other end of the Country if they can provide me with the best care. If it was my baby I would travel and there is accommodation there to stay in.
Vascular Services 3.62 There was widespread support for the proposals for Vascular Services, particularly with respect to developing a Centre of Excellence (with before- and after-care provided locally) and reducing costs where appropriate: It sounds reasonable if you are going to have excellence I think the before- and after-care should be kept locally because they are often more frequent visits I suppose we are short of money and we have to think of some ways to keep a good service but also being able to afford it.
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3.63 There were a couple of concerns – namely that centralisation will result in more travelling for more people and that if you do move to one single team then you will have single points of failure: If you have got a bad person who oversees that team then you will have a bad service whereas if there are different teams you have problem you can shift. But in theory I have no problems with it. 3.64 In terms of location, the general consensus was that Glan Clwyd would be most appropriate in terms of accessibility – although there was some concern about centralising too many services on the one site: Geographically the obvious one has got to be Glan Clwyd but you can’t do everything there unless they are going to double the size 3.65 One person had also received excellent vascular treatment at Glan Clwyd and thus was strongly in favour of developing services on that site: I have had a vascular operation done and I couldn’t wish for a better service than what I got in Glan Clwyd…I couldn’t fault the service.
Older People’s Mental Health Services 3.66 Although participants agreed with the proposal to strengthen community services for older people with mental health issues in principle, they also argued that this may not be the safest or most practicable option in practice for a lot of people – especially those suffering from dementia who may not be receptive to visits from community teams: I question the effect of pushing it out into the community If you have got an old person at home who has dementia and you have got some community support teams, are they going to answer the door and are they going to let them in? Whereas in hospital there is no choice The thing that worries me is, ok you can put more people out in the community to help, but is it going to work when you have got somebody who wants to just shut the door and lock themselves away, especially if they are living alone? My grandmother went through this. She went through a stage of refusing to take medicine. Her GP had to get involved with the Mental Health Service and then the Police because she wouldn’t let them in…it took forever to get sorted I guess older people want to be at home, but there are those elements of society which can’t be at home and when it comes to dementia it becomes an issue. As such, they desired more detail about what ‘strengthen community services’ will mean in practice; and they sought reassurance that the safety of older people with mental health issues will not be compromised by the removal of hospital beds prior to proper alternatives being put in place: I think the proposals are thoughtful and community care is very good. I would just like to see them more specifically stated If there is going to be a reduction in the hospital level, will there be an increase in resources at community level? What does community services strengthen mean?
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It’s all nice words to make you think it all makes sense. But there is nothing to make sense of really. It needs a lot more detail People are still going to get injured when they have got dementia. They will still have to go somewhere in a hospital. 3.67 The group was also disappointed at the lack of reference to providing support for carers and families (while caring for the patient at home or after taking the decision to move them to a residential care home) within the consultation document: The people who do most good with old people are the carers; they are the ones who are there most of the time. Social Services come in once every day or once every two days and are just ticking boxes really. There is no mention of carers and these are the most important people for looking after people in the community I know someone whose husband is going down with dementia very badly and she knows eventually she is going to have to put him in a place. When she does that her own house is going to have to be sold to pay for it, and when she does that she is in hell of a situation and this is why I don’t think this goes far enough as far as the community is concerned. 3.68 There was some concern about the stated longer-term aim of moving all inpatient services from Ysbyty Cefni to Ysbyty Gwynedd. Participants argued that this would be especially detrimental for dementia sufferers who need a large degree of familiarity in their lives – and for their families who must have regular contact in order to provide that familiarity: People will remember places that they grow up… My mum’s best friend has got dementia and two or three times a year she goes into a home for respite care and she comes home and she doesn’t remember where she is or can’t find things. It’s because she has forgotten whilst she has been away. Routine is important You’re away from your family and friends which is key to the treatment and management of that condition A lot of these people would need to see their relatives regularly for a reminder. If the families are going to go there, say, once a week, then they are going to forget more even quicker I don’t think it’s good because there are lots of people with older partners. There is the problem of travel really for the older group I feel that you are talking about older people, who possibly have older partners who don’t drive any more. Plus their children would be in their 40’s, 50’s who are working and then there is the difficulty of them going to visit. 3.69 Some people also felt that this would represent a return to ‘institutionalised’ care, with all mental health patients contained in one location: What sort of facility would you provide for everybody to be in one place? Surely there are not going to be huge long dormitories. I have this imagine of a big institution That really is worrying; you are going back to the age where they had a mental home in Denbigh for instance.
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Community Services and Primary Care 3.70 Again, although participants readily endorsed the principles behind ‘enhancing care in communities’ and ‘moving care from hospitals to the community’, they were somewhat sceptical about the achievability of the proposals in practice (driven in some cases by personal experience), and desired more information about what exactly they will entail: I think it’s very good if it does work I think there has been a lot of broad statements made…some of the objectives to me seem unobtainable and they are aiming to high A friend of mine’s father went blind and he was very unstable. And someone just went in once a day to cook food and that was it; she couldn’t get any help other than that. He was constantly falling over because he couldn’t see anything. In the end he did go into a home. She couldn’t get any other help for him and that went on for a long time To me it’s just words on paper I think the objectives put down there are great, but it’s very nebulous really I would want a few more facts rather than just ideas I have no problem with what they are trying to achieve but there are no hard facts. 3.71 In terms of specifics, one person described their experience of witnessing their best friend die at home from cancer, with apparently excellent community ‘end of life’ support. They were of the view that, if this can be provided properly, it is invaluable to the patient and to their family and friends: I have experienced this last year, my best friend died of cancer. She died at home and they were really good. It was less distressing for her immediate family with regards to them not having to travel every day and she had a good level of care. They moved the bed downstairs for her, they had visits from nurses every four hours day and night, occupational health therapists there and everything. 3.72 People also commented on the important role of the Health Visitor in community healthcare. It was argued that the role has diminished somewhat, resulting in less well-developed children attending school still wearing nappies, with speech problems and, in some cases, unable to use a knife and fork: Health visitors – they don’t do a lot now compared to what they used to do. They come into schools still wearing nappies and I spend my time ringing up GPs when years ago the health visitor would have done that They don’t go out anymore. We are now getting children coming into school still in nappies and with speech problems. There was a strong feeling that this is a direct result of Health Visitors not making frequent enough visits to families – especially those that most need help, but are most reluctant to engage with mainstream services: It’s no good just ringing somebody… If the Health Visitor visited more they pick up on parents who need parenting skills. In my school we have parenting classes and the mums that needed to come didn’t come. We even had parents that didn’t turn up for the speech therapist appointments and things like that. The parents who need the help you never see.
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3.73 Finally in terms of community healthcare, participants commented on the importance of face-to-face contact with health professionals, and did not feel that this should be wholly replaced with the use of technology (although this does, it was felt, have an important role to play): You need face-to-face. This telephone stuff and video stuff is fine if you are technically savvy but for a lot of people, talking over the phone in detail or through video is not a happy experience My mum had a stroke and she rang the doctor to say she wasn’t feeling right and he said to take Paracetamol. I knew straight away it was a stroke. If he had seen her, he would have known.
Community Hospitals 3.74 Several participants commented on the inappropriateness of both the Royal Alexandra Hospital in Rhyl and Prestatyn Community hospital as modern healthcare facilities – and also on the amount they must cost to run: It’s not before time. I went to the Royal Alexandra the other day. It’s huge. It must cost the earth to keep going The majority of that building can’t be used. It needs bulldozing. It’s a waste of space. Something needs to be done and if they can provide those services in a new place I think it’s great. 3.75 As such, the group was very much in favour of developing a new integrated facility for Rhyl and Prestatyn on the Royal Alexandra site – on the strong proviso that the facility is in place before existing services are removed: We have got to remember the Health Service is funded by us. And would you want your money being spent on an old crumbly building or spent where we would like it to be spent - on the service? It must be a pleasure for staff to work in these new hospitals and for the patients to be treated in them. The old buildings are really depressing Develop the site, then close the other services I want commitment to keep it open until the facility is in place. 3.76 Indeed, the group commented that there is much disquiet over this proposal in Prestatyn – and that a lack of reassurance over the provision of interim services is one of the main reasons why: In the meeting in Prestatyn they said it will be closed soon and then the new one will take a good few years. This is a worry for the NHS beds isn’t it? A lot of people in Prestatyn are up in arms about closing Prestatyn Hospital because of the loss of beds in the interim They [BCUHB] were asked the question of whether Prestatyn will be kept open in the meantime and they couldn’t answer it. 3.77 There was also some interest in how exactly the site will be redeveloped given that is it a Grade II listed building.
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3.78 While it was acknowledged that usage of the Minor Injuries Unit at Ruthin is low, participants were of the view that this is because few people in the area are aware of its existence: It’s underused because nobody knows it is there. I don’t think it’s advertised very well I was totally unaware until recently that there even was a Minor Injuries Unit. Two years ago my wife fell off her bike and thought she had broken her leg. We got her home with great difficulty and the next day I took her to Glan Clwyd to get her X-Rayed when it would have been an awful lot simpler to take her 500 yards down the road to Ruthin. As such, it was suggested that if the facility were to be better advertised/promoted, it would be far better used and worth maintaining. 3.79 The primary concern for most of the group in relation to closing the Minor Injuries Unit at Ruthin (along with others in the area) was the potential subsequent impact on demand at Ysbyty Glan Clwyd – and again it was felt that maintaining and better promoting the MIU would encourage better use of it, which would then lessen demand on the acute hospital: A few months ago a consultant at Glan Clwyd stated that the hospital was almost at breaking point; to me it seems like the wrong time to close satellites down I had an emergency with my son at Glan Clwyd and by the time he had the operation he was nearly at the limit of the appropriate time span and he could have ended up permanently damaged. And that was because there was people with cut fingers, drunks etc. Before anybody saw him we were there for two hours at least. And when the nurse came they put him straight on Morphine, that’s how bad he was People go to Glan Clwyd with minor injuries and they just block it all up for people with real emergencies They will be blocking up the space with minor injuries at the main hospital when it could be done at the Minor Injuries Unit I would say don’t close it, promote it! And this will take pressure off Glan Clwyd. 3.80 Some people also sought reassurance that, if the MIU does close, routine appointments for, say, dressing changes will be available locally in order to minimise patients’ inconvenience: I worked in Ruthin and a friend I worked with had an operation on her knee which needed to be dressed every day for three weeks and then every other day for a couple of weeks and she could use her half hour lunch break for that. I know Denbigh is not far, but it’s just the fact that at least she carried on working and wasn’t claiming benefits which she could do. It would have been six weeks out of work so they should still have that locally. 3.81 There was little concern about centralising X-Ray services in the ‘hub’ hospitals – particularly in terms of ensuring more consistent opening hours and in limiting the amount of money that must be spent on expensive new equipment: You don’t really need X-Ray everywhere…I see no problem with centralising it It’s a problem if you don’t know which day it is available And if the equipment is old and outdated then you can see why It’s a big cost an X-Ray machine isn’t it so you can’t have new ones everywhere?
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Flintshire (held in Flint)
3.82 Due to the extent of local feeling about the proposed closure of Flint Community Hospital, three groups were held in the town. The first discussed the range of BCUHB proposals, whereas the other two focused solely on the proposed hospital closure. 3.83 Attendance at the first group was good (eight participants), whereas it was more varied at the two convened specifically to discuss the proposed hospital closure (ten participants at one and five at the other). The larger group was, however, able to shed some light on the lower attendance at the smaller one, with some participants describing the efforts by local campaigners and the Flintshire Leader Newspaper to deter people from coming along: We have had dreadful press. They are handing this article out in the town. It happened to me when I was coming here and my husband yesterday and it is ‘any thoughts on the community hospital debate, no takers? Ok then, how about 30 quid? After all that was the going rate down in the town’s Church Street last week. The cash was being offered by clipboard types from Opinion Research Services, a University of Wales spin out company, to anybody who wanted to join a focus group’. And it goes on and on and on. It says ‘this consultation has poured petrol over an already fiery conflict over the proposal to close the hospital the organisation plans’ People are very angry that we are here tonight. I was phoned this afternoon by someone saying that people were dropping out. 3.84 Encouragingly, however, all participants were happy that they had attended the group, and felt that they had learned something and been able to voice their opinion. They also understood the reasons behind providing an incentive payment: I feel like I have gained information from it We could have sat here and said nothing for the £30 basically, that’s what they are saying in the papers but we have all said things and had a conversation about it I would have been happy to come here and have my say without the £30 but I know this is normal practice…it’s not just about this is it? They have incentives all over the world.
Awareness of Consultation and Proposals 3.85 Across the three groups held in Flint, only one person had not heard of BCUHB’s proposals for the area – although very few had seen the Health Board’s consultation document outlining the reasoning behind them. Indeed, some were not even aware of the document’s existence. 3.86 Many of those who knew of the proposed closure of Flint Hospital had participated in the ‘Save Our Hospital’ march through the town. Again, however, they (and others) knew little of the detail behind the proposal – or any of the other proposals put forward by BCUHB: I took part in the ‘Save Our Hospital’ walk but I don’t really know much about it really… We hadn’t heard anything prior to the march People have just come in and said ‘that’s it we don’t need it anymore’. Where does that come from? I know some of what’s going on but not much
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I spoke to half a dozen people before coming tonight and none of them had a clue about anything apart from that Flint Hospital is closing I’m not sure about all the proposals I think it is about closing hospitals. 3.87 It was argued that, aside from a consultation document that very few people have seen, little ‘official’ information has been provided by BCUHB – and that people are feeling ‘starved’ of information about the consultation and the proposals: I get the impression that not many people know about it and not much effort is being made by the Health Board to explain other than the odd interview People have been starved of the information. This information void is apparently being filled by the local media, which was not thought to be ideal given its propensity to sensationalise: The local media don’t help…they like sensational headlines. A lot of the changes will affect the elderly and they will worry and panic if they see a headline saying ‘hospital will shut’. 3.88 As for their initial feelings about BCUHB’s proposals, it is to be expected that the groups focused on the proposed closure of Flint Community Hospital – and were vehemently against it. The closure has, however, been expected in the area for some time, and certainly since the development of a new hospital in Holywell: This has been on the cards for many years and we knew it was coming What it boils down to is that the Health Board isn’t going to have two well-funded hospitals within five miles of each other despite the rise in population in both areas. It’s as simple as that It was going to happen from the moment they built a brand new community hospital in Holywell. From the moment the plans were passed there, Flint was doomed All facilities have been put in place in Holywell ready for this to be closed. The physiotherapy is up there, they have all hearing testing up there They have built a massive hospital at Holywell, when really it should be in Flint. Once that was completed that is where all the proposals came to close this one. 3.89 Further, although it was acknowledged that the hospital no longer offers a wide range of services, this was thought to be a situation of BCUHB’s making in order to justify its closure: Whenever I go there they say you have to go to Glan Clwyd for that or Holywell for that. They should have a few more things in the hospital then maybe it will be more inclined to stay open I haven’t gone to Flint for years because I wouldn’t have thought they had minor injuries anymore…I would just go to Holywell I think people tend to forget about Flint now because they only do blood tests and if you have an injury people won’t go there because they will be sent elsewhere anyway The facilities have been downgraded. So that has created that situation
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They keep chipping away and have left it with the minimum. It’s a culmination of chipping away. Gradually, gradually, gradually running it into the ground Half the problem is that over the last 10 years the service has become less and less and less; the equipment to do certain things is not there. There has been lack of investment in the hospital which has undermined its existence Has there been a running down of service deliberately at Flint so that Betsi Cadwaladr can convince people of the need to close services? Been run down, lack of investment. How many years have they been denying funding to redevelop Flint Hospital and they go and build a swanky new one in Holywell? 3.90 Essentially, people believed that: Flint Community Hospital will be closed regardless of what people say; that the decisions were actually taken some time ago; and that the consultation process is simply the Health Board ‘going through the motions’: People think it has been decided and this is just a cover up They say ‘we are going to do a consultation, we are going to listen to the public and take it all on board and listen to the buzzwords of the day’ but they will not listen anyway I think a lot of people think it’s going anyway and the decision has been made. Hopefully we will be proved wrong As soon as they said the hospital was going to be closed everyone panicked and thought ‘well that is the end of it’ and that’s when the march came into being and a lot of people attended that. But then I heard that the march made no difference whatsoever and they were still going to go ahead and close the hospital. 3.91 Also, it was alleged that BCUHB has already undertaken a trial closure of Flint Community Hospital in order to test the feasibility of doing so: They have shut Flint for three months. They could have had a problem but it looks like they were doing a test run to see if it was feasible.
Neonatal Intensive Care Services 3.92 Participants at Flint could see the logic behind the proposal to provide Neonatal Intensive Care Services for North Wales from Arrowe Park and most were prepared to support it, albeit somewhat reluctantly in some cases. The general sense was that, although it would be preferable to develop services locally, if the best care can be provided by centralising services at Arrowe Park then parents will be prepared to travel there: I would want the best treatment for my baby I can understand these proposals for young babies Where children are considered you want the best care It’s a small number we’re talking about and I would assume there would be accommodation at Arrowe Park for families.
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3.93 One participant had particular experience of having their child treated at a Centre of Excellence and strongly believed that the centralisation of certain services results in far better patient outcomes: My son suffers from Crohn’s disease. We eventually went to a specialist hospital in Liverpool that was so well linked up with other departments that they found out what was wrong with him very quickly. The big thing to me is you have to have this specialised group. So the Centres of Excellence should bring about this sort of thing They also understood that providing services for the critically ill can be very labour intensive and thus very expensive – and that if BCUHB was more explicit about this then people would better recognise the need for centralising certain services: If you want 24/7 cover in all three hospitals you would need five specialists minimum at each hospital and the back-up staff which is very expensive. The reasons for having Centres of Excellence is that the number of people who need specialised care is small but the number of people who provide the care is huge. They are trying to consolidate the very narrow band of care right at the top for the really critically ill people. Why don’t they just tell people that because it makes a lot of sense? 3.94 Despite the general support outlined above, there were some concerns about the proposals – namely: the potential risk to the baby of having to travel a significant distance; the widening disparity between Centres of Excellence and other healthcare facilities; and the impact of long-term care being provided at the Wirral on the lives of parents: If it was my child I would travel to the end of the earth as long as that child had the best care but are there any risk factors on the effects of the travelling on a very sick baby? It’s difficult to argue with the logic and it does make sense to centralise it. But how long do you let the disparity between these Centres of Excellence widen? Effectively you are putting your life on hold while you have a sick infant in that situation….some employers are not that sympathetic. 3.95 Only one participant was of the view that Neonatal Intensive Care Services should be developed in North Wales on a matter of principle. They questioned: why shouldn’t we have this in our own country? Why do we have to go cap in hand to the English for everything?
Vascular Services 3.96 There was support for the Vascular Services proposals, particularly with respect to developing a Centre of Excellence (with before- and after-care provided locally) – although there was some concern about the pressure under which that centre will be operating and that, once the service is consolidated in one location, it will be difficult to return to the status quo if centralisation proves to be unworkable: I would want to go where the best people are as long as after-care is in the other three hospitals When you have only one place doing it then all the pressure is on that one place I respect the fact that clinicians have said this. But once you go with one you can’t go back to the three again.
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3.97 A few participants were reluctant to either endorse or reject the Vascular Services proposals due to what they saw as a lack of information, and thus knowledge, about them: We are not fully informed about it It is pretty vague The information is not coming out…if you haven’t got that information you can’t make any decisions. Give us the simple information and then we can think about it. 3.98 In terms of location, it was agreed that Glan Clwyd would be the fairest location for the North Wales Community.
Community Services and Primary Care 3.99 Participants readily endorsed the principles behind ‘enhancing care in communities’ and ‘moving care from hospitals to the community’ insofar as the vast majority of people would prefer to receive care at home to being in hospital for any length of time: If people have the confidence to live at home and have the care then I’m sure they would choose to do that Nobody wants to stay at hospital for a month do they? If you are in for a night it is bad enough If people are well enough then they would want to do that. However, like other groups, this one was somewhat sceptical about the achievability of the proposals in practice (driven in some cases by personal experience) – and felt that, in many cases, older people may be more appropriately cared for in a medical facility: Being in the community with support doesn’t work I know somebody who was terminally ill and was in hospital but his end didn’t come as quickly as expected. He was sent home for the day to boost him. He was in agony in the middle of the night and they couldn’t get anybody out to give him pain relief. That is the reality…you try getting a health professional out in the middle of the night to administer pain relief to a dying man. In hospital he would have been seen to If you come home from hospital and you need a carer, they only release a carer for half an hour for breakfast, dinner and tea so you’re fed. It’s not to take you out, or aid you to go to the toilet or pass you things during the day. It’s not 24-hour care in terms of everyday things. Whereas in hospital you can have all this care I have got a lot of friends who work for home care and they have only had basic training, where the standard is nowhere near a nurse or doctor would need to supply. 3.100 Indeed, this (and the fact that it also provides respite for families) was given as another reason for the retention of Flint Hospital: There are two different levels of care. That option has always been available to go in your own home, but then it’s good to have the option to go to hospital as well. There are people that need to go to hospital
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That’s what Flint Hospital is all about. If they go in there for six weeks respite, that builds them up for another three or six months and helps them stay in their homes during that time The families get respite as well. 3.101 The possibility that older people being cared for in their own homes could become isolated was raised and, once more, it was said that having the option to be admitted to a local hospital when required may lessen the loneliness somewhat: Keep people at home, but don’t make them rely on it. These old people will have to stay in their house all of the time It’s just promoting people to stay in their houses and never come out. Even a trip to the cottage hospital is a kind of day out; they are seeing people Are people getting depressed because they haven’t seen other people? In hospital they get seven other people to talk to. 3.102 Participants were sceptical about the costs involved in providing such care properly – and questioned how BCUHB will be able to afford it. Further, there was some feeling that the proposals represent an unacceptable transfer of cost from BCUHB to the County Councils and to the patients themselves: I think it would be a great cost to be honest How are they going to afford to offer 24-hour care? You talk about support for people in their own home, who pays for it? The County Council and the patient not Betsi Cadwaladr. This is just a transfer of cost to the County Council…and the Council is restricted on how much money it can give.
Community Hospitals: Flint 3.103 As aforementioned, all participants across the three groups were (at least initially) vehemently against the proposed closure of Flint Community Hospital. The reasons for their opposition were many and varied, but the main ones are outlined below: The loss of an efficient, flexible service I have my blood tests there and I get my results the next day. The lab is fine and it hasn’t got to be sent away anywhere I’ve been to Flint and it’s been quick; and they see you’re late. If you’re going to Glan Clwyd or Wrexham or Holywell they’ll send you away to come back another time. There’s no concern for the community there The staff in local hospitals are very efficient by and large and very flexible in the way they work The distance to Holywell Community Hospital – especially for the elderly and seriously ill with no relatives or friends to take them there, or those who cannot afford the travelling costs: Most people could walk to the Cottage Hospital; when you start doubling or trebling the travel distance then it’s unreasonable and unfair The distance from here to Holywell is unreasonable for a lot of people
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I have to use Flint regularly because I am on Warfarin and I have to have blood tests done. I would have to go to Holywell then which is too far It’s ok for us but what about all these pensioners that are living on their own? How do they expect them to get to Holywell? How is a 90-odd year old lady supposed to get to Holywell unless they have somebody like me who will take them? My mum, she is 84. Obviously we can get her there. But other people who have no family will struggle With unemployed people, if they didn’t have the money to reach the services it could be jeopardising their health The inaccessibility of Holywell Community Hospital by public transport If you were disabled, when you get off the bus stop at Holywell it is quite a walk There is quite a walk from the bus stop to Holywell hospital; it’s not in the town. There is quite a trek from the bus stop up to the hospital For really frail people, it’s all uphill. Ask somebody 70 or 80 to do that! The potential for the distance to Holywell leading to missed appointments for, say, dressing changes If it’s on your doorstep then you’re more likely to use it…for a dressing change for example. If you have to go elsewhere then people won’t go there…how many people will say ‘I can’t be bothered’? People of a generation; if it becomes a chore they withdraw. I was in Flint the other day sitting next to two people in their 80s and 90s and they had walked there to get their dressings changed. My concern is that their ability to maintain those dressings will be adversely affected because they will think ‘I can’t be bothered’…they won’t get their dressings changed and complications set in The town’s large (and expanding) population warrants a community hospital – especially when compared to, say, Holywell and Mold I asked for the numbers of population in towns, because a hospital is supposed to support a population. The population for Holywell according to the census of June 2011 is 6,153, Mold has 9,565 and Flint has a population of 12,703 people and they are going to take it all away. The figures speak for themselves Flint is the second biggest town in the whole of Flintshire and they are taking our hospital away. The biggest town, Buckley, has 15,000 which are split between Mold and Deeside hospital. How can they do it? I think Flint is the second biggest town in Flintshire. We have got a huge catchment area as well I don’t think Holywell is a bigger community than Flint. To get rid of the Flint hospital would be such a shame. It’s a bigger area. Why does ours have to be closed? It just doesn’t seem fair when we’ve got an enormous growth in population
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The potential for increased demand on other hospitals – and for Flint residents to be turned away if they are full There will be longer waiting times at all the other hospitals in the area The bigger ones are going to have to take up the strain of the smaller ones My friend went in in the morning and she was still on the trolley at eight in the night because they couldn’t find her a bed at Glan Clwyd. If there are a shortage of beds now what is going to happen when they shift all the people there? I have been on the wards at Glan Clwyd and the nurses are so bloody busy, they can’t cope with it My wife was taken to Wrexham and she was considered an urgent case…it was seven and a half hours before she was seen - so I can’t see that they can cope now The queues for these places are already massive…don’t send people from Mold and Flint to them as well What happens if Holywell is full? They will admit Holywell patients over Flint patients The increased demands on the time of relatives and friends If you have got family that can take you in the car fair enough. But it’s still unfair for the family. Maybe the son or daughter has work issues The potential for increased demand on (and thus cost of) the Ambulance Service and other hospital transport Some people can’t drive and some people can’t afford transport. It will put an enormous strain on the Ambulance Service as people without transport will be calling them more to take them to Holywell? They need something in Flint. If it comes down to money it will cost them more to send them here there and everywhere. Say, for instance, somebody in a chair had to go to Holywell. They would need a special type of minibus, they would have to get up there and then it would have to wait and then get you back. 3.104 Although the practical issues above are clearly concerning to people, when all is said and done, Flint Community Hospital is seen as a valued community resource that has ‘always been there and always should’. The townspeople are used to having its services on their doorstep and, although they acknowledged that people in other, more rural, areas travel a great deal further than five miles to their nearest hospital, it was said that in the same way as these people are used to travelling, the people of Flint are used to having their hospital within easy reach: The hospital has always been an institution to Flint and all of a sudden they are going to take it away in a drop of a hat If the hospital has been there for years and that’s where people have been going then it should stay that way The clue is in the title ‘community hospital’ - Flint is my community People are used to going to a hospital and then all of a sudden they are being told to travel
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It’s a community hospital and it’s been here for a very long time. I just want to see it stay where it is. Just to throw it all away will be devastating The cottage has been part of the community for a long time and people have strong feelings about it. Indeed, to many, the proposed closure of the hospital is simply another example of the erosion of services in the town and has added to the anger already felt at Flint being the poor relation of the county: Why people are feeling so angry is that here we have the ancient market town and we have lost our police station, our magistrates’ court and now they are taking our hospital. They are even starting to demolish houses…they are taking away our future. We seem to be hit from right, left and centre. It’s not just the closure of the hospital. 3.105 Many participants also have an emotional attachment to the hospital, having either been treated there themselves or seen relatives receive excellent care there – some in their last days: The service and care they give them here is second to none I know people who use it regularly and they don’t seem to have an issue with it. The quality of service is quick and efficient The thing is we have all had personal things with that hospital here I watched my mum pass away there and I know a lot of other people have had relatives pass away there My mum wouldn’t have got the care anywhere else, it was marvellous and the staff were amazing My mother died in the Cottage Hospital and she could never have got better care anywhere. In the bigger hospitals she didn’t see anyone for hours and hours. Also, the fact that having a Hospital locally enables terminally ill people to die close to home (and with the support of their family and friends) was considered to be another powerful reason for retaining it: If you live your life for 80 years in Flint, why should that person die somewhere else? People who live in Flint don’t want to spend their last days in a separate town when they have been so loyal to their own For the last year of their lives at least patients have their own people to go and see them. 3.106 On a final note regarding opposition to the proposal, participants disputed the figures provided by BCUHB to support the closure of Flint Hospital – particularly those pertaining to the number of inpatient beds in use and the numbers of people using the MIU: With the inpatient beds at Flint, that is on one day on one hour of that day – the figure doesn’t take into account other times of the year. It’s not average use across a 12 month period I’d be interested to know where they got the figure of six patients a day. The nurses are running around busy so they must be dealing with more than six patients a day. 3.107 Moving on to the proposed new Primary Care Resource Centre for Flint, participants in one of the three groups were unaware of the plans to provide this facility:
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We thought there was going to be nothing In Flint all we hear is that they are getting rid of the hospital We didn’t even know about the new place, and that’s what the problem is really. Other than the beds the facilities are going to be the same. 3.108 After some debate, although the group was concerned about the loss of inpatient beds from the town, most they they could reluctantly accept this, providing the hospital remains open until the Resource Centre is functional: Once you leave the beds you will never get them back If the money saved by getting rid of the beds was to go towards improving the hospital site people would be more understanding As long as they have minor injuries then the only difference is beds. It’s not much for people to travel. I wouldn’t find that an issue as long as the new place is built first. If we were getting something in return, like better quality of building and services that’s absolutely fine. Its modern day and things move on. It’s just the case of 10 or 14 beds being moved to a five mile away hospital. It’s just give and take but not to the extreme which is being proposed It sounds better than what we have got now except for the minor injuries things The primary care centre must be built before they do anything to Flint Cottage The services we have now should be there until the new one is built I don’t agree with the hospital being closed until 2016 until a new one is implemented I think the hospital should stay as it is until they have built a new place. 3.109 Some, however, did not consider it reasonable that the people of Flint should have to wait until 2016 for this new facility, and so expressed a preference for developing the existing hospital to house the proposed Resource Centre: I don’t understand why they wouldn’t use a building which they have got now I can’t understand why we are getting promised all of these new fantastic things in 2016. Why don’t they just make the cottage hospital better now rather than build a whole new building in three years’ time? I think they should just redevelop the current building. It would be more beneficial putting it into the building that’s already there I just can’t see why Flint can’t just have an overhaul. We can understand that it’s an old building. If it needs modernising fair enough, let’s modernise it. Let’s not just throw it away. 3.110 It was also considered imperative that some form of minor injuries and phlebotomy service is provided there – and many people would be reassured to know that the facility could cater for, say, dressing changes: I wasn’t aware that there was going to be another facility available. It’s a great idea to have a modern centre that will have extra services. But I don’t think all services should be taken away. There needs to be some compromise and minor injuries are a very important thing in a community
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You have to have minor injuries in this town. Aside from the population, you have two high schools. You have four primary schools. They have actually built in Flint a school for children with disabilities for the whole area. Accidents will happen. You have to have a Minor Injuries Unit in this town for the number of children for starters. Also, we have an industrial park that needs the service There should be a minor injuries unit. You need that in every town really. The quicker they get treated the better it is for everyone There has got to be some kind of support for a community of this size. With the population we have to do things like basic blood tests Would it be possible for the people who have to go for blood to go there? That would put a lot of people’s mind at rest rather than travelling elsewhere. 3.111 Another of the three groups reserved judgement on the Primary Care Resource Centre until they knew exactly what would be provided there, where it will be sited and when it will be operational: Unless they say what services will go in the Primary Resource Centre then it’s just another building They need to be explicit about what will be in this new centre, when it will be built and where exactly it will be. In terms of site, there was a great deal of preference for retaining the existing hospital site given its prime location within the town: There are a lot of bungalows across the road where the elderly can go straight there. There is an elderly population around there. 3.112 The third group, which remained opposed to the closure of the local hospital at the end of the session, was concerned that, if Flint Community Hospital is closed and BCUHB can see that the town is functioning without it, it may deduce that the Primary Care Resource Centre is not required, leaving Flint with no healthcare facilities except for GP surgeries: Maybe they’ll just see how we get on and they won’t follow through. They’ll be like ‘see you actually don’t need it, you have managed’ If they did close it, if you need treatment you will need to go somewhere else. Then they will turn around and say ‘what did you need a hospital for you have managed to go elsewhere?’
Community Hospitals: Mold 3.113 There were a couple of Mold residents at the first Flintshire group, and they were greatly concerned about the proposed closure of the X-Ray department and Minor Injuries Service at their local hospital. The main reasons for their opposition were: It represents the loss of a well-used, efficient (and relatively new) community resource Mold Minor Injuries Unit is very well used…it is very busy; it’s chock-a-block I don’t see how what’s being proposed can be more efficient than what’s being done in Mold now. If it’s about efficiency then we should keep Minor Injuries Units
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Is there any reason for this? Mold Hospital is quite new? We go through all this infrastructure commitment and then all of a sudden it’s not up to it any more. Mold’s growing population - and the number of schools in the area - warrants increased, not decreased, services Mold has doubled if not trebled in population recently; to close services at the hospital is atrocious and illogical. I would assume there would be more services to cope with the larger population There are a dozen huge primary schools and two secondary schools in Mold – there must be minor injuries and the pupils need to be seen quickly The potential increase in demand on other hospitals One of the biggest things people go to Mold MIU for is dressings or having stitches removed instead of tying up Wrexham. 3.114 It was also alleged that the Mold Community Hospital League of Friends has offered to purchase a new X-Ray machine for the hospital in a bit to retain the service there – and participants could not understand why this offer would not be taken up by BCUHB: You could say there’s an excuse for getting rid of the X-Ray Unit at Mold as it’s not fit for purpose - but the League of Friends have offered to buy them a new one so where’s the argument?
Gwynedd (held in Dolgellau)
Awareness of Consultation and Proposals 3.115 None of the participants had seen the consultation documents produced by BCUHB before the sessions, and had not been aware that there was a formal public consultation exercise being undertaken. All were keen to take part in the survey after seeing the printed materials and requested the web address to enable them to do so. 3.116 Formal publicity aside, most of the participants had been expecting some changes to services because of frequent local media stories (various stories of changes and cuts have apparently been running for the last 12 months). Moreover, some said they had witnessed first-hand a gradual downgrading of Dolgellau and Ffestiniog community hospitals (particularly A&E and inpatient services) which they saw as reflecting a more general reduction or reorganisation of health services in the region: We’ve seen Dolgellau be downgraded over the last few years. The A&E went first and now we have an out-of-hours service We heard in the paper that beds were going from there too Ffestiniog used to be a brilliant hospital and still is in many ways. The community has been fighting to save it, but I think it’s a done deal. 3.117 As for their initial concerns, participants were concerned about ‘cuts’ to primary care services (and the impact on immediate primary care in emergencies) and for local healthcare services for the long term- sick. They were less concerned about some services moving to centres of excellence and were generally supportive of developing specialist services that would reduce costs and improve quality of care.
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Neonatal Intensive Care Services 3.118 Participants suggested that specialist Neonatal Services have traditionally been provided further afield - including over-the-border. They did not express any great concern about this, providing existing generalist maternity services remain robust in the region (although it should be noted that there were no young mothers at the session): It’s not an issue with going to Arrowe Park if the service is far better and outcomes are improved for mothers and children The numbers needing the treatment are so few that it makes sense to use the best facility. 3.119 In general, the overall justification for centralising specialist services was understood and supported by participants. However, they called for assurances that patients would be spared unnecessary consultations and appointments over long distances, and that pre- and after-care could be provided closer to home: I think most people don’t think about the distance if it’s the best service you can get. What people object to is travelling miles and days for routine appointments and follow-ups which are often very short I think we’re used to travelling for specialist treatment now - providing of course you can get home as soon as possibly or get follow-up treatment nearby.
Vascular Services 3.120 Participants again understood the unsustainability of providing sub-standard specialist care over a number of acute hospital sites. They would prefer to see the quality of care improve, along with outcomes for patients. However, people stressed that specialist services can only operate effectively if there are good local primary and secondary care services available to back them up. This would ensure that patients can be stabilised, diagnosed, referred and transferred quickly and efficiently without undue risk to their health: Having good local hospitals and GPs goes hand-in-hand with having specialists in these big hospitals - I don’t think you can have one without the other or it won’t work Routes to specialist care start with GPs or at a general (acute) hospital. The quality of care is only as good as the people doing the referring and knowing what’s best for patients.
Older People’s Mental Health 3.121 Care at home for those with Dementia or other mental health issues was regarded as the best option - providing BCUHB is able to recruit enough staff to provide a decent standard of care. Participants suggested that existing community care staff already cover too large a geographical area, and that these plans will only compound this. Further, mental health services in general were regarded as almost non-existent, therefore considerable investment would be needed to ensure the success of the proposal: If money is tight, how are they going to recruit and pay for all the staff they’ll need? I’m not sure it’s going to work not unless they can double or triple the existing staff working in mental health and elderly care.
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3.122 Moreover, because of the nature of the illness, respondents suggested that staff should be able to speak Welsh - as most of the elderly people in the area would struggle with English: I think most elderly people would like to be cared from at home or close to home, but they need to be around familiar people and people they can understand or it gets confusing or even frightening for them. 3.123 Participants concluded that, without community respite care for friends or relatives caring for elderly people with mental health issues such as Alzheimer’s or Dementia, there would be increasing pressure on families to cope with patients’ complex needs themselves. Some people suggested that this will inevitably lead to an increase in families (or others) placing elderly patients into care homes. As a consequence of this plan, it was felt, local authority care home services and sheltered accommodations will increasingly function as an elderly mental health service overflow for general and community hospitals: Caring for someone with Dementia is very draining, so there needs to be some respite care or beds available when they’re needed This will lead to lots and lots of old people ending up in care homes because they haven’t got the support there - either from friends, relatives or the professionals - to keep them in their own homes for very long.
Community Services and Primary Care 3.124 Participants felt that the shift to a ‘care closer to home’ policy appears to be cost driven rather than a strategy developed for the benefit of patients. They suggested that the demand for hospital beds is driving patients to be discharged prematurely and that, without significant investment in home and community care, lives could be put at risk: The hospitals want people out as soon as they can regardless of the risks - they have targets to hit. All this at a cost to the patient in my view Care in the community in other contexts has never worked - will this be different? 3.125 In addition, respondents suggested that the plans will put pressure on local housing infrastructures and stock because many of the area’s homes are not suited to being adapted to allow patients (such as the elderly and/or the disabled) to be cared for at home. This, they felt, will put more pressure on limited social housing stocks, sheltered accommodation, care homes and social services more generally: People with special needs or need adaptations to their homes will struggle with the types of housing we have in Ffestiniog. There’s not much in the way of suitable properties like ground floor flats for access or adaptation. Some people will have to move or sell up or go into care - things like that. 3.126 Participants agreed that, in principle at least, routine check-ups and the monitoring and evaluation of patients are most sensibly done closer to home (either at a GP or community hospital) as this would reduce the burden on general hospital waiting times and reduce hospital transport costs. However, they also expressed caution, suggesting there is a lack of clarity in the community care plan about where the additional staffing will come from – and how it will be paid for. It was suggested that, for the plans to succeed, BCUHB will have to invest significantly in more primary care staff to provide the level of community care that will be needed. Overall, they doubted whether this would be workable and cost effective in the long-term:
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If people are going to spend less time in hospital, where are the staff going to come from to care for, assess and monitor these people? I can see how this could work on paper but GPs are already choc-a-bloc and getting an appointment is almost impossible. So how are these plans going to work?
Community Hospitals 3.127 Participants felt strongly that because of the distance, geography and time it takes to get to A&E at Ysbyty Gwynedd, the specific proposals around community hospitals will leave the population of South Gwynedd and the Lleyn Peninsula very exposed and vulnerable in emergency situations. As such, the development of a full A&E service (or at the very least a 24-hour MIU function) at Alltwen Hospital in Tremadog was advocated: Alltwen needs upgrading to cover the population here. It’s a huge distance say from Aberdaron to Bangor If Ffestiniog and Dolgellau are effectively closing, we at least need Alltwen or it’s Aberystwyth or Bangor for the nearest hospital doctor There have been millions of pounds spent on Alltwen, and is a brand new hospital, but is essentially useless in an emergency! The whole of the south of Gwynedd and the entire Lleyn Peninsula is without any sort of emergency service after 8pm. Alltwen should be open 24 hours at the very least. 3.128 There was also a general suggestion that MIUs should be available for longer hours than those currently offered, and that they should provide more acute care: Minor Injury Units only provide a first aid kit and is not a reliable service for real emergencies. I would have to drive from Criccieth to Alltwen only to be sent up to Bangor. Well I’d sooner not risk it and just call an ambulance. 3.129 Participants also commented that proposed changes might not reduce (but actually increase) reliance on 999 and ambulance services and this will have a significant cost and public safety implication: I know money is tight, but we don’t want to see cuts that will put lives at risk. If there’s no accident and emergency open or minor injuries to assess someone, then that will put more strain on 999 and, at worst, put lives at risk. 3.130 Participants questioned the validity and logic of increasing care closer to home, while at the same time reducing local community hospital services. Community hospitals, they suggested, take the overflow - and therefore reductions in some community hospital services need to be offset by providing additional services at the remaining facilities. For example, the specific plans for X-Ray service reduction at Ffestiniog would, participants suggested, increase the burden on Ysbyty Gwynedd unless it is balanced by these services being increased elsewhere (at Alltwen for instance). 3.131 Participants were concerned that the proposed reduction in local hospital inpatient beds at Dolgellau and Ffestiniog means that there will be no local respite or convalescent services for local people (and particularly for long term and/or elderly patients). They perceived this as another form of abdicating responsibility for care back to patients’ families and friends. In addition, some people suggested that the proposed changes will lead to more pressure on general hospital wards in the form of increased
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bed blocking – and that relatives will have to travel further to visit and care for patients over long periods, or be forced to receive them back at home for care: There’s nowhere local for people to recover from major operations and long-term treatments. People want to be near to home to recover and Bangor is about the nearest place now. Ysbyty Gwynedd will be full to the rafters It will just mean more full beds there with people having to travel long distances to visit, or by the sounds of these plans people will be forced to go home - like it or not Fine if there’s enough staff to come and keep an eye on you, otherwise it’s down to the family, if they have one, to do all the work. 3.132 Reacting to the specific proposals for community hospitals in Gwynedd, there was strong support for retaining the Memorial Hospital at Bleanau Ffestiniog. Participants emphasised that closing Ffestiniog hospital will make the community (and visitors during the summer months) very vulnerable. They suggested that the proposed model is more suited to urban areas because it does not take into account the terrain and additional travel times for residents in rural Wales – and one example was provided of the significant distance which would now need to be travelled for even a relatively minor wound: You used to be able to walk into Ffestiniog and see someone who could stick your hand or anything like that. I went there to get a large splinter removed a few months ago and I was sent straight to Alltwen, they then sent me from there to Ysbyty Gwynedd because they couldn’t touch it because it had gone so deep They’ve opened a new mountain biking trail in Ffestiniog, and the amount of accidents there is quite significant. Well, you’ll need the RAF helicopter to take them to Ysbyty Gwynedd if there’s an emergency because you wouldn’t have a hope on these roads. 3.133 As well as the reasons already mentioned, participants worried (and had heard through the local press) that the hospital will be used for drug rehabilitation: The changes mean losing all medical front-line services at the hospital in favour of drug rehabilitation services which do not meet the needs of the community. 3.134 Blaenau Ffestiniog residents at the group stressed how good the hospital staff and facilities are, and suggested that the decision to close it has been influenced the politics of ownership of the building (currently the hospital building is given to BCUHB by a community trust set up for the welfare of slate miners) – and has not been made in the best interests of community safety and public health: It’s a great hospital; the buildings are fine and don’t need renovating or repair It’s a political decision because the Trust do not own the building and can’t do what they want with it. 3.135 Finally, one participant claimed that skewed data collected by the NHS has contributed to the decision to close Blaenau Ffestiniog Memorial Hospital: Ambulances were told not to go there in recent months so there has been an incorrect picture painted about the need to have Accident and Emergency services there on which decisions have now been made.
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Wrexham (held in Chirk)
Awareness of Consultation and Proposals 3.136 Eleven diverse people drawn from a wide area attended the Chirk focus group, including some with recent experience of maternity. Most of the group members thought they had heard relatively little about the consultation issues, but those that had were concerned about: The closure of the MIU at Chirk The future of Wrexham’s neonatal unit BCUHB’s use of the Staffordshire hospital The possibility that Welsh residents might not be prioritised when sent over the border to Chester and Shrewsbury for treatment Funding pressures.
Neonatal Intensive Care Services 3.137 The discussion showed that participants found it difficult to accept that long-term complex intensive care for neonates is very different from more routine short-term intensive care – and so they were reluctant to accept that the service could not be provided satisfactorily at BCUHB’s current centres: Why can’t our two centres do this job if they can look after short-term intensive care? When one of my twins was not feeding, he had to go into intensive care – so we can cope with these cases locally. 3.138 Some of those who accepted the difference between the two levels of care were worried about how well babies could be transported to Arrowe Park and whether mothers and children would be separated. Other concerns were that: Arrowe Park might not have the capacity for North Wales babies Using Arrowe Park will only increase recruitment difficulties in the Welsh centres, if they are seen as second best Arrowe Park’s consultants should divide their time between different sites and visit Wrexham hospital to care for babies who would not then need to leave Wales
I cannot see why they cannot get the medical expertise at Wrexham, including by travelling and/or by telephone links The costs of services should not be taken into account at all when considering the health of neonates and children. 3.139 In the context of these comments, about half of the participants tended to overlook or dismiss the fact that for the sake of only about 36 babies per year BCUHB would need to recruit about six additional consultants at considerable cost in order to match Arrowe Park’s Level 3 service. 3.140 However, there were other points of view that were more supportive of BCUHB’s proposals to contract with Arrowe Park: Highly qualified medical personnel want to work in large well-equipped teams and centres, not one with 36 babies a year – it is just not realistic to aim for that at Wrexham!
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In my opinion, a real specialist care unit is the best so I’d be prepared to travel to wherever is best service for my baby We have to recognise the nature of this large rural area. We cannot afford to provide everything here. 3.141 Not surprisingly, in the context of the sets of the contrasting comments above, the eleven participants were almost exactly divided in their views – with six thinking BCUHB’s proposal is reasonable and five wanting to reject it. 3.142 Finally, it is notable that no-one in this group objected to using Arrowe Park on the grounds that Welsh babies might be born in England.
Vascular Services 3.143 Compared with the divided opinions on neonatal services, there was considerable immediate support for the vascular services proposals. For example: It’s definitely reasonable to have a vascular centre of excellence in North Wales – this is different to the last proposal which seemed like impoverishing our own services This is reasonable; we need to have a proper centre with enough doctors to deal with the 300 really serious cases. 3.144 Therefore, there was unanimous support for the principle of concentrating complex vascular services. 3.145 However, opinions were divided on whether there should be two vascular centres or one – for example: Two centres would be better – one in the East and one in the West. There will be increasing demand, enough for two centres We have to be pragmatic about how we service our very rural population – we cannot afford the luxury of two specialist centres for our small area. 3.146 Perhaps not surprisingly in the context of many participants’ views about costs (see neonatal services above), most members of the group favoured two centres rather than one. In reaching this conclusion, they assumed that both Wrexham and Bangor would be selected as the centres: they did not take into account that Wrexham’s centre would be very close to Chester’s.
Older People’s Mental Health 3.147 There was considerable support for the principle that as much care as possible should be provided in the community for older people who are mentally ill, rather than in acute hospitals. One typical comment was: For dementia the best care you can have is with your family! 3.148 Overall, the focus group was not critical but supported BCUHB’s proposed reduction of inpatient mental health beds for older people – partly because they favour community care in principle and partly because they are critical of the care likely to be available in hospitals. For example, there were comments that: People get no dignity in NHS hospitals!
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At Wrexham and Glan Clwyd the care of the elderly is disgusting at the moment – people just get left and neglected in them both. 3.149 But, as a result of the current review, the group was keen to see real improvements in the community care and diagnosis of elderly mental illness: The treatment in hospital and in the community can be awful At Wrexham, there were no facilities for my mother with dementia and a broken arm It is hard to get prompt diagnosis and current help in the community is laughable – my mother (who was not diagnosed) got half an hour’s care three times a day Some dementia cases are effectively just left in their homes – so we need to improve care in the community for dementia. 3.150 The focus group’s general conclusion was that the care of older people with mental health issues represents a considerable challenge for BCUHB and all health authorities – and that the current review: Is a major opportunity for the Board to make excellent improvements in people’s dignity…to improve diagnosis and services and to give proper medical care in the home.
Community Services and Primary Care 3.151 Overall, the focus group supported BCUHB’s proposed extension of community services and primary care – mainly because the principle of reducing unnecessary admissions to acute hospitals and enhancing local care was readily endorsed: This would be positive – it needs more services by health visitors and others, but it is good because no one wants to go to hospital unnecessarily More care in the community would empower nurses and others to do things that people go to GPs for now. 3.152 However, while endorsing the principle of community care readily, the group had some important concerns about the need for big improvements to current services: Community care is fine in principle; it is just the implementation that is the problem! These services need to be protected and funded properly We would like to see independent research to monitor the effectiveness of community care. 3.153 In this context, there were some severe criticisms of some GP services – particularly in terms of their limited hours and difficulty of access: GP access is very poor – it seems like a diminishing service. It should be a six-day service for working people to be able to access Even if I’m willing to see any GP, it can take three to four weeks for an appointment in Llangollen You have to try to call at 8.30 for an appointment that day – but it’s usually engaged! 3.154 It should be stressed that people’s experiences varied and by no means were all poor. For example, hearing the comments just above, one person declared: But I can always see my GP within two to three days!
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Community Hospitals 3.155 Given that the meeting took place in Chirk, it is not surprising that the discussion in this section focused on Wrexham and Llangollen hospitals. 3.156 There was some disquiet about the closure of the MIU at Chirk – mainly on the grounds that local people would have to travel further to Wrexham; but there was less direct concern about the proposed changes at Llangollen hospital. For example, some typical comments were: The bus route to Wrexham is poor and going there can take a long time The local service will be very badly missed – I’ve used Chirk MIU a lot and they are helpful. 3.157 Other concerns were also expressed about the proposed changes at Chirk: Will they really increase the facilities at Wrexham hospital? The MIU nurses do other things as well – so there is no cost saving in making these changes Why is the Deeside being developed when it is so close to the border? We see hospitals that work – so I’m worried about a loss of some services to create the hubs. 3.158 However, there were also comments that supported the proposals: You often have to go to Wrexham because Llangollen is only open from 10-2pm – so this will not make much difference to me We do need to control costs or we shall lose the NHS we have! 3.159 Other comments stressed that some people will readily travel for the best services: If my children have an accident, I take them to the special children’s unit at Chester – in order to avoid the drunks at Wrexham hospital I’d go to Chester for any real injury to my child. 3.160 On the basis of all the considerations, by a majority of more than two-to-one the focus group felt that the principle of centralising MIU services was reasonable; but by the same majority they opposed the actual proposals for Chirk hospital. 3.161 A couple of people suggested that Llangollen community hospital has been deliberately run down in order to legitimise its closure, but this view was not general. Indeed, after discussion the group was unanimous that it is reasonable on the basis of the evidence to close the hospital. Some influential comments were: You cannot actually get into the Minor Injuries Unit at Llangollen – there’s no service there for much of the time if you ring up GPs have been sending patients elsewhere (for chiropody, for example) rather than referring them to Llangollen If the closure means the loss only of the 10 beds, it is OK – providing the other services continue to be provided It’s a very old unsuitable building after all! 3.162 In this context, all eleven members of the group concluded that BCUHB’s proposals for Llangollen are reasonable.
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4. Public Meetings Main issues and themes from the public meetings
4.1 This lengthy chapter is in two sections. The first section, Summary of Main Findings, presents a short review of the main issues and themes raised in the public meetings; and the second section reviews in more detail the discussions at each of the 16 meetings (covering 48 sessions). 4.2 The public meetings were held in convenient locations across North Wales. Each meeting received a presentation from senior Health Board staff on proposed changes, followed by a question and answer forum between attendees and staff. The discussions were wide ranging and covered a considerable diversity of issues about the proposed service changes. The fact that a total of over 1,300 people attended the 48 sessions highlights the interest and concerns that local people had. 4.3 Most meetings showed both positive and negative views about particular aspects of the changes; some acknowledge the need for change while many were very concerned about the loss of highly valued local services. On balance, attendees were largely sceptical about the proposed changes, and many felt the proposed changes keenly, both in general and more specific terms. However, this was not exclusively so, and some proposals were welcomed and supported.
Summary of Main Findings
Hospitals in Our Communities 4.4 BCUHB faces significant challenges in delivering future services. Population changes, a new emphasis on care at home and some hospitals and services being no longer fit for purpose mean change is necessary. 4.5 Overall, people recognised that there are pressures within existing services and that future services need to address this, as well as meet the needs of a changing population. Many concerns were expressed at the travel and transport costs to patients of accessing health services in fewer locations across North Wales, both in rural and more urban areas. 4.6 A recurring worry was the transition from the existing to the new service; many comments were made that this process needs to be managed effectively in order to minimise risk to patients. Many concerns were highlighted regarding the potential additional pressure the proposed changes may have on local GPs. 4.7 Nearly all sessions included comments and questions regarding the potential savings that BCUHB must make and several attendees questioned whether this is deliverable via the service changes. 4.8 One hotly debated topic concerned the proposed closures of hospitals and services: various action groups had been formed and petitions collected. Some people were critical of the proposals and the technical details of the review process that was used to formulate them.
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Community Healthcare ‘Hubs’ 4.9 Ten hospitals will act as hospital ‘hubs’ in local areas, where a broad range of services can be delivered, including Minor Injuries and X-Ray services. 4.10 There was considerable discussion of the ‘Hubs’ proposals at most meetings. Several sessions referred back to what people perceived to be promises made as part of earlier Health Service review processes; comments were made that these alleged promises were now being broken and some attendees said how they now lacked confidence in what is being proposed. 4.11 Many meetings raised the issue of population growth and whether projected population changes had been satisfactorily incorporated into the ‘hubs’ proposal. There was significant debate about the proposed locations for the ‘hubs’ and various alternative suggestions were made. 4.12 The issue of travel and transport costs likely to be incurred by patients in accessing ‘hub’ services was raised often. There were concerns that the distances involved may lead to more pressure being placed on local GPs. Several people queried whether an Equalities Impact Assessment had been undertaken regarding the ‘hub’ proposals. 4.13 Finally, many meetings were keen to hear what the Health Boards proposals were for any redundant assets no longer required when ‘hubs’ are developed.
Minor Injuries Service 4.14 The service review contains a principle of focussing Minor Injuries Services at fewer hospitals, with specific proposals to provide services at ‘hubs’. 4.15 There was considerable focus on the changes to the Minor Injuries Service in several meetings, but not all. Key concerns were around how the decisions to create ‘hubs’ were made, and attendees were keen to understand this better, with several requests for more detail on current and projected service usage volumes. 4.16 Requests, too, were made for more detail on the cost savings envisaged from the individual (e.g. localised closures) and collective changes (i.e. the full service review). 4.17 Two areas - Mold (2,408 signatures) and Colwyn Bay (930 signatures) - had raised petitions against the proposed closure of the MIU services there. 4.18 Transport issues featured again in discussions: attendees highlighted the rural nature of North Wales and the complexities of using public transport. The implications of the proposed changes for GP services was also raised in several meetings.
X-Ray Services 4.19 The service review contains a principle of focussing X-Ray Services at fewer hospitals, with specific proposals to provide these services at ‘hubs’. 4.20 There was either little or no discussion about the X-Ray proposals at most meetings. However, there was extensive discussion at five meetings (Tywyn, Ruthin, Pwllheli, Caernarfon and Mold). 4.21 One significant issue was how the decision to focus X-Ray Services at the proposed ‘hubs’ location was made. People were sceptical that their views would actively influence the final decisions regarding where ‘the hubs’ would be.
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4.22 Most meetings generated questions regarding the financial and statistical information that had underpinned the proposals for change, especially at Tywyn, Ruthin and Pwllheli. 4.23 Discussions regarding the location of the ‘hubs’ centred on the cost/benefit analysis of various service location options, the cost to patients of travel and the reliability of public transport. 4.24 Some attendees questioned whether the staff recruitment issues BCUHB faced had influenced the location of proposed ‘hubs’. 4.25 A key concern was that remaining services would be at risk of future closure after the ‘hubs’ are developed.
Older People’s Mental Health 4.26 There is an excess of beds for elderly people with mental health needs and they are not well utilised. There is also a need to strengthen services to provide better support to enable people to remain in their homes. 4.27 A considerable range of issues was raised regarding the future shape of Older People’s Mental Health Services. Overall, this was a keenly debated topic of considerable concern to attendees. 4.28 The issues raised covered future demand from increasing numbers of older people with dementia and the implications of this for Health and Social Services in structuring their future service offer. 4.29 In addition, concerns were raised about older people living alone, and the need for a preventative care service for them – as well as the level of respite care provision for carers. People also sought reassurance that an out-of-hours service would be available for older people. Several meetings raised the issue of the quality and range of provision in private nursing homes. The possible issues in recruiting and retaining specialist staff was also highlighted. 4.30 The issues around the rural nature of North Wales and the challenge this presents in terms of travel and accessing services at home were also raised.
Neonatal Intensive Care Services 4.31 The service review includes a proposal to relocate acute neonatal intensive care services to Arrowe Park, Wirral. 4.32 The proposed changes were discussed in all sessions and aroused considerable interest amongst attendees. There was a clear polarity between those who want local services and those who want the best possible services and no overall consensus view emerged. However, many meetings regretted the loss of specialist neonatal skills from North Wales. 4.33 In terms of the services offered by Arrowe Park, attendees sought reassurance that it could cope with the volume of demand from North Wales. They also asked about the quality of care and sought reassurance that this will be up to an appropriate standard. 4.34 Transport and travel were key concerns. People were worried about the logistics of transferring serious cases from North Wales to Arrowe Park and how this would work in the interests of the child. They also wanted a professional service to support parents at a difficult time. 4.35 Some meetings queried how comprehensive the service level agreement with Arrowe Park would be, and wanted BCUHB to ensure it would cope with future demand and deliver on quality and cost.
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4.36 Finally, concerns about Arrowe Park being in England were raised. Potential difficulties included the provision of a Welsh language service, Welsh money being spent on an English service and ‘Welsh’ babies being born in a different country.
Vascular Services 4.37 The service review proposal suggests the creation of one specialist centre to deliver high quality vascular services for North Wales. 4.38 The proposals were discussed in most, but not all, meetings. Where discussed, the meetings were mostly in favour of the proposal. 4.39 The focus for discussion centred on the implications of having one specialist centre. Some attendees saw risks in this and were particularly concerned about travel and transport to the specialist centre and the risks of this for very ill patients. 4.40 There was some discussion in several meetings about where the centre will be located and some alternatives were proposed. People in the far west of North Wales were concerned that they could lose out disproportionately by having to travel the furthest. The location could also mean continued recruitment issues for specialist staff if it is not in the ‘right’ place. 4.41 One concern was how the new service will cope with emergency cases, even with a preventative approach.
Local Service Changes involving Closures 4.42 The proposed changes to local services, especially where these will result in the closure of existing services, was a key feature of the meetings at Blaenau Ffestiniog, Rhyl and Prestatyn, Llangollen and Flint.
Blaenau Ffestiniog 4.43 The meeting at Blaenau Ffestiniog was preceded by a protest meeting which attracted around 150 protestors – and serious concerns were raised at the meeting about the proposed closure of the Memorial Hospital. The main worry was around the loss of beds, the MIU and X-Ray provision. 4.44 Firstly, people queried how seriously the consultation would be treated by the Board. Secondly, people were concerned that the consultation process had not been systematic: it was stated that questions and responses to the Board had received no response and people sought reassurance that the petition raised in the local area would be taken into account. 4.45 More detailed comments and questions were raised around the future of Ysbyty Alltwen, and people requested clarity about the services it will provide in future.
Rhyl and Prestatyn 4.46 There was discussion of the proposals at both the Prestatyn and Rhyl meetings, although the most significant concerns were raised at Prestatyn in the light of the proposed closure of the town’s community hospital. 4.47 There were considerable concerns about the closure. Firstly, people sought reassurance as to the future use of the building and whether BCUHB is planning to dispose of it. Secondly, there were concerns that
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current services will cease before new services are launched. Finally, people highlighted the risks to local older people with mental health problems resulting from the closure.
Llangollen 4.48 There was discussion of the proposal to close Llangollen Community Hospital at both the Llangollen and Wrexham meetings, although the most significant concerns were raised at the former in the light of the proposed loss of inpatient beds. 4.49 Transport issues featured again in discussions: attendees highlighted the distances to travel, the cost of transport and overall access to other hospitals. There were also concerns that current services would cease before new services were launched. Further, people were anxious about how the remaining Llangollen services will cope with potential future increases in demand. 4.50 People also sought reassurance that funding for the proposed new primary care service is confirmed and secure.
Flint 4.51 There was considerable opposition to the proposal to close Flint Community Hospital and many attending were committed to the continued campaign to save it. 4.52 Several concerns were raised regarding the proposed new Primary Care Resource Centre (PCRC), mainly around how it will work, whether the predicted costs are accurate and whether the available funding is sufficient to meet these.
Overall Themes 4.53 Inevitably, in a series of 48 meetings, several themes emerged consistently. These cross-service issues were wide ranging and reflected regular concerns from local people.
Reduction and Loss of Services 4.54 Most meetings regretted the loss of services and impact this may have on health services in North Wales: Loss of any service will be hard for North Wales (Rhyl) There seemed to be a trend to outsource too many specialist services outside of the region. (Llangefni) 4.55 There was particular opposition to reductions in services at a local level and several groups had been formed to resist the proposals locally: The overall picture seems to be that in some areas there is strong opposition to particular local proposals, whereas other areas have not strong objection to the proposals in principle, but have major reservations about the practicality of greater care in the community and don’t want to see changes introduced prematurely. (Caernarfon)
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Cost Savings 4.56 The forecast cost savings from the changes were treated sceptically - and many were made for more details on this, both in overall and individual service terms: In page eight of your document you state that you have reduced your management cost by 20%. I’m questioning your financial probity as the figures in your accounts over the last three years do not add up to your claims. This is all about cost cutting (Mold)
How will BCUHB reduce its costs? Where does the Board stand at the moment in terms of comparisons with other Boards’ costs in England? (Caernarfon)
Adequate Funding 4.57 People also sought reassurance that adequate funding for services is available: Is the Health Board getting the appropriate level of funding through the WAG? (Chirk)
Joint planning and working with Social Services 4.58 The emphasis on community based health services engendered considerable discussion, particularly around the relationship between Health and Social Services. Many attendees questioned the effectiveness of this relationship and the strength of joint planning for the new health service. There was also confusion about the role of each agency in the provision of care. 4.59 There was scepticism about services provided by Adult Social Services, and a suggestion that the Health Board needs to work closely with Social Services to provide a seamless service. 4.60 There was considerable criticism of how Social Services currently provides adult social care: Home care often attends people for only about six minutes and it can be completely inadequate (Llangollen)
I had great healthcare support for my son who has MS. However, I had major problems with Social Services. (Wrexham) 4.61 The potential for costs to be passed between agencies was recognised: If healthcare costs get passed to Social Services it could bankrupt them (Flint) Costs will be passed onto rate payers. (Flint) 4.62 The need for Social Services and Health to work, plan and implement services in a co-ordinated way was emphasised:
There is a perception that working relationships between Health and Social Services are not as close as they should be in planning for new services (Rhyl) Health and social services staff need to work together far more effectively in order to deliver enhanced care for those who otherwise might be in hospital. (Llangollen)
Older people 4.63 Many meetings raised concerns about how the proposed changes may impact on services to older people generally (not just older people’s mental health services). Issues around the rural nature of
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North Wales, its ageing population and the cumulative impact on service demand by many years of inward migration were raised. The proposed loss of much valued hospital beds in particular areas was also questioned: Surely there is an argument that would suggest given the increasing ageing population there should be more funding allocated to the local services provided at hospitals? (Ruthin) We live in a rural community and we are an ageing community, so where are the carers and volunteers going to come from? (Tywyn)
Care Services in the Community 4.64 A recurring issue concerned the consistency and quality of current care services in the community and the potential risk to them from the proposed changes. The policy emphasis on community based healthcare services in the new proposals was also a focus for comment: Many people who live on their own cannot really get the appropriate support - the aftercare can often be hit or miss (Mold) The issue of palliative care should be looked at again as there is not enough detail in the current proposals. A key concern is that there is often not enough support available for those who might be carers who are expected to provide the bulk of the care – quite often they are also in need of medical support and care (Ruthin) The sustainability of the proposed model for enhanced care in homes is based on the pilot from Rhyl and Denbighshire but I have real concern that the model will not work in this area because of the rurality of this area. (Ruthin)
Recruitment 4.65 The recruitment and retention of staff features as a key driver for change in service review. In considering these issues, the sessions discussed costs, staffing levels, training of new doctors and the additional pressures changes might mean for existing staff. The loss of training opportunities for new doctors was also a recurring concern: There were concerns about how BCUHB will be able to recruit important senior staff to this North Wales for the key services it is reorganising (Caernarfon) Concern at potential loss of Doctor training posts via the Deanery scheme. (Rhyl)
Travel and Transport 4.66 Travel and Transport for the population, many of whom live in a remote and rural area, was recognised as a particular challenge. Travel costs for service users and their families featured strongly in most sessions – attendees recognised that the impact on those on lower incomes in an area with weak public transport and relatively low levels of car ownership was a significant issue: How do you define reasonable travel distance people are expected to cover? (Tywyn) Transport and especially public transport is a major issue – for visitors and patients – the Board has to improve transport in order to focus on main hospitals. (Llandudno)
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Monitor the Impact of Changes 4.67 Many meetings requested that the impact of service changes should be monitored closely to test their effectiveness: How do you propose to monitor the impact of these proposals? (Wrexham)
Transitional arrangements from the old to the new system 4.68 The proposals envisage significant change to services over an extended period. Many sessions highlighted how there appear to be ‘gaps’ between when an ‘existing’ service ceases or changes, and when a ‘new’ service is launched. Attendees sought reassurance that effective transitional arrangements would be put in place. There was particular concern in those sessions where the closure of local facilities is proposed: What are the transitional arrangements? (Flint)
Role of GPs in the new service 4.69 Many sessions acknowledged the contribution made to community healthcare by GPs; however, there were concerns about how the new emphasis on community-based services may put more pressure on them: GPs currently provide a non 24-hour service – they are there only from 9-6 maximum and are not on duty at the weekend – so how can GPs cope with the expanded role? (Llangollen) The document should say at the beginning that ‘GP services cannot readily be changed due to their national contract’ so other routes are necessary. (Llangollen)
Welsh Identity 4.70 Wales and Welshness was a recurring theme in many meetings – and the main issues were around funding, language and identity. Where services are proposed to be relocated to England, many concerns were raised around how Welsh speakers will cope in a non-Welsh speaking environment. There were further concerns at the prospect of Welsh money being spent on English services (for example at Arrowe Park in Wirral). In summary, the key issues were: A strong desire for services to be available in Welsh - from doctors to nurses to support staff Concerns over the national identity of babies born outside of Wales The particular needs of a rural population were also identified Reciprocal funding arrangements with English health services to meet costs of summer visitors Whether the requirement for Welsh speakers acted as a brake on recruitment.
Views on the Consultation Process 4.71 Many views were expressed about the Consultation process itself. A key concern was how sincerely BCUHB is treating the process and the level of influence the public’s views will have.
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4.72 Many sessions, especially those affected by closures, questioned the transparency and accountability of the consultation process itself – and a number of attendees felt insufficiently informed to take a view on the proposed changes. Others wanted more opportunities to discuss the changes with BCUHB. 4.73 One particular issue was that requests for further information from BCUHB had allegedly not been responded to. 4.74 People were also concerned that the consultation exercise should include the views of both BCUHB staff and existing patients. 4.75 There were further issues around the administration of the process; some noted that not all citizens had received the consultation documents and there were concerns about the need to pre-register to attend the public meetings.
Balance of Opinion 4.76 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion. The majority of attendees were negative about most or all the proposed changes at Wrexham, Llandudno and Llangollen. Rhyl was generally favourable to the overall approach, albeit with major concerns on the neonatal and older people’s proposals. There were balanced opinions at Connah’s Quay. Several sessions had strong reservations about specific proposed changes to local services - especially at Mold, Prestatyn, Flint, and Blaenau Ffestiniog. At Tywyn, there were some criticisms of the proposals for enhanced care at home, as well as the loss of X-Ray services and changes to the MIU.
Follow Up Actions 4.77 Many meetings requested follow-up action by BCUHB as part of the consultation process. People primarily wanted BCUHB to: Clarify the services that will be provided at the Primary Care Resource Centres Provide more information about the options considered, the statistics underpinning them and the cost savings forecast for the service proposals Clarify the net impact of all the hospital bed change proposals: how many beds will be lost? Elaborate upon the details of the proposed preventative dementia service Clarify how the relationship between Social Services and the Health Board will work in the future Clarify where people can find its Equality Impact Assessment Advise on whether the support arrangements on travel, accommodation and language for neonatal services at Arrowe Park will be put in place Let people know the impact of the changes on the Deanery training programme for doctors
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Let people know the cost of the consultation process at a later date.
Findings in More Detail
Hospitals in our Communities
4.78 Presentations were given at each session covering the detail of BCUHB’s proposals. Their key focus covered the principle of fewer hospitals to improve reliability, and the principle of the same services available to all.
Summary of Main Issues Raised 4.79 Overall, people recognised that there are pressures within existing services and that future services need to address this, as well as meet the needs of a changing population. Many concerns were expressed at the travel and transport costs to patients of accessing health services in fewer locations across North Wales, both in rural and more urban areas. 4.80 A recurring worry was the transition from the existing to the new service; many comments were made that this process needs to be managed effectively in order to minimise risk to patients. Many concerns were highlighted regarding the potential additional pressure the proposed changes may have on local GPs. 4.81 Nearly all sessions included comments and questions regarding the potential savings that BCUHB must make and several attendees questioned whether this is deliverable via the service changes. 4.82 One hotly debated topic concerned the proposed closures of hospitals and services: various action groups had been formed and petitions collected. Some people were critical of the proposals and the technical details of the review process that was used to formulate them.
Current service arrangements 4.83 A range of views was expressed about current service arrangements. Many were satisfied with current services, but several examples of difficulties were given: We are happy with the high quality of care and service provided by Mold Hospital. It has a really good reputation locally (Mold) The local A&E department at Maelor Hospital, Wrexham are barely coping at the moment – in fact they are not coping at all, you’re often waiting for four or five hours! (Wrexham)
Future Drivers for Change 4.84 Although the sessions focussed on the proposals for change, there was discussion in several meetings about how longer-term drivers for change would be accommodated: The impact of the new housing developments in the area with 7,000 new homes being built and the consequent increase in population should also be considered to be in favour in Mold (Mold) What provision have you made for the projected increase to the population in Denbighshire (approximately 20,000) with the building of new houses? (Prestatyn)
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Travel and Transport 4.85 Costs to patients who have to travel was a recurring theme in nearly all the meetings, especially those in west North Wales. Key issues included the cost of travel, the relatively weak public transport service, the difficulties this poses for older people and the environmental impact of staff travelling more often and further: The cost of travelling to Deeside is prohibitive for many people - and with the likely reduction to the benefits system for carers - this will prove to be very difficult for many individuals (Mold) Transport issues need to be addressed for those in rural areas (Llangefni) Given the rural nature of this area of North Wales and the fact that some people living in the Lleyn Peninsula do not speak English and many do not have their own transport these proposals will not address the local needs of the community (Pwllheli) The proposals will increase the number and length of vehicle journeys - centralisation is bad for the environment in terms of pollution - how sustainable is all this? (Llangollen)
Role of GPs 4.86 Attendees recognised that the role of GPs will change as result of the proposed changes, and several had concerns about this: It’s pointless going to your GP as they cannot cope now! (Flint) We all support community care, but the GPs provide a limited service – they are there only from 9-6 (maximum) and are not on duty at the weekend – so how can GPs provide the core community services – and the Health Board has no control over GPs due to their national contracted status, so you cannot require them to participate! (Llangollen) Given the fact that GPs are going to be at the heart of this enhanced care in the community - How easy or difficult is it to recruit GPs? (Old Colwyn)
Transitional arrangements from the old to the new system 4.87 Most sessions included questions about how transitional arrangements will be put in place, and attendees had concerns over how BCUHB will avoid service disruption during the change process. Many also queried BCUHB’s ability to deliver new services and projected savings: Ensuring that existing provision is not closed before opening the new provision (Connah’s Quay) What are you doing about recruiting staff before you start closing services and delivering these additional services? (Tywyn) Careful planning would be required to ensure a smooth transition of staff and services (through the provision of appropriate training with regards to their changing roles). (Llangefni)
Current financial pressures/Calculations going forward 4.88 Nearly all sessions included comments and questions regarding the potential savings that BCUHB must make and several attendees questioned whether this is deliverable via the service changes.
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4.89 Many suggestions were made as to how further savings or efficiency gains could be derived. In addition, there was a strong appetite for more information about how the change calculations have been done: I know that financial resources are limited for the BCUHB - Why can the Health Board not reinvest their finances into some of the existing sites? (Wrexham) Why don’t the Health Board reduce the level of Admin Staff (approx 2,500) and maintain front line services? (Flint) Why don’t you reduce the salary costs of some of the Directors? (Flint) Who will pay for the additional costs for staff transportation? The £80,000 allocated for transport in this proposal is insufficient. (Flint)
Service closure proposals 4.90 The proposed closures of hospitals and services were hotly debated in the relevant areas. Attendees noted that various action groups have been formed and petitions collected. People were critical of the proposals and the technical details of the review process that led to their consideration: None of the proposals will improve care in Blaenau Ffestiniog (Blaenau Ffestiniog) How and why did plans change? In Welshpool in April for Town Councils it was clearly stated that plans were well advanced for improved Primary Care in Flint? (Flint) Closing Prestatyn will put even more pressure on Glan Clwyd (Prestatyn) Are the people of Flint guaranteed a bed in Holywell? (Flint) The Blaenau Ffestiniog hospital seems very busy and effective compared with other community hospitals – and there are a lot of elderly and disadvantaged people there – Blaenau should not be closed. (Blaenau Ffestiniog) 4.91 However, not all views were negative and the concept of specialist centres was welcomed in some sessions.
Balance of Opinion 4.92 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion. Opposed to the proposals: Mold, Flint, Prestatyn, Tywyn, Blaenau Ffestiniog, Wrexham.
Follow-up Necessary 4.93 There were some follow up actions which the BCUHB may wish to consider: Provide further details required about the services to be provided at the Primary Care Resource Centre(s). Provide the costs incurred as part of the consultation process at a later date. Provide further information on how members of the public can access some of the statistical evidence for their proposed recommendations.
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Provide, in writing, the criteria and rationale for the proposal that Alltwen should be a ‘hub’ as opposed to Bryn Beryl.
Community Healthcare ‘Hubs’ 4.94 The service review proposals will create 10 hospitals as service ‘hubs’ and distribute resources across North Wales.
Summary of Main Issues Raised 4.95 There was considerable discussion of the ‘Hubs’ proposals at most meetings. Several sessions referred back to what people perceived to be promises made as part of earlier Health Service review processes; comments were made that these alleged promises were now being broken and some attendees said how they now lacked confidence in what is being proposed. 4.96 Many meetings raised the issue of population growth and whether projected population changes had been satisfactorily incorporated into the ‘hubs’ proposal. There was significant debate about the proposed locations for the ‘hubs’ and various alternative suggestions were made. 4.97 The issue of travel and transport costs likely to be incurred by patients in accessing ‘hub’ services was raised often. There were concerns that the distances involved may lead to more pressure being placed on local GPs. Several people queried whether an Equalities Impact Assessment had been undertaken regarding the ‘hub’ proposals. 4.98 Finally, many meetings were keen to hear what the Health Boards proposals were for any redundant assets no longer required when ‘hubs’ are developed.
Trust 4.99 Several attendees at various sessions expressed a lack of confidence in what is proposed by BCUHB. Some also quoted previous studies and alleged promises made in earlier reviews, which they felt had not been kept: I do not have any confidence that any of this will work (Wrexham) You promised three years ago to keep our hospital open. How can you guarantee that you will deliver on your promise to develop a new health centre given the fact that a few years ago it was actually recorded in the minutes at a Council Planning meeting that you would build a new hospital? (Flint)
Decision making process 4.100 The decision-making process that led to the proposed ‘hub’ locations was also questioned. Several attendees at different meetings made the case for ‘hub’s to be located in different places. Others were concerned at how far apart the ‘hubs’ are and several suggestions were made about the potential for ‘mini-hubs’ to meet the challenge of a rural area: Nobody is explaining - how did the Health Board actually made this decision (Mold) We are telling you what we want. The important thing is that you are NOT listening. (Pwllheli)
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Population 4.101 Many attendees expressed concern that future population projections have not been taken fully into consideration in the decisions on ‘hub’ locations. 4.102 Several meetings highlighted planned new housing developments and people sought reassurance that these have been considered. The population and housing growth meant attendees at some meetings questioned the locations for the proposed ‘hubs’: What reference have you taken with regards to the Local Development Plan and a projected increase of 7,000 homes with a resulting increase in population of 17,000 in this area? (Mold) Flint is growing e.g. 900 houses will be built in Flint over the next few years. How will BCUHB cope with these extra demands? (Flint) By 2033 Population will increase by 60%. How will your proposal to close Flint which already has twice the population of Holywell? (Given the fact that Glan Clwyd already has a major issue with bed capacity). (Flint)
Location 4.103 The location of the ‘hubs’ was discussed extensively – and many suggestions were made for alternatives to those proposed: Should we as local people be the ones that choose where our local ‘hub’ should be located? Given the fact that we are the ones that are paying and using these services? We are telling you what WE want! (Mold) The ‘hubs’ are too far apart and they leave this area without sufficient cover (Llangollen) How did you arrive at the notion of Holywell as being the ‘hub’? Flint is far better as a location and has a population of 12,000 as opposed to Holywell which has approx 6,000 and Mold has 9,000. Holywell is at the end of the spoke and is definitely not a geographical hub (Flint) Bronglais should be seen as part of the ‘hub’ system to support those people living in South Meironeth (Tywyn) Why is Ruthin not the ‘hub’ as opposed to Denbigh? In the initial discussions prior to the consultation process it was stated that the ‘hub’ could have been either Ruthin OR Denbigh. (Ruthin)
Travel and Transport 4.104 The consistent theme of travel and transport, and the ability of people in remote areas to access services, was raised again while discussing ‘hubs’: There is a poor level of public transport in the area and the cost involved for local residents (Ruthin) It costs £44 a day to travel by taxi to Wrexham or alternatively it would be a five-hour round trip on public transport (Mold). 4.105 The move to more centralised ‘hubs’ led some attendees to comment that parking provision may not be sufficient to cope with increased demand: Parking is already difficult at Deeside, how will they cope with the additional demand? (Mold)
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4.106 The issue of more travelling for staff was also raised: How will extended travel around the community impact on staff? Have you talked to them about this? (Wrexham)
Equality Impact Assessment 4.107 A further issue raised in two meetings was whether BCUHB had undertaken an Equality Impact Assessment as part of the decision-making process: Did you undertake an Equality Impact Assessment? Looking for an Equality Impact Assessment under the Equalities Act – which has 9 characteristics – Age is one of these. (Flint)
What happens to redundant assets? 4.108 Attendees realised that the closure of community health and hospital facilities would mean that several buildings would become redundant - and they were keen to know of BCUHB’s plans for these: What are you going to do with the hospital? Are you going to sell it? (Flint)
Role of GPs 4.109 The important role that GPs will play in the new service was also raised in the discussions around ‘hubs’: GPs do not have enough time to care for their current patients so how will they have time to deal with the increase in population as well as the expectation that they get involved in enhanced care in the community (Flint) GPs seem to be failing to deliver the out-of-hours service so how can you guarantee that GPs will work on the enhanced care proposal? (Flint)
Balance of Opinion 4.110 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion in the session. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion. Opposed - Prestatyn, Flint, Blaenau Ffestiniog, Ruthin, Mold Favourable – Rhyl, albeit reluctantly.
Follow-up Necessary 4.111 There were some follow-up actions which the BCUHB may wish to consider: Provide better information on the website on the Equality Impact Assessment Provide staff with more information regarding the criteria used to underpin the proposed ‘hub’ model and how this information and evidence is used to determine locations.
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Minor Injuries Services 4.112 The service review includes the principle of focussing Minor Injuries Services at fewer hospitals, with specific proposals to provide services at ‘hubs’
Summary of Main Issues Raised 4.113 There was considerable focus on the changes to the Minor Injuries Service in several meetings, but not all. Key concerns were around how the decisions to create ‘hubs’ were made, and attendees were keen to understand this better, with several requests for more detail on current and projected service usage volumes. 4.114 Requests, too, were made for more detail on the cost savings envisaged from the individual (e.g. localised closures) and collective changes (i.e. the full service review). 4.115 Two areas - Mold (2,408 signatures) and Colwyn Bay (930 signatures) - had raised petitions against the proposed closure of the MIU services there. 4.116 Transport issues featured again in discussions: attendees highlighted the rural nature of North Wales and the complexities of using public transport. The implications of the proposed changes for GP services was also raised in several meetings.
Decision-making process 4.117 Most meetings considered how the decisions to close and relocate services were made. Attendees were interested in how demand modelling for services was undertaken, as well as the projected cost savings anticipated from the changes: What are the costs for closing Mold and opening MIU/X-Ray services at Deeside? (Mold) How much is being saved by closing Chirk? What are the savings? The additional cost of going to Wrexham for treatment is being passed onto the patient (Chirk) Why will the new Rhyl hospital not have a minor injury unit? (Rhyl)
Calculating demand for MIU services 4.118 There was a particular focus in many meetings on the demand for MIU services, and how this is subject to seasonal variations. Many requests for more detailed information about demand for the service were made. Where information was available (for example at Tywyn), people were reluctant to accept it and questioned its credibility: There is an enormous information gap across the whole of North Wales with regards to where local people can go to get MI treatment - who makes most use of the MIU? (Wrexham) You are closing Colwyn Bay and extending the hours at Llandudno yet only 2,000 people go through Colwyn Bay per year compared with 60,000 at Llandudno – which means a difference of 6 versus 60 per day (Llandudno) Increased demand taken in to account from increased population in the summer months? For example Talyllyn railway carries 40,000 visitors a year. (Tywyn)
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Transport 4.119 The recurring theme of travel and transport difficulties in rural North Wales was discussed alongside MIU changes. Public transport to some hubs (Deeside for example) is poor, requiring people to take several buses. The cost of travelling longer distances was raised again, and some felt this might mean a surge in demand for Ambulance Services: Costs of transport are prohibitive and may increase demand for the Ambulance Service (Pwllheli) The MIU in both Mold and Ruthin are closing. People will probably end up going to Maelor in Wrexham or Denbigh - they will have to travel some considerable distances (Ruthin) Some people may well decide to go over the border to England e.g. Oswestry for MI services (Chirk) If you had to access A&E or MI at Wrexham, it’s impossible to get there by public transport and a taxi will cost £24 each way and then there is 3.5 hours minimum wait. (Mold)
Role of GPs 4.120 The role of GPs in the new MIU service was also considered, and attendees were keen to know how this might work: Can GPs be required to provide minor injuries units? They can be asked if they want to, but they cannot be told to do so if they are reluctant – so how can you rely on them to be the core of the health service in the community? (Llangollen)
Balance of Opinion 4.121 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion in the session. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion. Opposed - Blaenau Ffestiniog, Old Colwyn, Mold, Flint, Chirk, Tywyn No opinion either way - Wrexham, Rhyl, Llandudno, Llangollen, Connah’s Quay.
Follow-up Necessary 4.122 There were some follow-up actions that BCUHB may wish to consider: It was suggested that consideration should be given to locating the GP “out-of-service” provision in Mold as opposed to Deeside. Need to promote and market the ‘Choose Well’ initiative more widely across North Wales.
X-Ray Services 4.123 The service review includes a principle of focussing X-Ray Services at fewer hospitals, with specific proposals to provide these services at ‘Hubs’.
Summary of Main Issues Raised 4.124 There was either little or no discussion about the X-Ray proposals at most meetings. However, there was extensive discussion at five meetings (Tywyn, Ruthin, Pwllheli, Caernarfon and Mold).
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4.125 One significant issue was how the decision to focus X-Ray Services at the proposed ‘hubs’ location was made. People were sceptical that their views would actively influence the final decisions regarding where ‘the hubs’ would be. 4.126 Most meetings generated questions regarding the financial and statistical information that had underpinned the proposals for change, especially at Tywyn, Ruthin and Pwllheli. 4.127 Discussions regarding the location of the ‘hubs’ centred on the cost/benefit analysis of various service location options, the cost to patients of travel and the reliability of public transport. 4.128 Some attendees questioned whether the staff recruitment issues BCUHB faced had influenced the location of proposed ‘hubs’. 4.129 A key concern was that remaining services would be at risk of future closure after the ‘hubs’ are developed.
Decision making process 4.130 The decision-making process and the principles and information supporting it were questioned at several meetings. The focus for comment was around the transparency of the process, the influence the consultation would have, and the principle of bringing services closer to people: Access to Eryri is excellent for many people but it will be much harder to go Ysbyty Gwynedd – and patients are already being redirected there – so this is not a genuine consultation because the decisions have already been taken (Caernarfon) What is the rationale for closing Mold as these are not mentioned in the information? (Mold) The proposals for X-Ray are not consistent with bringing services closer to the people in the community – because it involves people travelling to Bangor instead of Eryri (Caernarfon) With regards to the principle of providing care closer to home the proposal to remove the X-Ray from Bryn Beryl will be removing an invaluable diagnostic provision. I urge the Health Board to reconsider (Pwllheli) These proposals are not fair given the fact that the proposal is to close two X-Ray provisions in the East whilst you are closing five X-Ray departments in the West. (Pwllheli)
Costs and Volumes of Service Use 4.131 The meetings generated questions about the financial and statistical information underpinning the proposals for change at Tywyn, Ruthin and Pwllheli. There was considerable scepticism around this, as well as many requests for more information to be made available: What is the cost of running the X-Ray service in Tywyn? (Tywyn) What is the difference in the cost for transporting patients for X-Rays to Dolgellau? (Tywyn) What are the annual cost savings involved in implementing these proposal to close the X-Ray provision? (Ruthin)
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Transport and Travel 4.132 Several questions and comments about transport were raised in discussions around the X-Ray services proposal - especially at Tywyn and Pwllheli. These mainly covered the cost-benefits of various service location options, the cost to patients of travel, and the reliability of public transport: Have you consulted with those transport providers in terms of actually getting to Dolgellau? Once you do get to Dolgellau there is very poor transport to get to the hospital. (It only works 3 days!!) Then you have a big hill to walk up!! (Tywyn) Why should 30 people travel to Dolgellau [for X-Ray services] - would it not be better for one member of staff to travel to Tywyn? (Tywyn) The fact that this is a rural area and many people are reliant on a minimum wage it seems unfair to expect them to bear the additional costs of travelling further for X-Rays. (Pwllheli)
Longer Term Implications 4.133 There was considerable concern about the implications of closing X-Ray services and the impact on other services. For example, many questions were raised about the risk to the future provision of orthopaedic services, as well as the overall future viability of the hospitals that remain open: What is the future for Ruthin hospital if we lose the X-Ray provision? (Ruthin) Is there a danger that that if the X-Ray provision in Tywyn is closed that we could also lose the orthopaedic service in Tywyn? (Tywyn) Does this proposal undermine the long term future of the hospital? (Mold)
Recruitment 4.134 It was suggested that recruitment issues had influenced the decision-making process in relation to closing X-Ray services: The key issue is more of an employment issue as it has been stated that it’s difficult to recruit radiologists. (Tywyn)
Impact on Ambulance service 4.135 Many attendees commented that the closure of X-Ray services may have an impact on demand for the Ambulance Service: transport limitations locally may mean people try to use ambulances to access X- Ray services: Has anyone from the BCUHB actually discussed the implications of this proposal to close the X-Ray services here in Bryn Beryl with the Ambulance Service? Quite often some of the patients will also need to be accompanied by nursing staff (Pwllheli) What role will the Ambulance Service have in any of this? Travel is a major issue…mobility & transport appear to be major concern. (Mold)
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Balance of Opinion 4.136 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion in the session. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion. Opposed - Blaenau Ffestiniog, Tywyn, Pwllheli No opinion either way - Wrexham Generally favourable – Rhyl.
Follow-up Necessary 4.137 There were some follow up actions which the BCUHB may wish to consider: Review the premise for the X-Ray calculations used in the consultation document Consider the offer made by the Mold Hospital League of Friends to pay for the cost of replacing the X-Ray provision (Mold).
Local Services in Blaenau Ffestiniog 4.138 The proposals for change include expanding primary and community care services at Ffestiniog Memorial Hospital – but also the removal of inpatient beds to Ysbyty Alltwen.
Summary of Main Issues Raised 4.139 The meeting at Blaenau Ffestiniog was preceded by a protest meeting which attracted around 150 protestors – and serious concerns were raised at the meeting about the proposed closure of the Memorial Hospital. The main worry was around the loss of beds, the MIU and X-Ray provision. 4.140 Firstly, people queried how seriously the consultation would be treated by the Board. Secondly, people were concerned that the consultation process had not been systematic: it was stated that questions and responses to the Board had received no response and people sought reassurance that the petition raised in the local area would be taken into account. 4.141 More detailed comments and questions were raised around the future of Ysbyty Alltwen, and people requested clarity about the services it will provide in future.
Consultation Process 4.142 Strong concern was expressed by attendees and representatives of the Hospital Defence Committee (HDC) as to how genuinely and seriously BCUHB is taking the public consultation exercise. They explained that they had yet to receive a reply from BCUHB regarding their formal response - and alleged that HDC questions to BCUHB had received no response. Attendees also asked for reassurance that BCUHB will take account of the 4,000 signature petition against the closure of the hospital. 4.143 It was suggested that the Board should send its consultation document to every home in the area – and that there should be a full public meeting to discuss the local proposals. 4.144 It was stated that local people have little faith in BCUHB, and that they strongly wish to maintain local services at Blaenau Ffestiniog. Indeed, many people were concerned that the new proposals will not
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improve local services and that Blaenau Ffestiniog will lose important provisions – including X-Ray and minor injuries. 4.145 It was requested that the chair take a vote on the formal proposals at the first public meeting. No vote was taken. 4.146 A range of views was expressed as to the types of service people would like to see locally: Blaenau hospital should be able to offer IV infusions and blood transfusions – and diagnostics should be more readily available locally Priority should be to try to maintain the current number of beds in Gwynedd and not to reduce the number of beds.
Lack of clarity on Alltwen services 4.147 Many attendees were unclear as to what services are currently provided and will be provided in future at Ysbyty Alltwen: What is the current level and standard of provision in Alltwen Hospital? Alltwen Hospital does not offer a full range of services and we do not have much confidence in what it provides There is a waiting list for beds in Alltwen – so it is unwise to centralise services there.
Transport 4.148 The issue of transport for people living in a rural area was also raised: Travelling times are lengthy in this area and the roads can be congested Whatever transport is provided, there will be summertime travel difficulties to the other hospitals.
Balance of Opinion 4.149 Attendees expressed strong disagreement with the proposals for the Blaenau Ffestiniog Memorial Hospital.
Local Services in Rhyl and Prestatyn 4.150 The Health Board proposes a new hospital on the Royal Alexandra Hospital site (Rhyl) while closing Prestatyn Community Hospital.
Summary of Main Issues Raised 4.151 There was discussion of the proposals at both the Prestatyn and Rhyl meetings, although the most significant concerns were raised at Prestatyn in the light of the proposed closure of the town’s community hospital. 4.152 There were considerable concerns about the closure. Firstly, people sought reassurance as to the future use of the building and whether BCUHB is planning to dispose of it. Secondly, there were concerns that current services will cease before new services are launched. Finally, people highlighted the risks to local older people with mental health problems resulting from the closure.
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Closure of Prestatyn Community Hospital 4.153 The key concern was the proposed closure of Prestatyn Community Hospital, and particularly its local impact and how the transition to the new service will be managed to ensure no ‘gaps’ in service: Planning implications of Grade II listing for Royal Alexandra not taken properly into account in proposals (Prestatyn) How many beds will there be in the new Royal Alexandra? Won’t this be lower than we have overall now? (Prestatyn) Demand for service at Chatsworth is very real, especially for the elderly mentally ill – have you planned for this demand? (Prestatyn) Will the Prestatyn Hospital close before the new Royal Alexandra Hospital is open? Won’t this mean a disruption in service? (Rhyl) 4.154 There were also some concerns that financial motives may be driving BCUHB’s proposals: Why not sell Rhyl (which has more complex redevelopment and planning issues) and redevelop Prestatyn – it’s a more viable site? (Prestatyn) Closure is all about realising the capital receipt isn’t it? (Prestatyn) 4.155 Attendees also asked questions about the business case behind the proposals, and recognised the value of Prestatyn Community Hospital to the local community: Chatsworth provides a low-tech, high-care post-operative service for older people; isn’t there value in this? (Prestatyn)
Balance of Opinion 4.156 The Prestatyn meeting was very unfavourable to the proposals.
Local Services in Llangollen 4.157 The new proposals include extending primary care services in Llangollen while moving inpatient beds to local care homes and / or Chirk.
Main Issues Raised 4.158 There was discussion of the proposal to close Llangollen Community Hospital at both the Llangollen and Wrexham meetings, although the most significant concerns were raised at the former in the light of the proposed loss of inpatient beds. 4.159 Transport issues featured again in discussions: attendees highlighted the distances to travel, the cost of transport and overall access to other hospitals. There were also concerns that current services would cease before new services were launched. Further, people were anxious about how the remaining Llangollen services will cope with potential future increases in demand. 4.160 People also sought reassurance that funding for the proposed new primary care service is confirmed and secure.
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Transport 4.161 Many comments were made about the difficulties that will be involved in travelling to health services under the new proposal: Moving the inpatient and outpatient services to Chirk will create additional transport difficulties for Llangollen people – it is important to ensure that the current non-inpatient services are maintained in this area Transport to Chirk is difficult compared even with going to Wrexham.
Closing existing services 4.162 Many concerns were raised about the alignment between closing existing services and opening new ones. Attendees were keen for BCUHB to ensure a seamless transition: It is unwise to close our Community Hospital two years before a replacement service is in place I have seen a letter that says the hospital will close in 2013 and the new centre will not open until 2015 – so why do you want to close it now?
Remaining service 4.163 Concerns were also raised about how remaining Llangollen-based services will cope with future increases in demand: The health centre will struggle to provide any additional services because it is working at capacity now and is very busy – and there is little space upstairs We understand that you cannot justify a small number of beds in a new development – but we are concerned that all our current services like blood tests and dressings remain available when the hospital is closed – we need to ensure that those clinics remain here Many people are not aware that Chirk is a MIU. There is a need to promote these more proactively in our local communities.
Funding 4.164 A key issue that was raised several times concerned the firmness of funding for proposed new services; people sought reassurance that this would be forthcoming. A further issue raised was how donations made specifically to Llangollen would be treated: The Community Hospital has been neglected in terms of maintenance on the basis of shortage of money – so have you definitely got the money for the new Primary Care Resource Centre? You seem to be closing our hospital without the guarantee of getting the new capital funding – but that is irresponsible! If you are confident you will get the funding, then keep our hospital open meanwhile for the next two years The proposal should not proceed until there is funding for a definite replacement service.
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The River Lodge site 4.165 Several concerns were raised about the proposed River Lodge (Woodlands) site, particularly in relation to its ease of access for service users and the range of services it will provide: The Woodlands site needs a safe footpath access and a safe bus stop – those are crucial; and it should have a minimum number of beds It is a good idea to build a new facility but the current proposed location is unsafe in terms of access – and it is also a shame to lose the provision of inpatient beds – we would like a minimum of four beds in the new facility.
Older People 4.166 Several issues about the future care of older people were raised, especially as demand for services is projected to increase: To say that you propose to use nursing homes is very different to what we have now since they are not in the NHS and have different care standards while also charging The numerical demand for care for the elderly is increasing – and this will put increasing demands on inpatient services even if we increase care in the community – people who would now go into acute hospitals will need community beds instead.
Balance of Opinion 4.167 Some concern was expressed regarding the loss of services in Llangollen.
Local Services in Flint 4.168 The proposals for Flint include extended primary care services and the moving of inpatient beds to Holywell.
Summary of Main Issues Raised 4.169 There was considerable opposition to the proposal to close Flint Community Hospital and many attending were committed to the continued campaign to save it: You’re not interested in what we want as a local community We will challenge you at every stage of this consultation process We will take our campaign to the Health Minister and CHC. 4.170 Several concerns were raised regarding the proposed new Primary Care Resource Centre (PCRC), mainly around how it will work, whether the predicted costs are accurate and whether the available funding is sufficient to meet these. How much will it cost? I don’t think that we need this new provision. What we need is our local hospital We want to build a flagship Health Centre but not at the expense of hospital beds. Why can we not put all these services into one place?
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With regards to your proposals (for example a Primary Care Resource Centre in Flint costing £4m and then Llandudno costing £40m and others total cost is approximately £140m), how confident are you that you can deliver all of these?
Balance of Opinion 4.171 Attendees were extremely unhappy with the current proposals and were totally opposed to moving inpatient beds to Holywell.
Older People’s Mental Health
4.172 BCUHB says that there is an excess of beds for elderly people with mental health needs and they are not well utilised. There is also a need to strengthen services to provide better support to enable people to remain in their homes. Additional proposals for Conwy and Denbighshire, as well as Gwynedd and Anglesey, were also discussed at the relevant meetings.
Summary of Main Issues Raised 4.173 A considerable range of issues was raised regarding the future shape of Older People’s Mental Health Services. Overall, this was a keenly debated topic of considerable concern to attendees. 4.174 The issues raised covered future demand from increasing numbers of older people with dementia and the implications of this for Health and Social Services in structuring their future service offer. 4.175 In addition, concerns were raised about older people living alone, and the need for a preventative care service for them – as well as the level of respite care provision for carers. People also sought reassurance that an out-of-hours service would be available for older people. Several meetings raised the issue of the quality and range of provision in private nursing homes. The possible issues in recruiting and retaining specialist staff was also highlighted. 4.176 The issues around the rural nature of North Wales and the challenge this presents in terms of travel and accessing services at home were also raised.
Future demand for services 4.177 People recognised the challenge of accurately forecasting future service requirements given the complexity of population change and the forecast of increasing dementia amongst older people. For some, this meant the proposal to reduce bed space provision seems premature. Overall, attendees were concerned that the proposals may mean future demand exceeds service provision: Dementia demand is said to be growing as people get older; won’t better diagnosis mean even more demand? (Prestatyn) Will you have sufficient beds in the hospitals to cope with the demand from patients with dementia? (Caernarfon) Overall, the changes mean a net loss of beds for EMI don’t they? (Prestatyn)
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Preventative approaches towards dementia 4.178 Many meetings raised the issue of the need for a more preventative approach towards dementia and for more resources to be committed to this: What are your plans for the early diagnosis of dementia as this is so important for the early treatment of dementia (Flint) More preventative work with older people not yet presenting dementia issues should be undertaken (Rhyl) The is a hidden pool of people with dementia in the community but receiving no treatment. (Caernarfon)
Older People’s Health Care at Home 4.179 Most meetings discussed how services would be provided in people’s homes. There were particular concerns for people living alone given the challenging nature of dementia for independent living. There were other issues about how suitable the new service might be for people at home. Travel times for staff that have to travel across large areas were also raised: The HEC service doesn’t work now does it? (Prestatyn) These proposals do not really address the needs of those who live on their own – in reality the consequence is that the health carers will probably be spending most of their time travelling from one patient to another as opposed to spending time with the patient! (Tywyn) How many elderly people live on their own? What support is available for them in respect of one to one support in their homes? (Chirk) How can you provide appropriate support for elderly people who live on their own, particularly if they have not been diagnosed with dementia? (Llangefni)
Transitional arrangements 4.180 The transitional arrangements to be put in place to ensure a seamless migration to the new service were discussed in several meetings. Essentially, attendees were seeking reassurance that there would be no diminution of service during the transition phase: What are the transitional arrangements in terms of these proposals? (Tywyn) Closure plans appear to be ready to go before the new service has been defined, costed and agreed. (Rhyl)
Respite for carers 4.181 There were concerns that, in developing the new service, the needs of carers should not be forgotten. Indeed, current bed provision was perceived to be an important source for respite care for carers with very demanding responsibilities: It’s a 360 days 24/7 responsibility and reducing hospital beds would put more pressure on carers. Respite care is considered as being really important for carers (Llangefni)
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There are not enough respite beds available and I have concernc regarding access and flexibility for booking these respite beds (Old Colwyn) How can you really say that your supporting the carer (for those living in Lleyn) if the respite care is being provided in Llangefni? (Pwllheli)
Out-of-hours service 4.182 A further issue was the out-of-hours arrangements for service users with dementia. The level of service, and the hours it will cover were discussed in detail at several meetings: How are you going to get your mental health staff to cover and to provide appropriate support during the evenings (after 5.00pm)? (Tywyn) Will the new Homecare service cover nights? (Rhyl) More provision for out-of-hours services with specialist nurses and doctors is really important with regard to any future provision. (Llangefni)
Working with Social Services 4.183 The relationship between Health and Social Services was regarded as essential to a successful future service, although there was some scepticism about how this works currently - particularly which agency is responsible for what service. Several allegations were made about the poor quality of ‘privatised’ services for older people commissioned by Social Services: Some comment that this was privatisation as had happened in Social Services: Social Services’ service was seen to be of poor quality e.g. older people being put to bed at 5.30pm (Rhyl) A number of attendees expressed genuine concern and confusion as to who takes responsibility for the care of the elderly with dementia. Is it the Health Board or Local Authority? (Llangefni) What will be the impact of these proposed changes for Social Services? And will the costs be passed onto patients? (Pwllheli)
How many beds will close? 4.184 There was uncertainty about the cumulative impact of all the changes proposed by BCUHB in terms of bedspace, as well as evidence of rumours of further reductions being considered: Some serious concern expressed regarding the fact that hospital closures and bed reductions is reducing the amount of care available in the wider community (Llangefni) Lack of clarity about exactly how many Rhyl hospital beds will close (Rhyl) What are the current plans for Hafan? Will Hafan be closed permanently? (Pwllheli)
Suitability of Private Care Homes 4.185 Another major concern was the availability of suitable private care homes in the community. Further, several comments were made at various meetings about negative experiences at some homes:
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The suitability would appear to be even more critical and acute given the recent reduction of five Local Authority care homes along with the closure of a number of private sector care homes (Llangefni) How can BCUHB put patients with dementia into residential nursing homes? (Pwllheli)
Costs of new proposals 4.186 There were a number of concerns about the cost of the new service and the security of available funding for it. Attendees required reassurance that this was all in place and agreed: Concern that budgets won’t stretch to the new service proposal (Rhyl) How can you guarantee to provide the appropriate level of funding to support these community based support services? (Chirk) Do we have a break-down of the Board’s budget and costs to show how much more of the costs of healthcare for the elderly are having to be paid by the Board (Llandudno) What assumptions have been made in your business case with regards to the impact of these proposals to the County Council - you are only passing on these costs to yet another public sector body? (Mold)
Recruiting specialist staff 4.187 The challenge of recruiting specialist staff was raised at two meetings – essentially, people felt this could be an issue given the historic issues in North Wales: Scepticism about recruitment, training and retention arrangements for specialist nurses in dementia (Connah’s Quay and Old Colwyn) Recruitment of carers for the future, where are the new carers going to come from? (Old Colwyn)
Rural 4.188 The rural nature of North Wales meant that concerns were raised regarding how services to older people in the community could operate effectively and efficiently. The distances and prospective travel times seemed to many to mitigate against a high quality service. Further, there was a sense that the remaining mental health beds may present travel problems for local people to access and/or visit: How do you ensure equitable provision of services/support to those living in rural locations? (Chirk) There are acute transport and travel time difficulties to more distant hospitals – and patients appreciate their local hospitals where they are happy (Blaenau Ffestiniog) Which hospital would someone with dementia on the Lleyn peninsula go to within 40 minutes from their home? (Pwllheli)
Balance of Opinion 4.189 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion in the session. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion.
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Opposed - Flint, Tywyn, Rhyl, Connah’s Quay, Blaenau Ffestiniog, Pwllheli No opinion either way – Wrexham, Llangollen, Llangefni, Old Colwyn, Llandudno, Caernarfon, Mold Generally in favour – Chirk (with some reservations expressed about respite care and support for those living on their own).
Follow-up Necessary 4.190 There were some follow up actions which BCUHB may wish to consider: Clarify the future status of various current facilities and the net position regarding bed provision across North Wales Clarify the approach to be taken to preventative dementia service arrangements Clarify Health and Social Services roles in providing health and social care to older people with mental health issues.
Neonatal Intensive Care Services
4.191 The service review includes a proposal to relocate acute Neonatal Intensive Care Services to Arrowe Park, Wirral.
Summary of Main Issues Raised 4.192 The proposed changes were discussed in all sessions and aroused considerable interest amongst attendees. There was a clear polarity between those who want local services and those who want the best possible services and no overall consensus view emerged. However, many meetings regretted the loss of specialist neonatal skills from North Wales. 4.193 In terms of the services offered by Arrowe Park, attendees sought reassurance that it could cope with the volume of demand from North Wales. They also asked about the quality of care and sought reassurance that this will be up to an appropriate standard. 4.194 Transport and travel were key concerns. People were worried about the logistics of transferring serious cases from North Wales to Arrowe Park and how this would work in the interests of the child. They also wanted a professional service to support parents at a difficult time. 4.195 Some meetings queried how comprehensive the service level agreement with Arrowe Park would be, and wanted BCUHB to ensure it would cope with future demand and deliver on quality and cost. 4.196 Finally, concerns about Arrowe Park being in England were raised. Potential difficulties included the provision of a Welsh language service, Welsh money being spent on an English service and ‘Welsh’ babies being born in a different country.
Location 4.197 Most meetings discussed the relocation of neonatal services to Arrowe Park in some detail. There was a range of views from those supporting the proposal to those who opposed it. Several meetings raised queries on the information presented (plus requests for additional information on the costs and service volumes) and the evidence for change:
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The proposed use of Arrowe Park is an excellent idea (Llangollen) Most of the population accepts that this specialist service should be provided from the Arrowe Park centre – but we do not want to lose our good services that are sustainable (Caernarfon). What are the cost implications for sending the babies to Arrowe Park as opposed to keeping the provision in Wales? (Mold) Why have you not provided us with the actual costs as part of the consultation process? (Mold) What is missing in the consultation document is the quantitative data to underpin the rationale for these proposals. (Ruthin)
Loss of skills for Wales 4.198 A key concern raised in many meetings was the potential loss of neonatal specialist skills from North Wales. A particular issue surrounded the training of new doctors via the Deanery scheme and the implications that the number of training positions would decrease in North Wales. In addition, current specialist skills could be lost to other health services in other areas: Won’t the change mean that North Wales loses out in the training of new doctors via the Deanery programme? (Prestatyn) Doctor training: post graduate training via the Deanery scheme will likely no longer be ‘placed’ in North Wales if suitable Neonatal hospitals are not available – isn’t this an unacceptable loss for North Wales? (Rhyl) Are we not in danger of de-skilling our existing staff if we are sending our babies to Arrowe Park? (Wrexham) It looks as if these proposals will reduce the ability for the Health Board to recruit appropriate specialist consultants and medical staff (Flint) If there is no specialist Neonatal Care unit in North Wales. Will this diminish or make it harder to recruit neonatal specialists for North Wales? (Chirk)
Arrowe Park capacity 4.199 Many questions were raised over the capacity of Arrowe Park to cope with North Wales demand for specialist neonatal services, and the difficulties that could arise if this demand is not be met: Can Arrowe Park accommodate the additional babies from North Wales? (Wrexham) Does Arrowe Park have the capacity to take the babies from North Wales? What will happen if the beds are full there? (Llangollen) What happens if the beds at Arrowe Park are full? (Ruthin)
Logistics of Transfers 4.200 Concerns were also raised about the arrangements for the transfer of complex neonatal cases from North Wales to Arrowe Park. Attendees also sought reassurance that potential risks would be effectively managed:
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Would the transfer team for these babies be provided by AP? Who would make up the transfer team? (Wrexham) Have you looked at or calculated the potential risk of death to these babies who are likely to be transferred to Arrowe Park? (Wrexham)
Service Level Agreement with Arrowe Park 4.201 There was considerable interest in the contractual arrangements that BCUHB would enter into with Arrowe Park for neonatal services, and a concern that any agreement should be future-proofed: How secure will the service level agreement be with regards to Arrowe Park? Will the money be ringfenced? (Wrexham) Will Arrowe Park exploit us with higher charges at a later date? (Prestatyn) What would happen if Arrowe Park decides to double its costs over time and we end up having to pay more? (Llandudno)
Transport 4.202 The issue of transport for families from North Wales to the Wirral was raised in most meetings. There was a keen awareness of the difficulties of travel via public transport and the cost implications of all transport given the potential distances involved. Attendees also sought clarification regarding the role of the Ambulance Service in providing transport and the availability of the air ambulance for emergency cases: Has any research been undertaken to look at the impact of the additional travel will have on those families who have to travel to Arrowe Park? (Wrexham) Will there be any financial support for families who will be required to travel to Arrowe Park? (Flint) Tywyn hospital is important to local people; sending these babies to Wirral is like sending them to the end of the earth! (Tywyn) What impact will these proposals have on the babies and families who will have to travel from the rural areas of North Wales (e.g. Lleyn or Ynys Mon)? (Mold)
Support to Parents 4.203 The stress faced by parents with a sick baby was acknowledged in several meetings, and reassurances were sought that BCUHB would have appropriate services and accommodation in place to support families at a difficult time. Suggestions were made that a co-ordinator post should be created to ensure a seamless service: Will there be a co-ordinator employed to help parents with all the issues they’ll face – language, transport, problems and complaints? (Prestatyn) Can parents be accommodated while their babies are in Arrowe Park? (Llangollen) Are there facilities for families at Arrowe Park? (Old Colwyn)
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Consultation Process 4.204 Some concerns were raised about consultation on the Arrowe Park proposals. There was a degree of scepticism regarding how decisions were taken, and the influence of the consultation meetings themselves: I feel that the decision has already been made with regards to these proposals! BUT I still feel strongly that this service should be retained in Wales (Wrexham) Previous report (c.2005) had recommendations regarding a North Wales specialist neonatal unit appears to have been ignored – why? (Rhyl) Hasn’t the current service been run down in order to pave the way for the move to Arrowe Park? Doesn’t the high cost of locums and agency staff show this? (Rhyl)
Standards of Care 4.205 Standards of care for complex neonatal cases were discussed in several meetings, where people sought reassurance those at Arrowe Park would meet and exceed national standards: Are the standards referred to English or Welsh standards? (Flint) If the service goes to Arrowe Park, will the remaining service have sufficient capacity to provide staff needed for ‘excellent’ service? (Prestatyn) Does Arrowe Park currently meet the appropriate standards? (Old Colwyn)
Wales 4.206 A regular concern at meetings was that Welsh babies would be born in another country. Further, people felt the loss of their service to another country keenly, and were disappointed that Welsh finance would be spent on services there. Further, worry was expressed about how bilingual services could be provided at Arrowe Park: Why shouldn’t parents have the right to have their child born in Wales? (Rhyl) People who love Wales will not want their children born in England! (Llandudno) Can the Health Board consider the political implication of babies from Wales who are born in Arrowe Park being considered as being English? (Pwllheli) Why should Wales’s money be spent in another country? (Rhyl)
Balance of Opinion 4.207 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion in the session. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion: Opposed – Wrexham, Flint, Rhyl, Mold No opinion either way – Prestatyn, Tywyn, Llangollen, Chirk, Old Colwyn, Ruthin, Pwllheli Generally favourable - Connah’s Quay, Llangefni, Llandudno, Caernarfon Not discussed in detail – Blaenau Ffestiniog.
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Follow-Up Necessary 4.208 There were some follow up actions which BCUHB may wish to consider: Consider a Family Co-ordinator post to support Welsh parents in Arrowe Park Clarify issues around training via the Deanery programme and future of doctor training Demonstrate how the standard of the proposed service at Arrowe Park will exceed what is possible in North Wales Clarify the revised transport arrangements between North Wales and the new service Provide more detailed costs that underpin the business case as part of this consultation process.
Vascular Services
4.209 The service review proposal includes the creation of one specialist centre to deliver high quality services for North Wales.
Main Issues Raised 4.210 The proposals were discussed in most, but not all, meetings. Where discussed, the meetings were mostly in favour of the proposal. This seems like a really good idea. You have come up with some good ideas (Old Colwyn) No one is really going to oppose some of these major proposals. (Pwllheli) 4.211 The focus for discussion centred on the implications of having one specialist centre. Some attendees saw risks in this and were particularly concerned about travel and transport to the specialist centre and the risks of this for very ill patients. 4.212 There was some discussion in several meetings about where the centre will be located and some alternatives were proposed. People in the far west of North Wales were concerned that they could lose out disproportionately by having to travel the furthest. The location could also mean continued recruitment issues for specialist staff if it is not in the ‘right’ place. 4.213 One concern was how the new service will cope with emergency cases, even with a preventative approach.
Transport 4.214 The issues raised around transport were mostly concerned with the risks posed to vascular patients in travelling longer distances to receive treatment - and how this might be improved: Are we increasing the potential mortality rate of patients who have AAA by asking patients to be transferred to a specialist hospital which is further away than their local hospital? (Flint) Would someone survive if they had to travel any great distance? (Chirk) We are heavily dependent on the Air Ambulance; are you going to do anything to improve the service for this area? For example it can take at least 45min to get an ambulance from Dolgellau (Tywyn)
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Burst aneurysms/clots are very painful, yet you will be asking people to travel further for treatment? (Rhyl)
Location 4.215 The challenges posed by increased travel distances meant attendees discussed where the new centre of excellence should be located - and there was a perception that the far west of North Wales could lose out. For those in the south of the North Wales area, there was concern they may have to travel even further to South Wales or to England. Attendees also hoped that the new Centre would be served by good public transport: A lot of specialisms seem to be going eastwards so we need more support for the Bangor area – perhaps with Wrexham and Bangor as the two centres (Llandudno) All of the three potential hospitals for a specialist centre are too far away from Tywyn; they are well over 50 miles away!! (Tywyn) What about future accessibility given the poor level of public transport and the distance involved in travelling to a new specialist centre. (Connah’s Quay)
One Specialist Centre 4.216 There were also some comments made about the wisdom of focussing services in one centre and the available capacity this may have: It’s wild to make only one emergency centre of excellence – shouldn’t they all have a facility? (Prestatyn) How can just one centre cope? What kind of investment would it require? (Caernarfon) It is not desirable to have only one emergency centre for vascular services because of the travelling times – though one centre is acceptable for planned operations. (Llangollen)
Preventative Approach 4.217 One concern was how the new service will cope with emergency cases, even with a preventative approach: Won’t Emergencies still happen even if the proposal moves toward a more preventative approach? (Rhyl)
Specialist skills 4.218 Some comments were made about how the new centre may still suffer recruitment issues: Recruitment may still be an issue for specialist doctors (Rhyl) Is it possible that we might lose expertise in some hospitals by concentrating resources in just one or some hospitals? (Llangollen)
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Balance of Opinion 4.219 At each session, ORS observers were asked to make a judgement regarding the overall balance of opinion in the session. Where locations are not mentioned, this is because it was not possible to draw an overall conclusion: Opposed - Tywyn No opinion either way - Wrexham, Mold, Fold, Llangollen, Connah’s Quay, Blaenau Ffestiniog, Llangefni, Ruthin, Llandudno, Caernarfon Generally favourable - Prestatyn, Rhyl, Chirk, Old Colwyn.
Follow-up Necessary 4.220 There were some follow up actions which BCUHB may wish to consider: Clarify how the proposed improved medical retrieval service will be funded.
Other Feedback
Equality and Diversity 4.221 Numerous issues were raised in relation to protected groups throughout – for example, older people (age), mums and babies (maternity/gender) and disability (including mental health). The majority of these issues have been reported under the relevant proposals above. 4.222 The key Equality and Diversity issues that emerged from the consultation concerned Wales, the Welsh language and Welsh identity. In summary, the key issues were: A strong desire for services to be available in Welsh from doctors to nurses to support staff Concerns over the national identity of babies born outside of Wales The particular needs of a rural population Reciprocal funding arrangements with English health services to meet costs of summer visitors Whether the requirement for Welsh speakers acted as a brake on recruitment.
Services to be provided in Welsh Wales’s language provision at Arrowe Park; has this been organised? (Wrexham) How will Welsh speaking mothers get a language service in Arrowe Park neo natal service? (Rhyl) It is important for patients to have the opportunity to speak in Welsh, which comes naturally to them – so it is important that hospitals and community care have staff who are able to speak Welsh and to initiate conversations in Welsh; but in Llandudno, the staff seem reluctant to engage with patients in Welsh, even though they can speak Welsh themselves (Caernarfon) Very few medics speak Welsh – and it is very difficult to attract good Welsh speaking clinicians – so how will the BCUHB deal with this? (Caernarfon) There is nothing nicer than a Welsh-speaking doctor! (Caernarfon)
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What provision is being made for the provision of Welsh language for those parents who may have to go to Arrowe Park as well the provision for those elderly patients who may have either mental health issues or dementia? (Ruthin)
Welsh Nationality and Identity Identity: need for parents to be able to choose to have their babies born in Wales (Rhyl)
Rural people needs 4.223 Given the issue of an ageing rural population living in the immediate locality, concern was expressed about the implications of some of these proposals.
Wales related issues 4.224 There were concerns that many who use health services may not be from Wales - and people sought reassurance that reciprocal arrangements with Health Boards in England were in place to ameliorate cost pressures: Is Wales paying for (English) in migrants, retirees and holidaymakers who use our services? (Prestatyn)
Recruitment Has any research been undertaken to find out why it’s so difficult to recruit staff? Is it possibly something to do with the Welsh language requirement? (Tywyn)
Views on the Consultation Process 4.225 Many views were expressed about the Consultation process itself. A key concern was how sincerely BCUHB is treating the process and the level of influence the public’s views will have. 4.226 Many sessions, especially those affected by closures, questioned the transparency and accountability of the consultation process itself – and a number of attendees felt insufficiently informed to take a view on the proposed changes. Others wanted more opportunities to discuss the changes with BCUHB. 4.227 One particular issue was that requests for further information from BCUHB had allegedly not been responded to. 4.228 People were also concerned that the consultation exercise should include the views of both BCUHB staff and existing patients. 4.229 There were further issues around the administration of the process; some noted that not all citizens had received the consultation documents; there were concerns about the need to pre-register to attend the public meetings; and others questioned whether the sessions (and total consultation) were sufficiently long – for example: Is the length of time made available for this consultation really long enough? (Pwllheli)
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Stakeholder involvement in change proposals Have patients or any other stakeholders been involved in coming up with any of these proposals? (Pwllheli) Why have you not consulted with the Buckley Town Council? (Mold) Has there been any research amongst those that will be affected by these proposals? (Ruthin) These Public Meetings attracted many members of the BCUHB staff from the locality (District Nurses, Radiologists and GPs). Many of these staff felt that they were totally undervalued and that consequently morale is extremely low (Pwllheli) How involved have the local GPs been in this consultation exercise? (Tywyn)
Cost of consultation How much has been spent on this consultation exercise? You must surely then take account of the public comments. (Flint)
Will consultation views be actively taken into account? When we look at the whole consultation process it would appear that this is very much about cost- cutting and that we as local people have not had the opportunity to input and feed suggestions into these proposals and this makes me feel that it is very much a done deal (Mold) Given the distinct impression that these proposals were a done deal and there was no room for negotiation (Pwllheli) Thanks were expressed for the opportunity for listening to the proposals and for the opportunity to completing the questionnaire (Old Colwyn) How will the outcomes of the consultation process be fed into the decision making process of the Health Board? (Connah’s Quay) A number of attendees wished to express their appreciation and thanks to the BCUHB for arranging the public consultation exercise and for ensuring that it was attended by senior executives…’high powered delegation’ (Connah’s Quay) Is this a genuine consultation exercise or is it a done deal? (Wrexham) How transparent are these public meetings – I feel that you are just placating us. (Wrexham)
Lack of response to requests for Information The Mold CAG has a not had an appropriate response to its request for further information on the data used in coming up with these proposals. The Health Board have clearly not used the available data on projected population changes and therefore their proposals and their rationale would appear to be fundamentally flawed. (Mold)
Consultation material Some 17,000 households in Buckley had not had the consultation leaflets delivered (Mold) A number of people (approximately 17) in Chirk had not received the household leaflets (Chirk)
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It was stated that given the fact that many of the residents living in Flint were elderly the option of completing an on-line questionnaires was not really appropriate (Flint) It was also stated that out of 8,500 people only 1,130 had actually received the ‘Healthcare in North Wales is Changing’ information leaflet. (Flint)
Consultation timetable Is the length of time made available for this consultation really long enough? (Pwllheli)
Administration of the consultation Why did people have to phone a telephone number and leave their details name etc. to book a place at what is said to be a Public Meeting? This issue has raised a lot of suspicion by some older members of the public and made some of them very wary (Old Colwyn) This is not a true consultation; you will only allow questions and not statements (Prestatyn) It’s not real consultation; you don’t even note down what we say. (Prestatyn)
Management of the Public Meetings
General Administration 4.230 All consultation sessions and their locations were advertised locally: people who were interested in attending were asked to pre-register so that administrative arrangements could be made around seating, refreshments and disabled access. Three sessions were held at each venue - at 2.00pm, 4.00pm and 6.00pm. While not initially planned, all meetings were open public sessions: if attendees arrived who had not pre-registered, they were still allowed to attend the meeting. Consistent information was provided at each venue. 4.231 A Welsh translation service and disability access support was provided for attendees. Copies of the consultation document and questionnaires were also available and attendees were actively encouraged to complete them. Attendees were also invited to complete a Contribution Form should they have any additional questions or wish to write to BCUHB. Details of the BCUHB website were shared with participants.
Agenda 4.232 Each meeting Agenda consisted of an introduction by the Chair, followed by a series of presentations on key aspects of proposed changes to the Health Service. Locally sensitive items likely to be of interest to particular attendees were prioritised on the Agenda to enable more time for these items to be discussed. Question and answer sessions were allowed at each meeting following each presentation.
Role of the Chair 4.233 The 16 sessions were chaired by two people: Meirion Hughes undertook the majority of sessions (14), while Eddie Kinsella undertook two. The Chairs introduced each session and facilitated the ensuing meeting, including the question and answer slots. Each introduction outlined the Chair’s approach to conducting the meeting in terms of the conduct of the session, timings, subjects to be covered,
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introductions to staff from BCUHB, and the commitment to giving all who wished to speak the opportunity to do so.
Protests and Demonstrations at Venues 4.234 Protests were held in advance of meetings at three venues - Blaenau Ffestiniog, Flint and Mold: Blaenau Ffestiniog: a rally prior to the meeting sessions attracted c.150 protestors Flint: The protest rally march prior to the final session attracted around 1,000/2000 protesters with approximately 500+ outside the Town Hall. There was a broad cross section of all ages at the demonstration Mold: 120+ protestors.
Overview of the Public Meetings 4.235 Over 1,300 people attended the series of 48 meetings held at the 16 venues across North Wales.
Figure 44: Summary of public meeting attendance by location
Attendance Location Venue Session 1 Session 2 Session 3 Total Connahs Quay Council Chambers 9 8 14 31 Blaenau Ffestiniog Blaenau Community Centre 85 46 90+ 221+ Llangefni Anglesey Council Chamber 15 6 3 24 Rhyl WCVA, Morfa Hall 18 15 17 50 Prestatyn Scala Cinema 36 14 21 71 Chirk Parish Hall 16 7 10 33 Old Colwyn Eirias Park 25 4 8 37 Flint Council Chambers 41 20 85 146 Tywyn, Gwynedd Neuadd Pendre 56 43 27 126 Ruthin Llanfwrog Community Centre 39 33 24 96 Pwllheli Sailing Club 29 7 22 58 Caernarfon Plas Menai National Watersports Centre 25 11 10 47 Llandudno Craig y Don Community Centre 14 0 3 17 Llangollen Town Hall 43 24 22 89 Mold Theatr Clwyd 85+ 35 56 196+ Wrexham Catrin Finch Centre, Glyndŵr University 33 19 14 66
Notes
Blaenau Ffestiniog – the number of attendees at the third session is set at the venue capacity, although more may have been present. The meeting was preceded by a protest meeting and most but not all protestors were invited to attend up to the venue capacity.
Mold – Some people were unable to attend the first meeting (because of the capacity of the room) but were invited to attend the third meeting. Consequently, a larger meeting room was set up at the venue in order to accommodate any anticipated additional numbers that might wish to attend.
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Organisations and Interest Groups attending Sessions 4.236 The sessions were attended by a variety of people who were not ‘ordinary’ members of the public. These included voluntary organisations, political representatives and local community groups: those who could be identified are included in the table overleaf.
Figure 45: Summary of orgnisations and interest groups attending public meetings by venue
Voluntary Local Community Political Location Others Sector Groups Representatives
North Wales Police Voluntary Flintshire CC Connahs Quay - Community Health organisations Councillors Council Memorial Hospital Blaenau Ffestiniog - - - Defence League Community Health Llangefni Anglesey Shine - - Council Alzheimers Society Rhyl - - - Cuddles Prestatyn Hospital 2 x Assembly League of friends Prestatyn - Members 2 x GPs Solicitors for the Local Councillors Elderly Community Health Chirk - - - Council Colwyn Bay Civic Society Community Health Old Colwyn - Conwy CBC Councillors Colwyn Bay Action Council Group Flintshire CC Red Cross Councillors Northop Community Flint 2 x Assembly - Age Concern North Council Action Group East Wales Members Town Councillors Local Councillors (District & Town) Hywel Da Health Tywyn, Gwynedd - Talyllyn Railway Gwynedd CC Board Councillors Denbighshire CC Chair of Rural Councillors Ruthin Transport - Local GP Ruthin Town Red Cross Councillors Pwllheli - - - - Caernarfon - - - - Llandudno - - - - Llangollen - - - - Mold Local Action Group Flint Action Group Flintshire CC Council Mental Health Support (Hands off our Mold Buckley Town Council - Group Hospital) Mold Town Council Mold 2000 (representing local retailers)
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Adults with Learning Difficulties Community Health Wrexham Caia Park Community Local Councillor Older People Mental Council Health
Media Attendance 4.237 Media organisations were invited to all sessions and venues and attended at eight of the 16 locations. The following table identifies the media organisations that attended, where they could be identified. Please note that no media organisations attended the public meetings at Llangefni, Rhyl, Ruthin, Pwllheli, Caernarfon, Llandudno, Llangollen and Mold.
Figure 46: Summary of media attendance at public meeting by location
Location Media Connahs Quay BBC Wales BBC Wales Blaenau Ffestiniog ITV Wales Prestatyn Unidentified press reporter Chirk Wrexham Advertiser Liverpool Daily Post Old Colwyn Evening News ITV Wales BBC Wales Flint Evening Leader Daily Post Tywyn, Gwynedd Cambrian News Evening Leader Wrexham Daily Post
Key Issues presented at each Consultation by BCUHB 4.238 All of the meetings received a presentation from senior BCUHB staff about the proposed drivers for change to Health Service provision in North Wales. The presentation content varied slightly at each venue to better suit local circumstances and concerns.
Figure 47: Summary of public meeting presenters by location
Location Presenter Connahs Quay Mark Scriven, Medical Director Blaenau Ffestiniog Mark Scriven, Medical Director Llangefni Anglesey Clive Sparkes, Director of Therapies and Health Science Rhyl Clive Sparkes, Director of Therapies and Health Science Prestatyn Jill Galvani, Director of Nursing and Midwifery Chirk Chris Roseblade, Assistant Medical Director and Jill Galvani, Director of Nursing and Midwifery Old Colwyn Mark Scriven, Medical Director Flint Jill Galvani, Director of Nursing and Midwifery Tywyn, Gwynedd Clive Sparkes, Director of Therapies and Health Science Ruthin Matt Makin, Chief of Staff, Cancer & Palliative Care CPG Pwllheli Paul Birch, Assistant Medical Director
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Caernarfon Neil Bradshaw, Director of Planning Llandudno Clive Sparkes, Director of Therapies and Health Science Llangollen Clive Sparkes, Director of Therapies and Health Science Mold Jill Galvani, Director of Nursing and Midwifery Wrexham Mark Scriven, Medical Director
Introduction/Overview 4.239 Introduction to the Health Board area and the health services provided: BCUHB covers about 20% of the area of Wales with a population of 678,000 and a revenue of £1.2 billion.
Key Priorities 4.240 BCUHB aims to meet the needs of the population in terms of quality standards. Key priorities for change in the Health Service include: Bringing care closer to home Developing better specialist centres. 4.241 Most existing services are unaffected by the proposed changes including the emergency departments and major acute services on the three BCUHB main sites. Specialist services needing review are: Neonatal intensive care Vascular services Older people’s mental health Care in the community Community hospitals.
Neonatal Intensive Care 4.242 Very specialist service but one not meeting national standards. BCUHB needs to improve staffing/recruitment to keep services running – this would require about seven specialist doctors and nursing staff for a small number of babies each year – but it would be hard to recruit these even if there was sufficient funding. Therefore, proposal is to commission future services from Arrowe Park.
Vascular Services 4.243 BCUHB provides complex surgery for about 300 cases per annum. There is a changing balance between planned and emergency services. Evidence shows that specialist centres with appropriate resources and skills are preferable to smaller bases. Therefore, it is proposed that North Wales should have one specialist centre – combined with a good screening service to identify people needing to be referred to the specialist centre. Less complex vascular operations will remain on all three sites – e.g. varicose veins.
Older People’s Mental Health 4.244 The number of elderly people with dementia is increasing. There is a need to have early diagnosis to prevent people deteriorating and to support them continuing to live in the community. Recruitment of
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staff is very difficult, particularly in the west of North Wales. There is an excess of beds for elderly people and they are not well utilised – but North Wales does not have excellent community services in place – there is a need to strengthen them and to provide better crisis support to enable people to remain in their homes. Proposals are being made in order to shift resources to community services and include: Strengthening community teams and nurse liaison services Improving memory services for early diagnosis Closing mental health beds at Bryn Beryl and Dolgellau; Reduction in beds at Ysbyty Cefni Changing services at Glan Traeth in Rhyl.
Community Care 4.245 BCUHB wants to provide enhanced care at home – with care available 24/7 and with GPs at the heart of service delivery in the community. Care will be moved from acute hospitals to nearer to home – including, where appropriate, end of life care.
Community Hospitals 4.246 Some hospitals are no longer fit for purpose and some services are unreliable and not resilient – services in different places have different opening times, which mean service delivery is inconsistent and unreliable. Ideally, Minor Injuries Units should be open 8am-8pm, 7 days a week and X-Ray services are available 9am-5pm, 5 days a week. The proposals are to: Close Minor Injuries Units at Ffestiniog Memorial Hospital; Colwyn Bay Community Hospital; Ruthin Community Hospital; Flint Community Hospital; Mold Community Hospital and Chirk Community Hospital and open a Minor Injuries Unit at Deeside Community Hospital Close X-Ray services at Blaenau Ffestiniog Health Centre; Bryn Beryl Hospital, Pwllheli; Tywyn Hospital; Eryri Hospital, Caernarfon; Mold Community Hospital and Ruthin Community Hospital Develop better community services and expand primary care services at Ffestiniog Memorial Hospital; close the in-patient beds and provide this care at Ysbyty Alltwen Develop a new community hospital on the Royal Alexandra Hospital site in Rhyl to provide services for both Rhyl and Prestatyn, and close Prestatyn Community Hospital Develop a new Primary Care Centre in Llangollen and close Llangollen Community Hospital Develop a new primary care resource centre in Flint and close the inpatient beds Flint Community Hospital and provide this care at Holywell Community Hospital.
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5. Written Submissions Analysis of stakeholder responses to the proposals
5.1 During the formal consultation process 779 written submissions were received from professional, political, interest, voluntary and community groups as well as from many residents and staff. Both BCUHB and ORS have separately read and reviewed all the submissions in order to understand their themes and issues; and all of the submissions are available for inspection from BCUHB. 5.2 As well as identifying important themes, a range of the submissions have been summarised below by ORS in order to make them more accessible to readers. It was neither practical nor necessary to summarise all the submissions in the same manner, but in the sections below we have sought to highlight particularly important points of view and to capture the main themes, topics and arguments while retaining at least some of the documents’ original detail. Any selection of just some submissions (for detailed summary) is problematic, but we trust we have chosen a wide range and we apologise in advance to anyone who feels their document(s) should have been included. 5.3 Summaries such as these cannot do full justice to the arguments and evidence of the many submissions, but they at least make them more accessible and indicate the main points of view expressed. Each summary is prefaced with a ‘one sentence’ italic abstract by ORS which, of course, risks over-simplification – but we thought it worthwhile to take that risk in order to make important submissions even more accessible to readers. The submissions summarised below are: Professional Bodies and NHS Organisations Royal College of Surgeons Professional Affairs Board Royal College of Midwives Royal College of Paediatrics & Child Health Royal College of Nursing Wales Royal College of Psychiatrists in Wales Wales Deanery National Clinical Forum Chartered Society of Physiotherapy Hywel Dda Health Board Powys Teaching Health Board Wales Abdominal Aortic Aneurysm Screening Programme Public Health Wales BMA North Clwyd Division Welsh Ambulance Services NHS Trust
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Older People's Commissioner Community Pharmacy Wales Liverpool Women's Hospital UNISON. Local Authorities and Statutory Bodies Conwy County Council Denbighshire County Council Gwynedd County Council Flintshire County Council Isle of Anglesey County Council Wrexham County Council North Wales Fire and Rescue Service North Wales Police. BCUHB Staff Cardiology Department, Ysbyty Glan Clwyd Two Consultant General & Vascular Surgeons, Wrexham Maelor Hospital. Neonatal Advanced Nurse Practitioners Team, Glan Clwyd Hospital. Special Interest (inc. Voluntary/community) Groups Mold Labour Party Dwyfor Labour Party Wrexham Plaid Cymru Ffestiniog Memorial Hospital Defence Committee Community Hospitals Association National Specialist Advisory Group - Mental Health North Wales Social Services Improvement Collaborative. AMs/MPs Rebecca Evans AM (2 submissions) Janet Finch-Saunders AM Llyr Gruffydd AM David Hanson MP (2 submissions) Ann Jones AM (2 submissions) Elfyn Llwyd MP (2 submissions) Sandy Mewies AM (3 submissions)
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Darren Millar AM Aled Roberts AM Chris Ruane MP Antoinette Sandbach AM (2 submissions) Ken Skates AM (2 submissions) Joyce Watson AM. 5.4 As the summaries will show, the above are very varied: some professional groups believe that BCUHB has not been sufficiently radical in its review, but generally support what is proposed while others criticise particular aspects or proposals; local authorities are concerned above all about divisions of responsibility and funding between them and BCUHB; some of the special interest groups reject specific proposals and criticise them strongly, particularly the closure or removal of some services from community hospitals. Overall though, while local proposals provoke strong opposition, the majority of the submissions summarised below are not hostile to principles that BCUHB is using, but many are worried about aspects of the implementation – particularly how community care will be organised, delivered, funded and monitored, and whether it will be effective. People might approve of the goals, but worry about the means. 5.5 In addition to worries about the implementation of care in the community, there are other practical worries expressed in the submission: how will travel to Arrowe Park be managed and will there be accommodation and facilities for Welsh children there? How will the elderly and disadvantaged access centralised vascular services? Even if centralisation of complex vascular services is needed, how will more routine procedures be supported at the ‘other’ hospital(s)? And overall, how will people manage in travelling further to their hub hospitals? 5.6 But it is best to let the submissions speak for themselves…
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Summaries of Key Submissions
Key Submissions from Professional Bodies and NHS Organisations
Royal College of Surgeons Professional Affairs Board in Wales (RCSPABW)
The RCSPAB disagrees with BCUHB’s proposal to continue emergency general surgical services on all three main sites because they are unsustainable and not in the interests of standards, staff and patients. The review is too limited insofar as unscheduled general surgery was not included; but the RCSPABW supports the proposal to centralise vascular surgical services onto a single site. (ORS)
The RCSPABW has been involved in discussions with BCUHB in the context of RCS policy documents on Emergency Surgery Services, Association of Surgeons’ policies on the configuration of surgical services and the Vascular Society’s policies on vascular surgery services. The RCS has concluded that the status quo does not favour the best interests of patients or staff and BCUHB’s proposal to continue to provide emergency general surgical services on three sites is fundamentally at odds with the views of the RCS and the PABW – so the RCS cannot support the proposals which are unsustainable and not in the interests of surgical standards, staff, training and patients. The RCSPABW supports the proposal to centralise vascular surgical services onto a single site. The RCS participated in BCUHB’s comprehensive Unscheduled General Surgery review and commends the Health Board managers involved; but it adds that the review should have led to BCUHB consulting on this crucial clinical area.
Royal College of Midwives Wales
The RCMW’s main concern is that neonatal intensive care services should be safe, sustainable and as accessible as possible; and it does not oppose the Arrowe Park proposal. (ORS)
The RCMW is pleased that all three hospitals will continue to provide initial stabilisation and short-term intensive care, special care baby units and high dependency units. Some babies will require neonatal intensive care which should meet the national standards, but there are challenges in providing such a service in North Wales. The RCMW’s main concern is that, wherever located, the service should be safe, sustainable and as accessible as possible for women and their families in North Wales.
Royal College of Paediatrics and Child Health and Paediatric and Child Health National Advisory Group
The RCPCH says the reconfiguration of paediatric services should be determined by the needs of the local population and the resources available, and that BCUHB and the Welsh Government are best placed to make the difficult decisions. The guiding criteria should be the quality and safety of care rather than simple access. (ORS)
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The RCPCH has published “Facing the Future: Standards for Paediatric Services” which outlines 10 minimum standards for acute, general paediatric care to support safe and sustainable quality services for children and young people. The RCPCH knows the geographical considerations in North Wales and recognise that all inpatient units in BCUHB have arguments to support their current existence. However, while there are insufficient middle grade trainee doctors to deliver the necessary standards at all three units, the interdependencies of paediatric medical services with emergency unit provision and consultant-led obstetric provision means that the impact of changes to current services will be considerable. The RCPCH recognises that BCUHB’s proposed changes will produce different service structures across Wales, depending on the size and geographical location, local demographics, and workforce availability within the service. Reduction in the number of inpatient units should be offset by improving local urgent and emergency care systems and also complemented by multi-disciplinary community children's teams. In this context, the RCPCH believes that the reconfiguration of paediatric services should be determined by the needs of the local population and the resources available, and that BCUHB and the Welsh Government are best placed to make these difficult decisions. The transformation will have significant costs, a whole- system approach is required and the guiding criteria should be the quality and safety of care rather than access.
Royal College of Nursing in Wales (RCNW)
The RCNW supports BCUHB’s case for changel, but opposes outsourcing neonatal intensive care services to Arrowe Park rather than keeping them in Wales. It does not oppose the other main proposals, but comments that better financial and general planning is required for their successful implementation. (ORS)
Introduction The RCNW supports the case for change in the light of the many challenges facing the NHS and, in particular, the difficulty of recruitment and retention of clinical staff (a problem shared with NHS colleagues across Wales), which poses the most significant risk to the sustainability of healthcare services. These challenges make it important that the population receives safe care as close as possible to home while optimising health outcomes.
Consultation Process The RCNW commends BCUHB on the clarity and quality of its consultation document, but regrets that the public meetings were in its opinion mishandled – with restrictions on numbers and a requirement for pre- registration which led to some nurses being excluded.
Cost, Quality and Safety of Services in the Community There is no indication that there has been a robust assessment of the financial impact of the overall proposed changes of shifting care into the community and some of the proposals are dependent on successful bids to the Welsh Government for funding. The RCNW also questions whether there is evidence that the proposed community model is more cost and clinically effective than the current model?
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Minor Injury Units and Emergency Nurse Practitioners The RCNW notes that the proposal to close some of the less used services and re-locate some others to concentrate the skilled nurse workforce in the hospital hubs will require careful planning and there is a need to increase the numbers of emergency nurse practitioners (ENPs) as well as redeploying the current nurse practitioners from underused units. The RCNW asks how the recruitment and training will be managed in practice.
Mental Health Services The plans for improved mental health services are built around proposals to close mental health hospital beds at Cefni Hospital Llangefni, replace inpatient beds currently provided in Glan Traeth in Rhyl and permanent closure of the beds at Hafan Ward (Bryn Beryl Hospital) and Uned Meirion (Dolgellau and Barmouth Hospital) by strengthening community mental health teams to provide longer hours of service as well as support to patients in care homes. The RCNW says that this plan will require investment in increased staffing levels and the nurse liaison service.
Medical Recruitment The RCNW believes that as yet there is not a robust plan to develop the “other skilled healthcare professionals” and development of advanced practitioner roles would require investment of time and funding – and the challenge will only increase with the closure of some of the specialist services.
Neonatal Care Neonatal care across Wales has been an area of concern to the RCNW and urgent progress is needed. In this context, the RCNW is disappointed that rather than developing its services, BCUHB prefers to outsource all longer term neonatal intensive care to Arrowe Park Hospital. The RCNW opposes this proposal because: » Arrowe Park offers a very similar, rather than better, level of care to North Wales » There is additional clinical risk to babies in longer travelling times » Neonatal transport services in Wales are not 24/7 and this plan would increase pressure on them » There is a financial and emotional burden on families in travelling to the Wirral » Losing this service jeopardises the whole provision of neonatal care in North Wales » There a longer-term financial risks in outsourcing a service to English providers. The RCNW recommends that a development plan for neonatal services including investment in training, options for rotation and secondment, and extra support from the Liverpool Women’s Hospital are explored.
Transport Travel in a large rural area is an enormous challenge and BCUHB acknowledges that it needs to improve transport, but the plans for emergency transport via the Welsh Ambulance Service NHS Trust needs to be very robust and adequate plans have not yet been developed either in general or for the 24/7 emergency medical retrieval service.
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Royal College of Psychiatrists in Wales (RCPW)
The RCPW supports the move towards community rather than inpatient care, but wants to know how sustainable 24-hour emergency mental health care will be provided. [This submission is the same as the one from the National Specialist Advisory Group – Mental Health] (ORS)
Physical and Mental Health Care The RCPW supports the move towards community care with less reliance on in-patient models and believes the new approach will facilitate the integration of physical and mental health, but the strategy document does not make clear how better integration will be achieved with local authorities, third sector and the criminal justice system.
Specialist Mental Health Services Inpatient care is increasingly reserved for people who are very unwell and/or have highly specialised needs, but the plans for this specialist area are not specified; and it would be helpful to learn of the proposals to deliver a sustainable 24-hour emergency mental health service.
Workforce and Academic Linkage Recruitment for therapists, pharmacy and psychology is strong in Wales and perhaps these professional groups could take on newer extended roles. The RCPW would like to know how BCUHB plans to improve the psychological skills of all its workforce and develop a tiered approach to psychotherapies. There is a need to plan for the likely retirement of 30% of the senior mental health nursing workforce. There is scope for further developments with academic and professional training bodies.
Estates Mental health services should be provided from buildings of equivalent standard to high quality primary and general health care.
Wales Deanery (WD)
The WD says it is important for BCUHB and the Deanery to work together. (ORS)
The WD refers to its reconfiguration proposals for postgraduate medical training in Wales in the context of the challenges in training which directly affect service delivery and says that it is essential that BCUHB and the Deanery work together to reach models which are complimentary.
National Clinical Forum (NCF)
The NCF supports the proposals since they will aid the development of quality, sustainable services for North Wales. The review should have been even wider in also including an examination of the sustainability of other specialist services. The NCF supports as much care in the community as possible, but it is crucial to develop community services before reducing inpatient care. (ORS)
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Introduction The NCF’s response is 22 pages in length, including three appendices, and is in two parts: comment on the specific proposals and a summary of issues arising in the context of generic evaluation criteria based on clinical delivery potential. The Forum appreciates that public acceptance of some plans is difficult, but feels that its role is to concentrate on the clinical feasibility and sustainability of the service plans.
Criteria for the Evaluation of Service Reconfiguration Plans The key evaluation criteria are » Are the aims and objectives SMART (specific, measurable, achievable, realistic, and timely)? » Do they specify what is to be achieved? » Will it be possible to measure whether or not the objectives are being met? » Are they attainable? » Can they be realistically achieved with the resources you have available? Do they show value for money/ cost effectiveness? » When should the objectives be met? Has a timescale been set out?
Pre-Consultation Engagement with Betsi Cadwaladr University Health Board In early discussions with BCUHB, the NCF focused on the importance of future workforce sustainability, concerns about relying on trainee and ‘middle-grade’ doctors to provide a significant contribution to services, and the need to reconfigure service in a number of important areas. Whilst Forum members supported the general concept of moving services into the community wherever feasible, there was concern over how that might be achieved and the changes in community care infrastructure that would be required.
General The initial response of NCF was that this consultation was limited to only part of the whole healthcare service when it had been assumed that there might also be consideration given to secondary hospital- based services. Within the scope of the consultation document, the NCF supports the principles underlying the proposals. The urgent need for change is not confined only to this area of Wales, but is a challenge to all of Wales, and the UK as a whole. Therefore, the NCF supports BCUHB’s the ‘direction of travel’, subject to on-going work on the sustainability of some specialist services.
Enhancing Care in the Community The NCF fully supports providing as much care in the community as possible, but it is vital to develop community services before reductions in inpatient care occur. It is important that services are ‘pulled out’ by the new care pathways available, rather than being ‘pushed out’. In this context, it is important to ensure adequate staff and training and there may be issues to clarify about governance and the chain of responsibility for individual patients.
Hospitals in Our Communities The NCF supports the principle of identifying hub hospitals to provide quality care and the network proposed seems sound, providing patient journey times are as described. The NCF believes the long-term care of the population will be better served by the proposals as presented and support them.
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The NCF supports an all-Wales strategy to improve emergency patient transport and inter-hospital transfers.
Minor Injuries Services While appreciating the convenience for patients of widespread minor injury units, the NCF supports the proposals on minor injuries services, in the context of the development of hospital hubs.
X-Ray Services The NCF believes that the proposed sites for X-Ray provision are appropriate as a balance between accessibility and optimal activity.
Other Changes Subject to the assurances BCUHB has provided about travel times, the specific proposals for a number of areas and communities are reasonable in the context of the quality and sustainability of clinical services.
Older People’s Mental Health The NCF welcomes the proposals to strengthen community mental health services, but reiterates the training requirements and timescale issues which must be considered in the implementation of the changes. It also welcomes the proposals to liaise with social services and the third sector. The NCF supports the moves towards the integration of mental health within holistic care rather than isolation and supports the proposals to concentrate inpatient care on more ‘general’ sites.
Neonatal Intensive Care Services In such a specialised area of care as neonatal intensive care, there is a need to ensure a ‘critical mass’ of activity both in terms of facilities and staff to provide a high quality sustainable service. Given the small number of the babies born in North Wales requiring intensive care, it is hard to see how that ‘critical mass’ could be achieved. Therefore the NCF supports the proposal for these services to be provided by a larger unit, such as Arrowe Park Hospital, as a safe and sustainable solution. Assurances are required on the arrangements for families with regard to travel and accommodation.
Vascular Services The NCF supports the proposal to concentrate complex vascular surgery on a single site – on the basis of the need to maintain expertise and a ‘critical mass’ in this complicated field of surgery. The single site should be chosen on grounds of co-location with key investigative and supportive services, and transport and transfer arrangements must be robust.
Equality Impact Assessment The NCF would like to be assured that the planned changes had been ‘rural proofed’ in line with the recommendations of the Institute of Rural Health.
Implementation of Proposals The NCF believes the timescales seem reasonable, but there are some concerns over how long it will take to recruit and train staff for the move to the community. These are issues that need to be addressed as part of the implementation process for the proposals. There are concerns over the future availability of GPs, given the number of retirements and shortage of trainees. Close collaboration with professional bodies and the Postgraduate Deanery during the implementation phase will be important.
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Results of Evaluation Criteria The NCF uses a set of evaluation criteria against which to assess service plans. The main outcomes of the assessment are summarised below, with the various criteria as headings.
Access and integration of services Greater integration between specialist, general and community services will be required – and the current primary care arrangements will need to be assessed and prepared if they are to accommodate such change. This is a challenge for implementation and requires work to ascertain the extent of staffing and training needs. The service configurations will provide timely and appropriate access to care: it is important to temper closeness against the appropriateness and quality of care that will be provided. Consideration needs to be given to access to specialist services. The plan is based on clinical need rather than the current estate configuration. There is recognition of the need to provide quality efficient services with a critical mass to ensure sustainability. The issue of rurality is clearly identified in the document and further consideration will be needed during implementation of changes. Recruitment of GPs to work in rural areas is difficult and close collaboration with the appropriate professional bodies and Deanery will be needed during the implementation phase. Travel times have been ‘mapped’ and show acceptable accessibility. Work will need to be done with the Ambulance Trust and the third sector to reduce any adverse impacts of the changes. An All-Wales plan is needed for emergency transport and transfers, particularly for rural areas. The plan is ‘patient-centred’ and the use of community hubs to provide a range of investigations and services will reduce the need for acute hospital attendance. The transfer of neonatal intensive care to Arrowe Park will have transport and accommodation issues that will need to be addressed as part of the implementation process. There has been collaboration with adjoining Health Boards. There has been close working with Hywel Dda HB over the future structure and function of Bronglais Hospital and any consequences of ‘onward’ transfer. The plans also acknowledge the importance of working with local authorities and the third sector. This will be one of the challenges faced during implementation, in particular with regard to support services such as care homes and domestic care. It is recognised that there will be cost implications but these are countered by savings in the rationalisation of some aspects of service delivery. There will be a need within the implementation phase to assess the staffing and training needs of staff in the community. There may also be financial implications in the greater amount of staff travelling within the community. There are good examples of pilot work to support improved care delivered in the community, but the implementation will need to involve the identification of staffing and training needs for staff in the community. During the implementation, issues of governance over who has ultimate responsibility for an individual patient will need to be addressed.
Workforce The impending difficulties in ensuring the long-term sustainability of some specialist services will need to be considered (though it does not form part of this consultation). There are issues for specialist areas that will require collaboration with relevant Professional Bodies and training authorities to consider the impact.
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The issue regarding recruitment of GPs has been mentioned. There is also a need to assess the overall GP workload as this represents a threat to education and personal development opportunities. It is part of the role of the Postgraduate Deanery to ensure that training plans are aligned with national standards and professional bodies; this is a factor that will influence the choice of training site for trainees. There is a clear recognition that for adequate training, there must be a broad range of experience available and the potential to add rural care experience should be considered. Non-trainee, non-consultant clinicians are in short supply and plans should not depend on their presence in the future. This may be a particular issue for specialist services. The need to identify and satisfy the training needs of current staff has already been highlighted as an important part of the implementation process. The shift of care into the community will require an expansion of the of other healthcare personnel (rather than just nurses and midwives) – for example, therapists, pharmacists, scientists. The timescales looks reasonable though there will be additional work needed as part of the implementation process.
Quality and Safety Providing more care in the community aligns with the ‘dignity strategy’ and compliments the Older Persons Commissioner for Wales’ comments in terms of shifting away from institution-based care. A large part of the proposals centre around providing services in ‘fit-for-purpose community hubs. As part of implementation, consideration will need to be given to ‘out-of-hours’ cover for some facilities. There will need to be work on ensuring appropriate governance in respect of lines of responsibility for individual patients. Improving care in the community and the development of community hubs should increase the potential for prevention and admissions avoidance. However, it will also depend on the staffing levels and their training.
Buildings and Facilities The proposals to rationalise the existing services will entail the closure of some facilities. The concentration of some services into community hubs will allow those hubs to be ‘fit-for-purpose’. It is also encouraging to see development of new primary care facilities. The future role for or the closure of the current community hospitals is covered.
Compatibility across Wales The issue of close collaboration with other LHBs and closer links with other agencies has already been mentioned. Given that proposals for other LHBs are still under development, it is not possible to assess how BCUHB proposals will align.
Key Conclusions The issues on which the NCF has concerns mainly relate to the implementation of the changes, not to their underlying principles or the general direction of travel. The NCF supports all the following: » Shifting care, where possible, from a secondary care setting into the community is supported and aligns with current thinking on best practice
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» The development of community hubs to co-ordinate care is an appropriate proposal and is supported » The future role of current community hospitals (including their closure or changes to their function) » The arrangements for the rationalisation of Minor Injuries and X-Ray Services are supported » The proposals for the Blaenau Ffestiniog, Rhyl and Prestatyn, Llangollen, Flint and Tywyn » The proposals for Older People’s Mental Health both in terms of the community and inpatient changes » The proposal to provide Neonatal Intensive Care at Arrowe Park Hospital » The establishment of a single site for major vascular surgery. The NCF also concludes that: » The shift of care will require a great deal of change in the workforce and training of staff working in the community – and all this will need to be evaluated » Movement of care into the community will impact on primary care where there are issues of future GP recruitment and training, the need to enhance certain skills, the provision of suitable facilities and governance that require consideration and quantification » There is an opportunity to explore extended roles for a wide range of healthcare professionals – including nurses, midwives, therapists, scientists, and pharmacists » The planned changes in North Wales should be considered in light of how they may impact on neighbouring HBs and other providers. In particular, the strategic role of Bronglais Hospital needs to be explored in tripartite discussions with Hywel Dda and Powys Health Boards. » Accessibility is a key issue in any model of healthcare and patient transport (both elective and emergency) and inter-hospital transfer are issues that impact on all parts of the NHS in Wales. The NCF supports an all-Wales review of these services with a view to the development of a more comprehensive service. » The assertion that the current three secondary care facilities will continue to provide a wide breadth of clinical services concerns the NCF due to the serious workforce sustainability issues in some specialties. This is an all-Wales (and UK-wide) issue and the long-term sustainability of some services will need to be addressed.
Overall Opinion The NCF supports the changes proposed since they will aid the development of a high quality sustainable service for North Wales.
Chartered Society of Physiotherapists (CSP)
The CSP supports care closer to home and sees opportunities for physiotherapists and other health professionals to make a greater contribution within ‘extended primary care teams’; but it says that transport is a key issue to get right. (ORS)
The CSP says it is difficult to comment on reconfiguration plans without financial and workforce details demonstrating the affordability of the plans and that staff are available to deliver them. The CSP supports
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the principle that services should be close to people’s homes and it suggests that mobile physiotherapists will be available to make a positive contribution, particularly when they are able independently to prescribe; but the public needs to understand which services will be available. The CSP strongly supports the wider use of other skilled health professionals, including physiotherapists, to managing the risks of any shortfall in medical staff and believes this is an opportunity for the Health Board to consider using consultant AHPs and advanced practitioners. Transport is a key issue to get right where services are centralised – both for patients required to travel further for major trauma and surgery, who will need a fully-funded and accessible air ambulance, and for people more routinely accessing services locally and going to specialist centres. Repatriation should be a key part of planning and tele-medicine should be a norm, for clinicians and their patients. Transport issues will also have to be addressed for staff, particularly in relation to access in emergencies. It will be essential for BCUHB to work with local government and the independent and voluntary sectors to address transport issues. To prevent chronic conditions developing, early access to musculosketal services in primary care is important. Physiotherapy and other therapies should be seen as the ‘extended primary care team’ with a contribution to health promotion and ill-health prevention; and reablement is an important aspect part of enhanced care at home. Patients with mental health problems should have access therapists with specialist mental health expertise. The CSP also: » Has some concerns in relation to cross-border service provision with North Powys and looks for reassurance that services will not be adversely affected here » Notes the plans in relation to the delivery of neonatal care services, but does not comment except to say there will be travel issues for family and carers » Considers that more should be done to provide training and support not just for the medical profession, but for all staff: there is a need for robust training and retention policies across all grades and professions.
Hywel Dda Health Board (HDdHB)
HDdHB recognises the need for the modernisation of healthcare services and wishes to work in collaboration with adjoining health boards. (ORS)
HDdHB also recognises the need for the modernisation of healthcare services and supports retaining core services locally, where possible, while enhancing community and primary care. It says the BCU, Hywel Dda and Powys Teaching Health Board should continue to work together to ensure services in North Ceredigion (especially via Bronglais Hospital) support the populations of Tywyn, south Gwynedd and north-west Powys – in particular by establishing a joint Planning Forum for Mid Wales.
Powys Teaching Health Board (PTHB)
PTHB supports BCUHB’s direction of travel and believes the Boards should work with Hywel Dda to enhance joint planning and delivery of healthcare across rural Wales. (ORS)
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Why Services Should Change There is a need to balance the triple aims of population health, improving quality, safety and patient experience and controlling costs in a context of an aging population in a largely rural area. PTHB values BCUHB’s outreach services to Powys residents and wishes to make the best use of new technologies to support the delivery of healthcare and avoid outpatient appointments and unnecessary journeys for patients.
Working with Other Health Boards Powys, Hywel Dda and Betsi Cadwaladr Health Boards should work together to secure equitable access and the provision of comprehensive health care for mid-Wales. There considerable synergy between the approaches of Hywel Dda, Powys and Betsi Cadwaladr Health Boards to community services and the three health boards should enhance their joint planning and delivery of healthcare across north Ceredigion, north Powys and south Gwynedd while recognising the strategic role of Bronglais. PTHB would like any partnership approach to allow for alternative care pathways to be retained for Powys residents into North Wales or England for specialist services, rather than automatically assuming that the pathway of care will be to South Wales. PTHB agrees that in critical situations patients may need to by-pass Bronglais in order to receive specialist by being taken straight to an appropriate specialist centre. For the most rural parts of Powys, the proposed Emergency Retrieval Service will be one of the means by which services will be accessed in critical emergencies and PTHB withes to work with neighbouring Health Boards to support the delivery of this model.
Hospital Hubs BCUHB’s proposals for Community Hospital Hubs in the Dolgellau and Barmouth would mean some changes to the services provided from Tywyn Community Hospital and it is important to work together to maximise the resources shared across this area.
Neonatal Intensive Care Powys needs appropriate access to obstetric and specialist care and PTHB supports BCUHB in ensuring the best possible care for very sick babies, even if this outside of your borders. PTHB wants BCUHB to explore neonatal intensive care options for Powys residents in order to ensure that parents are offered the most accessible option.
Vascular Services North Powys is within the BCUHB catchment of the planned Aortic Aneurysm screening service which means that in time more men will be treated in North Wales. PTHB supports the proposals for a single centre and would like continued dialogue on the best site.
Mental Health Services Powys is concerned to improve the delivery of mental health services to the population of north Powys from BCUHB and is currently considering the options. BCUHB’s approach to older people looks promising and worthy of exploration for Powys residents since improvement is urgently needed.
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Wales Abdominal Aortic Aneurysm Screening Programme (WAAASP)
WAAASP recommends that BCUHB should have a single inpatient arterial site in order to meet professional and training standards. (ORS)
The National Vascular Society of Great Britain and Ireland says that for populations of about 800K a single site model is the best for all vascular work. It is possible to serve such a population using a network to deliver services, but there should be a single inpatient arterial site. With respect to treatment of AAA, the compromise requirement of 33 per year (100 cases over three years) will undoubtedly increase to 50 or more per annum shortly – so units that only just meet the current minimum requirement will struggle to meet the volumes soon to be required. Interventional radiologists have stressed the benefit of a vascular network to facilitate an interventional radiology on-call rota and to improve recruitment and retention; and a single site model may be difficult because it requires moves and alterations in working arrangements. However, there will only be 20 trainees recruited per year and with 17 UK Deaneries bidding Wales is unlikely to obtain a training post unless it achieves appropriate networks – which has major implications for future recruitment and retention of consultants. Therefore the WAAASP believes it best to move to a single site now.
Public Health Wales (PHW)
PHW supports BCUHB’s approach while recognising that further work is required on some issues. (ORS)
PHW broadly supports BCUHB’s direction of travel and believes public health has a significant contribution to make in relation to delivering the proposed changes. Health boards face challenges in delivering enhanced primary and community services in the context of workforce issues and the public health agenda – and it is recognised further work is required on some of these issues. PHW is committed to continuing its support to ensure the successful delivery of the changes outlined.
British Medical Association: Clwyd North Division (BMACND)
The BMACND accepts that the status quo is unsustainable; but it believes the Arrowe Park proposal should be reconsidered in favour keeping level 3 services at Glan Clwyd. It supports centralising vascular emergency survery, also at Glan Clwyd, but is concerned about the loss of community beds and believes some of BCUHB’s planning has been too vague. (ORS)
Introduction The BMACND accepts that the ‘status quo’ is unsustainable, but it believes resources could be used more effectively to care for disadvantaged patients who lack their own transport – though it acknowledges that polices are influenced by political constraints (particularly the desire to keep as much healthcare and funding as possible in Wales) even when some other service options are closer in England.
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The BMACND support BCUHB’s decision to maintain an unselected ‘medical take’ on all three of its DGHs, with A&E departments in each supported by a general surgical emergency service. In this context, the BMACND’s response focuses mainly on neonatal intensive care because it recommends that BCUHB should change its current recommendation.
Neonatal intensive care The BMACND believes that there is a widespread professional view that level three neonatal intensive care should remain in North Wales (at Glan Clwyd) and it recommends that the Arrowe Park proposal should be reconsidered. The BMACND says that: » Neonatal care in North Wales in not currently unsafe » Arrowe Park is not a level 3 neonatal unit and provides a lower standard of care than is currently available in North Wales » There is no evidence that Arrowe Park would improve neonatal outcomes and care there might be inferior » Arrowe Park has worse neonatal nursing ratios than Glan Clwyd » Evidence suggests that both in-utero and ex-utero transfers from the Llyn Peninsula to Arrowe Park could increase mortality rates; and there would be stress for families by being so far from home » The estimated bed days and costs of providing neonatal care at Arrowe Park could be a grossly underestimated; and in general, the costs of transfers and care to England are underestimated » The number of patients transfers has been underestimated (because for every baby delivered there are other women transferred with threatened pre-term labour that settles after several days or weeks or who might require pre-term delivery) and the actual number could be twice that estimated » There are ambiguities in the document about the scope of the transfers – will only extreme premature babies (27 weeks or under) be included or will it encompass all neonatal intensive care regardless of gestation? » Neonatal intensive care is not unsustainable in North Wales: Glan Clwyd has an excellent reputation for neonatal care and is an established sub-regional centre; independent reviews have concluded that there should be a single level 3 unit at Glan Clwyd; there are now capital costs in providing neonatal intensive care at Glan Clwyd; and support accommodation for families away from home is provided already » Both Bangor and Wrexham should run level 2 units in order to keep capacity and avoid the transfer out of Wales of non-intensive care babies » Glan Clwyd currently receives core trainees in neonatology, but these would cease; and trainees on rotations to Merseyside would expect to rotate to the Mersey Regional Level 3 Unit at the Liverpool Women’s Hospital and not Arrowe Park » The Arrowe Park proposal could compromise the ability to provide level 2 care by having detrimental knock-on effects » Welsh money should not pay for improvements in healthcare in England when it could help in getting the right staff in North Wales (given positive recruitment policies)
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» There has been investment in services for North Wales previously when national standards showed they were unviable and the same approach should apply to a core service such as neonatal intensive care.
Vascular Emergency / Major Surgical Service. The BMACND agrees that vascular emergency surgery service should be centralised on the same site as the cardiac catheter laboratory, at Glan Clwyd. This could free posts to help maintain general surgery on-call services across three sites and elective vascular surgery and clinics could continue on all three sites. Glan Clwyd is starting to upgrade critical and intensive care facilities, which are essential for these serious vascular cases.
Community Hospitals The BMACND is concerned that too many beds have been cut in North Wales, already – as evidenced by the queues of ambulances outside all three A&E departments and the frequency of alerts of bed shortages. Enhanced care in the community is supported in principle, but it is unclear whether the resources are available to make it an effective means of delivering safe high quality services. Nurses staffing minor injury units often perform other functions (setting up clinics for visiting secondary care consultants, phlebotomy, ECGs and other senior nursing roles) that complement primary and secondary care – and these roles may be lost as a result of closure of these units.
Older People’s Mental Health Services The BMACND is concerned about bed closures and the care of vulnerable patients being compromised. In this context, BCUHB’s plans are too vague for the BMACND to comment fully; but it is hoped that further discussions will take place.
Welsh Ambulance Services NHS Trust (WAST)
The WAST believes that BCUHB’s general strategy is correct, but wants to see more detailed service models and information on funding to meet additional costs. (ORS)
Strategic Level The WAST supports BCUHB’s strategic direction towards providing a greater range of care in the communities and recognises there is a potential to change services to improve the quality and outcomes of the services provided.
Operational
Cost and Funding WAST is unable to estimate the additional costs or savings, but the proposals will require additional resources to be made available to the Trust to support additional job cycle time, patient journeys, transfers between hospitals, repatriations, by-pass arrangements to centralised services, air ambulance, and up- skilling the workforce. Detailed discussions will be need to determine the level of additional resource required. In principle, WAST can support a wide range of service models, but funding would need to be made available in advance of the changes to any services.
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Closure of MlUs at Blaenau Ffestiniog, Colwyn Bay, Ruthin, Longollen, Fling, Mold and Chirk There could be a consequential reduction in ambulance response times due to increased calls and job cycle time. There will be a need for additional Advanced and Specialist Paramedic Practitioner Practitioners to compensate for the loss of MIUs; but clinical pathways and protocols will be required for GP-led services and for sites without MIUs. Overall, the public may use the ambulance service more frequently if they cannot go to their local unit. Seven MIUs cannot be closed without sufficient investment in alternative pathways.
Opening of an MIU at Deeside A clear referral procedure will be required to ensure that appropriate patients are referred to the new MIU by Trust crews in NHS Direct Wales. The provision of Advanced Paramedic Practitioners staff as part of the staffing of this new unit would promote greater integration and should increase the referrals from ambulance crews. The proposal could reduce conveyance to main Emergency Departments in North Wales and Chester.
Virtual Ward Model This proposal could support the improvement in ambulance response times, quality of service and clinical outcomes – so WAST supports the concept, but wants further details. It is important to ensure that information systems support the timely sharing of patient information and that additional referral pathways to refer appropriate patients into the acute teams and centres. There is an opportunity for the Advanced and Specialist Paramedic Practitioners to form part of the Acute Response Team, supporting patients in the community and avoiding admissions.
Transfer of Level 3 Neonatal Services This change will require the Trust to convey unwell children to the Arrowe Park and clear clinical tools will be required for this to be effective, safe and reduce variation. Trust crews will need immediate access to the two sites and the use of Helimed/Critical Care Service may increase. Staff within centres without Paediatric Services will require clear guidance on the type of ambulance to request for children requiring transfer. This will need to be in terms of clinical acuity and speed of response.
Single Site for Emergency Vascular Surgery Joint agreed guidelines are required for conveyance to the specialist centre. Staff requesting the transfer of a patient from a BCU hospital to the Vascular Centre will require training to ensure that ambulance requests for transfer are made with the appropriate priority both in terms of clinical acuity and speed of response. There will be a potential increase in the job cycle time; however further modelling will be required following analysis of patient flows.
Critical Care Transfer and Retrieval Service There is a potential for improved performance against Health Care Professional transport requests and clinical outcomes. The introduction of the Critical Care and Retrieval Service will establish an advance clinical service within the Trust, with Critical Care Paramedics (CCP) who will develop to "M" level status after training. Overall, there is an opportunity for the Trust to provide specialist staff to undertake the treatment of severely injured or unwell patients at incident scenes and to co-ordinate their transfers to specialist care.
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Older People’s Commissioner for Wales (OPCW)
The OPCW expresses some concern about the consultation process. (ORS)
The OPCW received representations from older people in respect of Flint and Prestatyn Community Hospitals and the BCUHB consultation process – and in response the Commissioner is concerned about the apparent: » Incomplete distribution of the consultation leaflet » Requirement to register to speak at consultation events » Requirement to pre-register for public meetings and the restriction to 50 people per session » Exclusion of some people from public meetings on the grounds that there were no spaces left » Failure to listen to older people.
Community Pharmacy Wales North Regional Committee (CPWNRC)
CPWNRC does not commend directly on BCUHB’s proposals, but supports the transfer of more care into the community and urges a bigger and more positive role for community pharmacies and “healthy living centres.” (ORS)
Community Pharmacy must play a critical role if BCUHB is to address future health and social care challenges. The NHS is not simply a service by doctors and nurses, but a multi-disciplinary service, and pharmacists are increasingly vital front-line providers, both as experts in the best use of medicines and as primary care campaigners and educators. Pharmacists are qualified, highly trained healthcare professionals who can provide a wide range of front line services that go beyond basic medicines dispensing, important as that is to patients. Indeed, some pharmacies elsewhere in the UK already offer services traditionally carried out in outpatient clinics, such as blood tests for patients on warfarin, which are more cost effective for the NHS and more convenient for the patient. BCUHB should put pharmacies at the forefront of tackling many current challenges, from the scandal of wasted medicines to the fight against sexually transmitted diseases. CPW is a willing partner in wishing to improve public health and is committed to working with the BCUHB to ensure that the community pharmacy network responds positively. Indeed, Community Pharmacy should be pivotal in rebalancing services toward prevention and early intervention – to help people change negative lifestyle their habits. Therefore, BCUHB should ensure that full vascular risk assessments and advice and support services to stop smoking/reduce alcohol/manage weight are available in every community pharmacy. Community pharmacies can provide advice and support on sexual health to those in both first and established relationships; and they are the provider of choice for Emergency Hormonal Contraception (EHC). If the sexual health needs of the population are to be met, then it is essential that every community pharmacy is able to offer a comprehensive range of sexual health services, including immunisation for cervical cancer, testing and treatment for sexually transmitted infections, the first supply of oral contraception and the treatment of erectile dysfunction. For those with drugs problems, pharmacies can, and across parts of North Wales do, provide clean syringes and needles; and they can, and often do, provide supervised consumption services for clients in treatment.
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Community pharmacy needs to be central to the medicines management regime. Whether it be improving patients` use of medicines, increasing safety in care homes, supporting safe transfer between care settings through the performance of medicines reconciliations, or providing medicines advice and support to other healthcare professionals, community pharmacy is pivotal to ensuring compliance with medicines regimes. Two recent case studies undertaken within the Welsh Chronic Conditions Management Demonstrator sites found that the involvement of community pharmacists and medication reviews does lead to more effective medicines management and has economic advantages. The community pharmacy-based Targeting Medicines Waste service will make the significant contribution to the reduction of wasted medicines. There is also a need for the national community pharmacy-based Discharge Medicines Review service for patients transferring between care settings and for the involvement of community pharmacy in the effective management of medicines processes in care homes In summary, the CPWNRC urges the BCUHB to recognise that community pharmacy could support the agenda in: » Targeted prevention — with pharmacies "re-branded" as “healthy living pharmacies” » Enhanced care at home — pharmacists could support an MUR service to support housebound patients » Movement of care from acute hospitals to the community – by pharmacies freeing GPs’ time by delivering a common ailments service » Minor injuries services – by delivering locally to their patients on common ailments » Older people’s mental health – by flagging patients for earlier diagnosis via referral procedures
Liverpool Women’s NHS Foundation Trust (LWFT)
The submission by LWFT amounts to a formal objection to BCUHB’s proposal to commission services from Arrowe Park without considering LWFT as an alternative provider – with a superior neonatal unit that already provides important services to BCUHB, would not involve significantly different travel times from North Wales, and could provide the services more cost-effectively. (ORS)
Introduction The LWFT comments on the proposal to outsource neonatal intensive care services for about 36 babies a year to Arrowe Park Hospital. It points out that BCUHB has apparently had no formal discussions with LWFT about the provision of these services – which it finds disappointing, given the long-standing relationship between the Trust and North Wales commissioners, and the excellent existing clinical relationships that support the transfer of care for women and babies across our two networks.
Formal Objection In this context, the LWFT formally objections to the proposal to commission from Arrowe Park without considering LWFT as a possible alternative provider, particularly because the Trust believes the current proposals neither provide the best care for babies in North Wales nor the best value for money.
Unit Status and Contractual Arrangements LWFT is the principal Level 3 Neonatal Unit for Cheshire and Merseyside; it provides care to over 1,100 of the most vulnerable babies a year through 54 cots (16 in ITU, 16 in HDU, 14 in SCBU and 6 in Transitional
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Care) and it hosts the Neonatal Transport Team for the region. In addition, the Trust has long-standing agreements for the provision of intrapartum care and Neonatal Intensive Care of other regions and networks, including North Wales, via BCUHB. The contract between LWFT and BCUHB has been in place for some years on a three-year rolling basis and its current value is £400k per annum. In 2012/13, the contract provides in the region of 300 bed-days for Intensive Care and the Trust transfers babies back to their local units as soon as is clinically appropriate.
Staffing, Training and Recruitment LWFT has delivered Level 3 Neonatal care as the principal unit in the region for several decades and remains one of the largest in the country – so staff on the unit have excellent clinical experience and exposure to the most complex areas of neonatology.
Recruitment The Trust has few problems recruiting to clinical posts and all recent adverts for specialist Neonatal Consultant Posts, Advanced Nurse Practitioner Training Posts or Neonatal Nursing Posts have been successfully filled.
Consultant Neonatologists There are 6.8 WTE Consultant Neonatologists dedicated solely to neonatal care – which provides a consultant neonatologist on site at the hospital from 9am until midnight supervising junior doctors and ANNPs, with an on call arrangement between midnight and 9am. Very few Level 3 centres nationally provide this level of resident cover. LWFT is the only unit in Cheshire and Merseyside where all the consultants have accredited sub specialty training in neonatology; and all but one have a post-graduate doctorate (MD or PhD) based on academic activity in neonatal medicine.
Junior Doctors Middle grade doctors have no responsibility for general paediatrics, which is compliant with the BAPM Service Standards. In contrast, Arrowe Park does not meet this standard as there the middle grade medical rota cross-covers General Paediatrics.
Advanced Neonatal Nurse Practitioners LWFCT has an active programme for the education and development of Advanced Neonatal Nurse Practitioners and there are currently 10 WTE Practitioners on the Unit with two in training. This is the largest ANNP group in the NHS.
Nurse Staffing The nurse staffing levels meet the North West Neonatal minimum standards and there is continuous professional development of staff.
Neonatal Intensive Care Provision Survival is improved with increased centralisation of neonatal care for very low birth weight and extremely preterm infants and there may be benefits of concentrating the care of the most preterm babies into a smaller number of units, as the best way to build expertise and improve outcomes. Not all Level 3 Centres are equivalent and survival is higher in centres that care for larger numbers of these babies. LWFT is the principal Level 3 Unit for the Cheshire and Merseyside Network and has been so for many decades. It has considerable experience in treating the most complex, sick and vulnerable babies.
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Maternity Care LWFT delivers over 8,300 babies per year, manages the most complex and high risk pregnancies for women in Cheshire and Merseyside and takes in-utero referrals from across the region/UK. It is the only unit in Cheshire and Merseyside with 98-hour resident Obstetrician cover and it also hosts the regional fetal medicine service – and even provides outreach support to Arrowe Park Hospital. LWFT’s maternity services have had capital investment of £5m over the last two years, with another £5m planned – and this has allowed the refurbishment of the antenatal and postnatal inpatient areas, the development of a dedicated triage, assessment and observation unit, a dedicated induction suite, additional birthing pools and bereavement rooms.
Cost of the Proposal It appears that the current plan for Arrowe Park services will involve costs of over £1M to develop capacity there for 36 babies per year – so the LWFT strongly advises that additional costs, if any, would be incurred if BCUHB built on its existing arrangements with the Trust.
Unit Development and Research LWFT is currently reconfiguring its Neonatal Unit to improve access for the sickest babies to the appropriate level of care, to improve standards and outcomes and to enhance the management and control of infections. The Trust also has a long tradition of clinical research collaboration in most national multi-centre trials and studies. Areas of specific expertise include clinical pharmacology, neonatal nutrition, neuro- protection, neonatal resuscitation, and circulation and family centred care. From March 2013 the Hospital will jointly host the Centre for Women’s Health Research and the Centre for Better Births with Liverpool University.
Parental Accommodation LWFT provides excellent parental accommodation for the neonatal unit, in modern flats immediately adjacent to the hospital.
Location and Travel Times If some neonatal care is to be provided outside of North wales, then proximity is important – so it is relevant that the difference in the journey distance to the Arrowe Park or LWFT hospitals is negligible, especially in the context of the bigger differences in care quality at the two centres. Moreover, the LWFT has an established collaborative approach to clinical care with colleagues in North Wales and across Cheshire and Merseyside.
Conclusion The Arrowe Park proposals have not given due consideration to LWFT as a viable alternative provider that would offer BCUHB better clinical outcomes and better value for money. The Trust is keen to discuss the issues with BCUHB as soon as possible.
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Unison Wales
Unison agrees with BCUHB’s mission statement but urges that changes to services should not be implemented before alternative provision is in place. (ORS)
Introducion Unison agrees with BCUHB’s mission statement, but it needs to be implemented with caution since services must be accessible to all. Unison’s role is not to approve or oppose changes, but to ensure that members of staff are treated appropriately. In general, the experience of members of staff should be given due regard to ensure that reorganisation improves services to patients – which means in practice: » The more staff with health and safety training the better » Staff should have clear, planned goals » Staffing levels are important » Bullying, harassment and abuse against staff relate to many negative patient experiences » Staff views on the confidentiality of patient information are mirrored by patient views of the privacy they are given.
Community Provision None of the changes to the existing service should cease before the service is ready to be delivered in the community because if there is no service in the community when current services cease, then people will suffer. GP out-of-hours should be reviewed alongside the minor injuries proposals. If a patient cannot get a local minor injury dealt with and the only alternative is A&E with a long waiting time then that service has worsened.
Collaborative working Collaborative working between the public services should be properly set up with clear management structures prior to implementation. Staff needs should be properly taken into account.
Neonatal Care WAST believes there are real concerns that transferred babies may be born in England – so, while costs may justify the proposal, the place of birth should be duly considered.
Projects and Lack of Detail Many of the changes are dependent upon funding bids made (or to be made) to the Welsh Government and there is no mention of what would happen if these are not approved, nor the effect if only some are funded. There needs to be fully completed Equality Impact Assessments, both for patients/carers and staff.
Responsibilities of and to the public UNISON absolutely agrees that people should not take the NHS for granted, but this principle should not be used in the future as to legitimise restrictions on care for those deemed "irresponsible" (for example, drinkers, smokers and the overweight). The NHS needs to remain a universal comprehensive service. Wales should avoid the current English model of personal health budgets – Unison wants personalisation, but
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without personal budgets. Information available to the public locally can vary, so consistency of information, suitably accessible should be a key objective.
Key Submissions from Local Authorities and Statutory Bodies
Conwy County Borough Council (CCBC)
CCBC supports the centralisation of some specialist services, including vascular services at Glan Clwyd, but questions the Arrowe Park proposal. It is particularly concerned that services at Colwyn Bay hospital are retained in full and that community services should be well established before any current services are withdrawn. It is not confident that enhanced community care can be successfully delivered. (ORS)
Budget and Resources CCBC believes that the consultation document is unclear about how all its proposals will be resourced. It is unsatisfactory to treat resources as a secondary issue and doing so weakens confidence that the proposed services are deliverable and sustainable. It is unclear how community care will be delivered and there is no acknowledgement of the need for recruitment and staff development plans. CCBC considers that additional funding will be required from the WG following implementation of the proposals. In any case, the council’s social services department will not accept any transfers of services from BCUHB until there has been full consultation and agreement on budgets.
Colwyn Bay Hospital The proposal to alter services at Colwyn Bay hospital is of particular concern and CCBC would like to be assured that all its services will be retained in full.
Llandudno Hospital Whilst this consultation does not propose changes in relation to Llandudno Hospital, CCBC is concerned that promises (made by the a Minister for Health) that Llandudno hospital will become a centre of excellence for breast cancer care are not being fulfilled.
Administration on Protected Salaries Following the creation of BCUHB, there are senior administrative and managerial staff with salaries, protected for 10 years, that exceed their current responsibilities. It seems untenable for protected salaries to be paid at the expense of health services and so BCUHB and CCBC should lobby to remedy this situation.
More Detailed Responses The CCBC submitted a more detailed response with 978 letters of concern from local residents. The issues raised in the more detailed response were as follows.
Enhancing Care in Communities Weaknesses in community care have been highlighted and CCBC is concerned that services need to be well established before any current services are withdrawn. The council is also worried about the financial implications for CCBC’s social services budget and wants written assurances that these fears are unfounded. What investment will there be to support health visitors and the Welsh language as a priority?
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There are clear challenges for the health visitor service. A more “homely approach” to care can only be achieved with a multi-agency framework understanding and funding with clear responsibilities. The development of educational programmes for patients is critical and should be a key priority of the Health, Social Care and Wellbeing Strategy. Enhanced care at home needs investment and negotiation with social services to ensure its success. There are concerns that responsibilities will be transferred to social care, with the distinction between social and health needs becoming less clear. CCBC does not support these changes without an acceptable investment plan. The Council would also like assurances that the Health Board has taken into account future population and need projections. The out-of-hours GP service is not fit for purpose and GPs seem reluctant to engage with the proposed model of care. Will it be possible to recruit sufficient staff for enhanced care at home?
Hospitals in Communities CCBC supports community hospitals as important for care in the community and asks if the Health Board has considered investing in Colwyn Bay and Llandudno hospitals? There is likely to be more demand for a minor injuries unit in Colwyn Bay and the hospital has an important role in reducing travel to more distant hospitals. Both Glan Clwyd and Ysbyty Gwynedd are experiencing blockages in their A&E departments, which has a knock-on effect for the North Wales Ambulance Service – and in the context of GP opening and appointment times closing the MIU at Colwyn Bay would create more of a bottleneck at Ysbyty Glan Clwyd. The Health Board proposes further investment in Llandudno hospital, but CCBC believes the money would be better spent at Colwyn Bay – indeed, Colwyn Bay hospital should not only be retained, but developed into a hub. There is enormous local support for the continuation of the MIU at Colwyn Bay.
X-Ray Services BCUHB’s general approach is welcomed, but consideration needs to be given to the X-Ray units’ opening times and there are concerns about the withdrawal of X-Ray services at Colwyn Bay, which will increase pressure at Glan Clwyd and Llandudno hospitals. As a minimum, the X-Ray units should reflect and complement the opening times of GP surgeries.
Older people’s mental health Considerable joint planning will be needed to ensure a range of services are developed to meet the degrees of dementia since dementia care is not only a primary care concern. There is a need to develop modern and innovative nursing and residential care solutions for people who cannot stay in their own homes, but it is unclear how the Health Board will invest to develop more mental health services for all dementia sufferers. It is unclear how the Health Board will support the increased responsibility placed on GPs and community support services, such as enablement and domiciliary care, and so far CCBC does not consider that BCUHB has engaged sufficiently with its local authority partners.
Neonatal intensive care services CCBC accepts that some specialist services need to be centralised to ensure critical mass, but it questions whether centralising on one site will adversely affect recruitment to the other sites. It also questions whether consideration has been given to: the transport of babies; standards at Arrowe Park and whether families and Welsh speakers will be well catered for there. Overall, CCBC asks for information on BCUHB’s plans for medium and longer term neonatal services in North Wales.
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Vascular services CCBC proposes that vascular services are centralised at Glan Clwyd due to its central position; but the council also asks about: the potential impact on members of the public who lack personal transport and find public transport unaffordable or inaccessible; the recruitment of key staff; and investment plans.
Finance CCBC appreciates the financial supplementary table that was made available in early October, but urges the Health Board to share more detail about investment in the context of deficit projections for the next five years. Two areas in particular cause the Council concern: the estimated cost of £4,252 million seems inadequate for a properly resourced enhanced care model across North Wales; and whether level of the Health Board’s investment in nursing care beds for patients.
Denbighshire County Council (DCC)
DCC is pleased that three DGH sites are being maintained while accepting the need for specialised services to be concentrated on fewer sites, including vascular services at Glan Clwyd; but it doubts the need for outsourcing to Arrowe Park. It broadly supports most of the proposals for community hospitals, but emphasises that existing facilities should not close until new services are properly in place. (ORS)
Localities and Community Services DCC agrees that the current pattern of services needs to change and that people usually want to be cared for at home when possible. It supports the concept of “hospital hubs” with a wider range of services available more locally, but the “the devil is in the detail” and the council seeks reassurance on some points and wants to see detailed implementation plans, with full local authority involvement in developing and monitoring them. BCUHB should commit to full engagement with a Local Authority/BCU Strategic Group to oversee implementation of the changes and to have budget-holding responsibility, appropriate governance arrangements, and accountability to both the local authorities and BCUHB. Such as Strategic Group could be a revised Health, Social Care and Wellbeing Partnership to cover Denbighshire alone or be joint across Denbighshire and Conwy. Meanwhile, the key areas on which DCC wants reassurance are that: » Existing services will not be stood down until the planned alternative services are in place » Financial aspects of the proposed changes will work in practice (including how investment in community services will be achieved in a three to five year period) » Primary care and community services will manage the increased workload (given the delays to GP appointments and recruitment difficulties) – for example, if not all GPs sign up to deliver enhanced care services? » Resources will be managed to avoid increasing pressure on social care services unduly » BCUHB can provide the investment required to open the new North Denbighshire and Llangollen community based facilities by 2015 » There are resources for health promotion in each locality » Investment can be managed in a balanced way – to prevent the scale and urgency of changes for older people eclipsing investment in children’s community health services.
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Rhyl and Prestatyn DCC believes that the choice of the Royal Alex as the site for the North Denbighshire community facility could play an important role in the regeneration of Rhyl and the council would like to be involved in how to conserve the key architectural features of the Grade II listed building while making it fit for modern healthcare provision. Meanwhile, the council asks how the proposal for 30 beds for the North Denbighshire facility has been calculated and suggests that the timetable for opening by 2015 is too optimistic. In any case, Prestatyn Community hospital should not close before other services are in place.
Ruthin and Denbigh: Location of Hospital Hub The Council is pleased about the future assured for Ruthin Community Hospital, but remains concerned about why additional available beds are not to be provided there, and about the re-opening of the day hospital. GPs in Ruthin believe that X-Ray services are essential to support both the orthopaedic and elderly beds. DCC is pleased that Denbigh Infirmary is likely base for a Hospital Hub because Ruthin hospital is rather isolated and the range of services and facilities at Denbigh Infirmary makes it the better option. However, the council would like to know the costs of maintaining both Denbigh Infirmary and Ruthin hospital; and it believes consideration should be given to creating a “joint hub”.
Llangollen DCC understands the proposals for Llangollen Community Hospital and is supports the redevelopment of the River Lodge site (though it is not ideal as the access for pedestrians and non-car owners is poor), but the council believes existing facilities should not close until alternative services are in place. The council is also concerned about wider public access to facilities after the closure of Llangollen Community Hospital, particularly for those without a car in the Upper Dee Valley. There should be a detailed Transport Strategy to match the new pattern of services and also an explanation of how services will be available through the medium of Welsh. The council strongly supports GPs providing a minor injuries service and it also supports commissioning beds from the independent sector in the Dee Valley (to complement enhanced care services) and the provision of inpatient beds at Chirk hospital – but re-ablement should be encouraged and the use of nursing /residential home beds should not increase long-term admissions to institutional care.
Pressure on Carers
There should be greater focus on carers, including access to respite services, information, advice and signposting. The council would like to see costed proposals for enhancing carer support included in the implementation plans for each locality – probably developed on the back of the Regional Carers’ Strategy, linked to the new Carers’ Measure; but proposals would need to be local and specific. The care that patients and carers receive on discharge from hospital should be suitable, and carers’ assessments should be done before every discharge.
Communicating with Communities It will take time for people to get used to the new patterns of services and so efforts should be made to communicate with local communities about new services.
Older People’s Mental Health The council supports proposals for early intervention and early diagnosis, crisis prevention, improved care in care homes, allowing/supporting people to remain in their homes and a reduction in reliance on acute
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hospitals. But DCC would like to see a more comprehensive account of how the implementation of these changes will affect older people with mental health problems, their families and their carers. Once more, new services should be in place before rationalising inpatient beds, especially at Glantraeth.
Maternity, Gynaecology and Neonatal Services plus Paediatric Services The Council is pleased that there will be investment in community child health and health promotion services and that most acute services in these specialisms will continue to be available from all three District General Hospital sites. Changes in community child health and paediatric services should take place in partnership with local authorities and involve multi-disciplinary teams, working across health, social care and education to meet the needs of children with disabilities/troubled children and their families. The contribution of mental health, substance misuse and disability service, and the corporate approach to domestic abuse issues, should be more joined up. The Council accepts the need for specialised services to be concentrated in fewer sites – providing that transport issues are fully considered and worked through.
Neonatal Intensive Care Services Ideally, neonatal intensive care should be available in North Wales, at Glan Clwyd, but providing that Arrowe Park meets required standards and represents good value for money, it is a reasonable solution. Transport difficulties need to be mitigated and consideration should be given to how services will be delivered through the medium of Welsh. More generally, the council is concerned that staff skills in North Wales in Special Care Baby Units and neonatal care will be maintained so that staff will still be attracted to work in this area and care for most babies can continue to be delivered locally. Overall, the council would like further information to compare the costs and merits of a North Wales and Arrowe Park service.
Non-elective General Surgery The council is pleased that aspects of elective and non-elective general surgery will remain at the three District General Hospitals, but it also accepts the need for centres of excellence and increasing specialisation. It emphasises the importance of appointing staff to maintain non-elective general surgery at Glan Clwyd hospital.
Trauma and Orthopaedic Services The council is pleased that trauma and orthopaedic services will be retained on each of the three DGH sites, but also accepts the need for more specialised services to be organised on a regional and networked basis, on the assumption that transport issues are addressed. Expansion of these services will lead to greater demands on community and local authority service for equipment, adaptations and therapy services – so detailed implementation plans are needed to ensure that the whole care system is resourced.
Vascular Services The council supports Glan Glwyd as the major arterial surgery site. It recognises the need for specialisation, but would like more information about: the impact on patients and families in terms of safety and travel; and the viability of a one-site model.
Transport Transport is an integral aspect of the changes proposed by BCUHB and is particularly important for older people, people with disabilities, and people from areas of deprivation where car ownership levels are
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lower. Currently, though, transport does not work well: the Welsh Ambulance Service Trust (WAST) criteria are strict and take little account of rural issues; and people are often referred to community transport without considering whether that sector is able to provide the required service. The required more flexible approach to transport is likely to be costly, but there are no costs for transport in the current assumptions, whether for WAST or for other forms of transport provision. This is a major omission and BCUHB must draw up detailed transport plans to support the delivery of future care models.
People with learning disability DCC wants confirmation that the Liaison Nurses (at each of the DGHs) will be made permanent posts so that people with learning disabilities will be supported. Staff of both acute and community services will need to develop skills in providing healthcare for learning disabled people.
Gwynedd County Council (GCC)
GCC recognises the need for change and welcomes the change of emphasis form acute hospitals to community care – while saying that the new approach will need improved joint working with local authorities and the third sector, finding strengths and weaknesses in proposals for local hospitals, and stressing that changes should not be implemented until new services are in place. (ORS)
Introduction GCC recognises the need for change even when achieving it difficult due to loyalty to current local services. It accepts that the present situation is not sustainable and believes BCUHB should continue its efforts to convince people of the need for reform.
General Principles GCC welcomes the change the emphasis from acute hospitals to the home and community care – while recognising that the new approach will require improved joint working and partnership with local authorities and the voluntary sector. The preventative agenda is welcomed and also requires inter-agency co-ordination. However, the consultation document does not detail the full business and funding options for the proposals, and it is unclear how transport assistance costs will be met. Gwynedd’s rural nature presents particular challenges with financial implications. The council welcomes the coming collaboration between Hywel Dda, Powys and BCU Health Boards as an opportunity to ensure a better co-ordination of services.
Issues Relevant Gwynedd The proposals to move services from Bryn Beryl, Blaenau Ffestiniog and Tywyn hospitals to ‘hub‘ hospitals in Dolgellau and Alltwen is contentious in those areas and raises concerns regarding continued services local for the future. The council asks for a ‘vision’ to reassure communities who are losing services as part of the present proposals. The council welcomes the proposals to strengthen Dolgellau, Alltwen and Ysbyty Gwynedd Hospitals. Regarding the proposals to close Hafan ward, Ysbyty Bryn Beryl and Meirion Unit, Dolgellau, there is concern that there are no arrangements in place to support the people affected to live in the community. The council asks BCUHB to keep small units of up to four beds in the two areas to expedite family care.
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Gwynedd carers have concerns – primarily about whether additional support will be available and in place before the changes are implemented, how problems of recruitment will be overcome and what travel provision there will be. Regarding the emphasis on helping people to live at home, the council wants to be assured that BCUHB will shoulder the financial burden no costs will fall on the council. Blaenau Ffestiniog is a deprived area and the proposal to remove beds and the minor injuries unit seems likely to be increasing the health inequalities that already exist – so the council opposes the closure of the Memorial Hospital.
Conclusion The Council accepts the need to modernise services and is keen to collaborate with BCUHB to win the trust of Gwynedd residents and ensure sustainable services for the future, but it asks that changes are not implemented until new services are in place or plans approved and financed.
Flintshire County Council (FCC)
FCC broadly supports the Arrowe Park and vascular services proposals, but urges BCUHB to withdraw all its proposals because, although strategically sound, they lack proper planning. (ORS)
Introduction FCC recognises the need to change some services and supports the principle of providing primary and community services close to people’s homes, but the council is concerned over the financial sustainability of the proposals and how BCUHB will ‘balance the books’. For example, how will investment in community services reduce reliance on hospital admissions? The council criticises the requirement to pre-book places at the scheduled public meetings because it seems to have limited access and some towns did not have dedicated local meeting.
Older People’s Mental Health Proposals to strengthen older people’s mental health service in the community are cautiously supported, including the transfer of resource from some inpatient beds (for example in Rhyl) to community care services. However, reassurance is needed that the needs of carers in a crisis will be fully addressed.
Neonatal Intensive Care Services FCC supports the Arrowe Park proposal providing: suitable transport is provided for babies and parents, with free family accommodation; treatment is available for mothers as well as children; and the services meet national standards.
Vascular Services The council accepts the proposal in principle provided transport facilities are acceptable and that patients will return to their local hospitals as soon as possible.
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Community and Enhanced Home Care FCC supports preventing of illness through community-based interventions and the intention to work closely with social services. It also supports providing services closer to home as a general approach, but its concerns are that: » The full costs of the service are met by BCUHB (with no cost transfer to local authorities), including not only care package costs, but also professional interventions and equipment and adaptations » GPs are committed to the model » BCUHB can sustain the cost of the service and will enter into discussions with the council development of the service.
Hospitals in the Community Due to the increasing number of elderly people and housing development plans, the council doubts that Flintshire can sustain a reduction of 14 fewer community hospital beds (resulting from the closure of Flint hospital). The council needs more information if it is to understand the proposed configuration of services.
Hospital Hubs/ Minor Injuries Unit/ X-Ray Services In principle, FCC supports having consistent services at local hospital hubs and locally-delivered minor injury units, which should be developed further in the light of Flintshire’s size and growing population.
Flint The Council is not convinced that Flintshire can lose 14 community hospital beds and BCUHB has not convinced Flint residents that the Primary Care Centre would compensate for the loss of community hospital beds and an accessible minor injuries unit.
Mold The proposal to remove minor injuries services from Mold has no regard to Mold’s status as a transport hub and the business case has not been explained. It would make sense to retain Mold’s minor injuries unit and X-Ray facilities since it is equipped and would not need a big upgrade.
Deeside The council supports Deeside’s status as a hub and the proposals to strengthen the services provided there.
Transport The proposals would mean that many people in Flintshire who do not have a car will be required to travel much further for specialist health services – so the need for appropriate public transport is paramount at a time when WG funding for transport is reducing. BCUHB has apparently drafted a transport specification without consulting local authorities or locality leadership teams. The council doubts the capacity of the Welsh Ambulance Trust to provide sufficient transport for scheduled out-patient/other visits given the current and rising demand for its services.
Informal Carers FCC believes that detailed and sensitive assessments of the impact of the proposed service changes on carers will need to be carried out before any final service change can be agreed.
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Cross Border Issues Cross Border specialist service provision is not part of the review, but FCC is concerned that north-east Flintshire residents should continue to have the choice of using the Countess of Chester Hospital as their local acute hospital. The council is also concerned that the use of Gobowen, Clatterbridge, Walton, Broad Green and Alder Hey for specialist services in the north-west of England will continue and that people near the border who have to use English-based pharmacies will continue to receive refunds.
Partnership Working The council recommends establishing a senior managers/ Member forum in Flintshire, with senior representatives from the council and the BCUHB.
Conclusion The proposed service developments that are strategically in the right direction, but lack detailed planning – so the council cannot support them without major reservations and has passed a resolution saying that: » The council rejects the proposal to close Flint Community Hospital and its minor injuries unit » The X-Ray services at Mold Community Hospital should be retained » The minor injuries clinic and Deeside Hospital facility should be opened as proposed For these reasons, FCC urges BCUHB to withdraw the current proposals with immediate effect.
Isle of Anglesey County Council (ACC)
ACC wants to strengthen Welsh language provision and move more services into the community to reduce pressure on acute hospitals and provide accessible care. The council accepts the centralisation some services, including long-term specialist neonatal care at Arrowe Park, but believes accommodation should be provided there for patients’ families. The best use should be made of Cefni and Penrhos Stanley community hospitals, and sufficient resources should be available to strengthen mental health care and other community services. (ORS)
Accessible Services for All For ACC the foremost way in which services do not meet the needs of users is in the use of Welsh, for some of the most vulnerable groups (including the elderly and those with dementia or learning difficulties or mental health problems) cannot get services in their preferred language – and so it considers that language requirements need to be strengthened when appointing front-line staff. ACC welcomes the proposals to move services to the community and increase expenditure on community health services in order to provide accessible services closer to where people live.
Public Health Challenges All agencies and key stakeholders should work together in order to address public health needs (such as the prevention of smoking/alcohol/drug abuse and promotion of healthy eating and exercise). There is scope for greater collaboration between the NHS and local authority services such as education, leisure, public protection, housing and social care.
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Acute Care Services It is vitally important to ensure that key healthcare services are available within reach of the population in Ysbyty Gwynedd and consideration must be given to remote rural areas such as north Anglesey – so ACC agrees with moving services closer to the people in order to reduce travelling difficulties. ACC does not oppose the centralisation of long-term specialist neonatal services at Arrowe Park, but believes accommodation for parents should be provided on site. More generally, it does not oppose the centralisation of other specialist services, but believes there is a need for local authorities and transport providers to collaborate to ensure that affordable transport is available in rural areas: consideration should be given to the transport requirements of some service users in accessing the services and the convenience of their visitors. For example, the needs of those receiving daily cancer treatment in Glan Clwyd should also be considered along with the practicalities of travelling there for treatment.
Primary Care and Community Health Care BCUHB should consider providing primary care services and integrated 24/7 responsive community care in order to reduce unnecessary admissions to Ysbyty Gwynedd. It should ensure that GPs and out-of-hours services support people in their homes to reduce the pressure on secondary care services reduce the disruption for elderly and vulnerable people. Local plans providing more integrated enhanced care services should be developed and more attention should be given to tele-health services and also to helping people to understand health problems better and look after themselves to reduce illnesses. Local collaboration through local area groups, led by GPs, should be extended to ensure better co-ordination and the provision of more integrated services in the community via surgeries, pharmacies, dental surgeries and optometry services. In this context, there is a need for more clarity on the leadership role of the locality development groups in remodelling primary and community health services in line with BCUHB’s proposals. In particular, there is a need to strengthen the following: » Health visitor and school nurse services » Services to support children with disabilities and long term health conditions and their families » Community mental health services » Joint initiatives with leisure, social services and voluntary organisations to reduce falls amongst older people » Programmes to help people with chronic conditions to manage them better » Tele-health monitoring services to reduce travelling to health centres » Collaboration with social services to support carers.
Cefni Hospital and Penrhos Stanley Hospital (Community Hospital Hubs) ACC believes Anglesey is fortunate in having two good community hospitals which are greatly appreciated by the people of Anglesey and Arfon and further afield. Their services should be expanded to ensure: » Sufficient beds for recovery and rehabilitation for patients from acute hospitals » Sufficient dementia care beds in Cefni Hospital » Minor injury and X-Ray services in Penrhos Stanley Hospital to reduce pressure on emergency services in Ysbyty Gwynedd
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» Services for outpatients » Occupational and physio-therapy and other therapy services.
Mental Health: Older People ACC supports strengthening community services for people with dementia, but believes there should also be sufficient hospital beds for dementia care. The council is concerned by the proposals to reduce beds in Cefni Hospital – though moving dementia beds to Ysbyty Gwynedd would release the building so that primary and community care could be strengthened there. Cefni Hospital offers great opportunities for the co-location of health and social care services, and resources should be maximised to integrate health and social care for the elderly; children who are vulnerable or in need or have disabilities, and for adults with learning or physical disabilities. ACC also mentions the need to plan for: staff; how to maintain the local hospital if its beds are reduced; support for carers; the costs of care in the community; collaboration with the education department; and information and preventative services in collaboration with the third sector.
Comments and General Questions The ACC submission ends by asking several questions. What plans are there to strengthen dementia care within the community and how will they be funded? What are the implications of these plans for users’ and carers’ travelling and for respite care? How will equitable and stable services be provided for Anglesey (compared to areas where specialist services are being centralised)? What are the implications for the NHS workforce? How to strengthen collaborative asset management with other authorities?
Wrexham County Borough Council (WCBC)
WCBC ask questions about neonatal intensive care, vascular services and older people’s mental health, but does not oppose the proposals. The main thrust of the submission is to raise questions about how enhanced 24/7 community care will be delivered. (ORS)
Neonatal intensive Care The council is concerned that care cannot be provided nearer to Wrexham and also asks if Arrowe Park meets required national standards, can provide family accommodation and will treat Welsh patients equally with English ones. But it does not directly oppose the proposals.
Vascular Services The council asks whether the proposals will reduce waiting times, what are the costs, and what sites have been identified for Triple A Screening, but it does not directly oppose the proposals.
Older PeopIe’s Mental Health The council asks what evidence is available that demonstrates the greater effectiveness of the proposals, but the council does not directly oppose them.
Healthcare Services Where You Live The council asks:
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» How proposals to strengthen community teams would be implemented in areas of cross-boundary working? » How appropriate representation on locality groups would be ensured? » Whether residents living in boundary areas will have equitable access to services? » Is there an effective financial plan for Enhanced Care at Home? » Are GPs committed to the model of care and will they be sufficiently resourced to undertake the required roles without lengthening patient waiting times? » Are there sufficient staff to provide Enhanced Care twenty four hours, seven days a week service? » Can optimum health and social care be delivered without pooled budgets? » Whether the proposed closure of Llangollen Community Hospital will increase bed blocking? » In relation to the proposed closure of minor injuries units, will more facilities be provided to ensure waiting times in Wrexham Maelor do not increase? Or will the proposals put more pressure on A&E there?
North Wales Fire and Rescue Service (NWFRS)
NWFRS recognises the need for healthcare changes and says that BCUHB’s plans balance local access against requirements for specialist services. It does not comment on specific proposals but wishes to develop the current partnership in the context of community care. (ORS)
NWFRS recognises the need for the health care changes that BCUHB is proposing and appreciates the inevitable tension between local delivery and the maintenance of specialist competences. The NWFRS recognises that the increasing number of elderly and infirm people will require it to undertake increasing community safety interventions and in this context it wishes to develop the existing partnership working between NWFRS and BCUHB – in particular by: » Sharing information about vulnerable people and having a close working relationship on the ground » Assessing living arrangements and safety through the home fire safety check process » Auditing premises falling under the Regulatory Reform (Fire Safety) Order and considering the capacity of the residents to evacuate themselves safely » Receiving information about operational risks such as machinery or oxygen.
North Wales Police - Chief Constable (CCNWP)
The CCNWP does not comment on the detailed individual proposals, but makes observations on delayed ambulance responses and access to services for those with mental health problems. (ORS)
Emergency Ambulance Provision The CCNWP reiterates concerns (previously raised) about the availability of ambulances to respond to calls to people injured in assaults, collisions or other incidents to which police are called. There have been an increasing number of instances where, due to the unavailability of ambulances, transport of patients to
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hospital has had to be undertaken by police officers who are neither trained nor equipped for this role. The police appreciate the recent constructive dialogue with BCUHB and the Welsh Ambulance Service Trust, but the collective impact on ambulance response times of the closure of local facilities does not appear to have been considered in detail in this document. The ambulance service’s response to calls for assistance should be a key consideration in future reform of health service provision in North Wales.
Mental Health Services There have been occasions when the police have had to detain mentally ill people at police stations because of difficulties in arranging assessments by medical professionals out-of-hours; and there have also been times when police officers have suffered significant delays after taking people to mental health assessment units. The proposals to improve access to mental health services will be of interest to North Wales Police.
Personal Alarm Services NWP are increasingly called to provide an urgent response to alarm activations for vulnerable people or where the monitoring centre are unable to contact the registered user of a device: from 09/2011 to 09/2012 North Wales Police were asked to attend such calls on almost 700 occasions. The balance of care being moved from the acute hospitals to community-based provision must have sufficient resources to provide for 24/7 response, so that the police are not further drawn away from core roles in public protection. Care plans agreed by the service provider with families should have sufficient resilience, in terms of the number(s) of family members or other carers, who can be called to assist the vulnerable person, prior to consideration of calling police.
Key Submissions from BCUHB Staff
Cardiology Department (Glan Clwyd)
Glan Clwyd’s accreditation for the catheter laboratory’s interventional cardiac procedures requires the availability of on-site vascular surgery – and so the submission recommends that this interdependency should be taken into account when vascular services are reorganised. (ORS)
Authors The submission comes from four Consultant Cardiologists (Christopher Bellamy, Paul Das, Eduardas Subkovas and Nicholas Waterfield) and a Professor of Vascular Studies (Michael Rees).
Interdependency of Vascular and Cardiac Services Invasive and interventional cardiac services for North Wales are provided at the Glan Clwyd Cardiac Catheter Laboratory and procedures are done on weekdays from 9 to 5, with an on-call service to deal with post-procedural complications. There is a proposal to the Welsh Government for a second catheter laboratory that will facilitate the repatriation of most invasive and interventional cardiac procedures to North Wales and when this service begins the catheter laboratory will undertake procedures 24/7. Vascular complications occur in about 1 in 200 cardiac procedures, some of which require interventional vascular radiology procedures, while others require emergency vascular surgery. Such patients often have
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unstable cardiac conditions and be haemodynamically unstable; and they are often are fully anti- coagulated with dual or triple anti-platelet therapy – so urgent on-site vascular surgery is required. The accreditation for the catheter laboratory at Glan Clwyd to do interventional cardiac procedures requires the availability of on-site vascular surgery during procedural hours. When a 24/7 interventional service is provided, 24/7 on-site vascular surgery will be also be required.
Recommendation In this context, the authors recommend that BCUHB takes into account the co-dependency of cardiac and vascular services when vascular services are reorganised.
Two Consultant General and Vascular Surgeons (Wrexham)
The two Wrexham consultants argue separately that concentrating major arterial surgery on a single site would make routine vascular services unviable at the remaining two acute hospitals without improving overall patient safety; they believe a two-site model is more reasonable. (ORS)
Tony da Silva Tony da Silva says BCUHB is proposing a one-centre major arterial model for about 300 major cases whereas clinicians have proposed either a one- or two-site option. He believes that the plan fails to recognise that the 300 most serious cases form a relatively small proportion of the total vascular surgery, which includes a wide range of urgent in-house referrals plus emergencies from other hospitals. This work is only possible with the daily presence of a vascular surgeon: vascular cover is part of a "continuum of care" which cannot be compressed into a half session by a visiting surgeon. With a single centre, patients currently dealt with by one hospital team might have to be transferred urgently to the arterial centre or wait for the local surgeon to review their cases. Currently, patient transfers to other hospitals in the network are kept to a minimum, due to the fact that there is always a local vascular surgeon to assess such patients, but this will no longer be the case with a single arterial centre – and so the ‘other’ two hospitals will be disadvantaged. In contrast, a two-centre solution will disadvantage only one hospital and is a more reasonable compromise solution – particularly because, if only one vascular centre is chosen, then vascular cover in the others may dwindle to only a ‘presence’; whereas with two centres continuous local cover would still be possible at all times in two of the three hospitals. In any case, visiting surgeons operating one day a week in one centre will not really form a larger team: they will still spend most of the time at their local hospital looking after their pre-operative and post- operative patients and dealing with local referrals. A "larger team" will not improve the quality of AAA surgery once the Vascular Society’s threshold of 33 AAAs per annum has been reached; and two centres performing 42-45 AAAs per annum would have similar results as one performing 90 AAAs per annum. The Vascular Society only refers to a threshold for AAAs, yet the Board has generalised improved results to all 300 arterial operations. BCUHB is already the best in Wales for AAA and carotid data entry, according to the Vascular Society audit reports. It has been estimated that for a population the size of North Wales, one AAA life may be saved per annum by centralising aortic surgery, but this would be at a cost to other patients (with ischaemic limbs due to unavailability of local vascular surgeons).
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Ursula Kirkpatrick Ursula Kirkpatrick opposes BCUHB’s proposal that emergency and complicated arterial surgery should be based in one acute hospital on the grounds that BCUHB’s proposal prematurely truncated a North Wales review of vascular services and that routine vascular services would become unviable at the remaining acute hospitals if the plans were adopted. Currently the three North Wales hospitals each provide full working day cover for vascular problems, most urgent vascular patients do not transfer for emergency surgery overnight, and the vast majority of patients stay ‘in house’ for their care. There is likely to be no overall improvement in patient safety from centralising vascular surgery if there was not a guarantee of a vascular surgical presence on the other sites; and the north and south Mersey vascular service reconfiguration models mean that surgeons are based at their local hospital and continue to provide the care of vascular patients in house, only moving to the ‘arterial hospital’ to perform the major arterial surgery. In North Wales, though, the numbers of surgeons involved and the distances between hospital preclude being able to provide on-site vascular provision during the working day at ‘non-arterial’ hospitals. In North Wales it is likely that only one life a year could be saved by vascular centralisation; but services to a large group of patients would face corresponding disruption. Given there are only two vascular surgeons at each site, it is not possible to both maintain routine presence during the normal working day while covering all vascular emergencies and major arterial surgery at a distant hospital. It is not realistic to provide the daily review of urgent vascular referrals, cover for in- theatre vascular injuries, outpatients, diagnostics, venous surgery, vascular fistula access surgery, and post- operative arterial rehabilitation at non-arterial sites. The Vascular Society supports centralisation, but only in the context of full maintenance of local services with staffing for in-house referrals and local clinics. It specifies that only patients requiring intervention or emergency treatment should be transferred, but this is not possible in North Wales given the numbers of vascular surgeons involved and the distances between hospitals.
North Wales Advanced Neonatal Nurse Practitioners (Glan Clwyd) (NWANNPs)
The NWANNPs argue that the dangers of post-natal transfers to Arrowe Park have been under- estimated while the merits of care there have been exaggerated. They stress the risks and inconvenience of transfers to the Wirral. (ORS)
Clinical Care BCUHB states that only 36 babies a year in North Wales will be affected by the proposed changes to use Arrowe Park, but this statement is misleading: the proposed changes would have a much wider impact for all North Wales infants who require neonatal care, and it would not improve care. For example, for extremely premature infants who cannot be delivered in hospital, post-natal transfers from Ysbyty Gwynedd to Arrowe Park would be 72 miles and from Glan Clwyd would be 40 miles; and during the transfers they would lack clinical support services and be travelling at speed. Other critically ill babies will suffer delays in treatment due to the transfers. For example, assuming a call was placed to Arrowe Park Hospital for a time-critical transfer within an hour of birth at Ysbyty Gwynedd, and if the retrieval team departed Arrowe Park within 30 minutes of the call being received, the baby could be about 5.5 hours of age arriving at Arrowe Park – so, for example, therapeutic cooling could be commenced within the six hour window for treatment.
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Arrowe Park is not a centre of excellence, but just a district general hospital which does not offer any additional neonatal services compared with Glan Clwyd. Indeed, specialist tertiary neonatal services are provided for Glan Clwyd, Wrexham Maelor and Arrowe Park at Liverpool Women’s Hospital NICU. So if the plans go ahead, Welsh babies will get no extra benefit from care at Arrowe Park; but they may be exposed to additional risks and they will be further away from their homes and their families.
ANNP Training, Recruitment and Retention Should medium and long term intensive care not be carried out in North Wales, it would be impossible for ANNP students to acquire the skills and knowledge to complete their training without an eight-month placement in a tertiary level unit, elsewhere – though the requirement to spend such additional time away from home is likely to make the ANNP course unattractive to potential applicants from North Wales. After training newly qualified ANNPs would also need six months’ secondment to a unit providing medium and long-term intensive care. Therefore, during the initial year of training and the subsequent apprenticeship, the ANNP would be paid by BCUHB, but work elsewhere. There is also a possibility that ANNPs working locally may seek employment in units elsewhere which provide intensive care. This same risk also applies to neonatal nurses which could result in significant recruitment and retention issues.
Nursing Education and Training It is well recognised that retention of specialist nursing skills requires on-going experience, but this would not be sustainable following the loss of medium and long term neonatal intensive care. Should medium and long-term ventilation not be provided in North Wales, then it would not be difficult to run course at Welsh universities which require practice in clinical competences. For example, intensive care training placements for pre-registration nursing students are currently provided locally; clearly this would also be impacted by the loss of neonatal intensive care services in North Wales.
Medical Staffing Should neonatal intensive care be moved from North Wales, the Welsh Deanery would no longer send medical staff to the units, which would exacerbate the shortage of appropriately trained medical staff.
Welsh Language and Identity The proposal undermines the importance of families being able to converse in Welsh throughout their stay and will result in some infants being denied the fundamental right to be born in Wales.
Parents Removing parents from their homes and support networks will make be an added burden that could last for months, but this is unjustifiable since the services at Arrowe Park are no different to those currently available in North Wales.
Transport for Families Transport across North Wales to the Wirral is not easy, even if you have a car, and a significant number of families will be unable to finance regular travel costs. Although Arrowe Park proposes offering accommodation, some parents will be unable to be resident due to other childcare commitments and there will be a significant impact on family life. Situations are likely to arise when a baby’s condition deteriorates and parents are unable to get to Arrowe Park to be with their baby when it dies.
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Breast Milk Breast milk benefits infants and reduces morbidity and mortality, but but if families are not able to visit the hospital regularly this will be unavailable.
Impact on Other Stakeholders There will be increased numbers of pregnant women who will require specialist midwife and doctor-led transfers to the Wirral, leaving less staff available locally to care for other service users. This will impact on the ability of the ambulance service to carry out other emergency work, as these transfers are undertaken by paramedic crews using fully equipped vehicles. There is a significant disparity between NICU provision in North and South Wales, for the South has three NICUs, whereas BCUHB’s proposals would leave North Wales with no facilities at all for medium and long term neonatal intensive care.
Key Submissions from Special Interest, Voluntary and Community Groups
Mold Labour Party (MLP)
MLP argues that Mold needs small injuries and X-Ray services because it is a natural hub to a sizeable community. (ORS)
The consultation was unwise in couching many proposals in negative terms, for people will clearly object when they are told a facility is closing or a service is being withdrawn. Participation in the public meetings was made more difficult by the requirement by the requirement to pre-book and the limited capacity of the venues, so that some people were turned away. What was needed but totally lacking was a positive exposition on the benefits of the proposals: the potential benefits were seriously underplayed. The proposal centred on the concept of hub hospitals, but Mold is a natural hub for a sizeable community and has significant small accident risks in the schools population and it needs a minor injuries unit and X- Ray facilities. Of course there have to be limits: we accept that a 24/7 service in every community is not affordable; but given the difficulty of reaching Deeside, and the intractable parking problem at Wrexham Maelor, and the need for quickly available medical help during school days, I would strongly urge that the proposal to discontinue MIU and X-Ray services at Mold is dropped forthwith.
Dwyfor Labour Party (DLP)
DLP urges BCUHB to rethink its proposals radically in order to meet, not jeopardise, the health needs of rural communities in uplands areas of North Wales. The Board should not close community hospitals, but make better use of them with step-up-step-down facilities while also developing level three intensive care neonatal service in North Wales. (ORS)
Introduction DLP submitted a detailed 23-page document expressing its regret about BCUHB’s strategy and saying that the one thing worse than ‘no change’ is making the ‘wrong change’. DLP considers that BCUHB has unwilling to answer reasonable questions and to provide justification of its proposals.
Important Omissions From The BCUHB Strategy
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While saying that patients in Wales do not always get the best possible outcomes from their hospital care, the Longley Report does not advocate change for change sake, and in some areas it shows that change may be unhelpful and carry risk. DLP feels it is unsatisfactory to embark on ‘change plans’ that seek to improve outcomes for some, but only at the cost of diminishing outcome prospects for others. In passing, it should be noted that BCUHB is not consulting on changes in four services despite the close relationship of these specialities with the list highlighted by Longley – so paediatric and child health, maternity and gynaecology, non-elective general surgery and trauma and orthopaedics were all excluded from the consultation. DLP says that for paediatrics and obstetrics, BCUHB proposes to make changes to services without consultation, but the evidence to justify such changes does not appear to have been published. It says that paediatric units will continue at each of the three acute hospitals, but (at the instigation of the Deanery) one of them hospitals will be downgraded to be a non-training hospital and the overall, the number of beds is to be reduced, with those in the PAU unit only available for limited hours each day. BCUHB has decided that such a downgrading and bed reduction does not constitute a major change and could be implemented without any consultation. Similarly, without formal consultation, BCUHB has said that obstetrics will continue at each hospital, but one unidentified site will be downgraded as a non-training doctor site.
Day Surgery Procedures It is disappointing that BCUHB has not made proposals to increase day surgery procedures in North Wales because doing so would reduce waiting times in several specialties and release acute beds and funding.
Budget Management DLP believes that BCUHB’s plans are driven primarily by the need to make significant savings in the face of reduced funding from the Welsh Government; but DLP says that considerable efficiency savings are possible from BCUHB’s annual budget of £1.2 Billion, particularly in relation to outsourced services.
Commentary on the Proposals
Community Hospitals and the Need to Travel BCUHB’s aim appears to be to cut expenditure on community services and community hospitals by £l4M per annum by reducing 15 community hospitals to seven hubs and by dismantling community services in Ffestiniog, Colwyn Bay, Ruthin, Llangollen, Flint, and Mold while also downgrading community services in Bryn Beryl (Pwllheli), Tywyn, Chirk, Dolgellau & Caernarfon. DLP believes there is no evidence that Wales has too many hospitals: Longley argued only for the migration some care services from acute hospitals into community ones; some local GPs believe Dwyfor is not overprovided with beds; and OECD and NAO statistics support the same conclusion.
Efficiency Gains Wales has the longest length of acute speciality stays in hospital of any of the home countries: 6.3 days in Wales compared with 4.3 days in England. Welsh health boards are not making the best use of their community hospitals to free up acute beds, but bed-blocking will be worse if community beds are taken out of the system. Closing community hospitals is incompatible with moving care closer to home.
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Community Health Services Proposal BCUHB’s strategy assumes that enhanced health and social care services can substantially increase the number of persons who can be cared for in their own homes rather than hospital. However, there is no coherent planning, management and governance model across the health and social care systems: each system is focused on managing its own concerns with insufficient joint solutions to common challenges. BCUHB does not describe how it will address these points and it proposes only a loose affiliation with local authorities, without integrated budgets and teams. DLP says alternatives to acute hospital admission can result in improved patient experience and outcomes, but evidence on savings/costs is mixed and likely to depend on local circumstances. Involving multidisciplinary teams with nurses visiting at least daily and physicians at least every three days can give outcomes similar to hospital care and be cost effective for less severe or complex needs, but for patients admitted first to acute hospitals and then transferred to hospitals at home, the evidence is mixed for outcomes and costs. There is a role for community hospitals as centres for integrated care, including diagnostics, outreach services and minor surgery, especially in rural areas; but there is a lack of evidence for the role of beds which tend to be used for people in old age suggesting admissions are largely related to age and disease complexity rather than disease specific. Therefore, the evidence does not clearly support BCUHB’s strategy for localities and community services.
The BCUHB HECS Pilot The pilot Home Enhanced Care Scheme in North Denbighshire has been claimed to have been successful, but the evaluation papers published the Prestatyn-Rhyl urban area pilot show a mixed response and no evidence of cost effectiveness. In any case, local communities have no confidence in BCUHB’s proposals.
Locality Structure BCUHB has not disclosed agreements it has reached with local authorities in respect of localities to support the primary and community care strategies and local councillors are not aware of any commitment to support the BCUHB’s proposed strategy. There is no recommendation in the Welsh Government that localities should have only one hospital hub. BCUHB plans to operate as l4 localities, but the areas are based on historical local government boundaries, some pre 1974.
Hospital Hubs The proposal for three acute and seven community hospital hubs is entirely random, without an evidence base, for BCUHB has shown that "three-plus-seven" hospitals model does meet local needs. However, limiting the principal service centres to the seven hubs leaves large areas of North Wales without reasonable access to healthcare services; the nature of the supporting role of the seven community hospitals is not fully defined; and BCUHB has not published details of the outpatients services that it proposes to provide. Meanwhile the public focus can only be upon the service withdrawals and reductions that have been proposed. Bryn Beryl and Tywyn community hospitals are to be downgraded to have minor, possible temporary, support roles. The minor injuries unit in Blaenau Ffestiniog is to be closed and Alltwen and Dolgellau will be open 12 hours daily from 8 to 8 while Tywyn and Bryn Beryl will provide an 8-hour service 7 days a week in summer but only a 5-day service between October and March – even though, if a minor injury service is not available locally, the tendency to call 999 for an ambulance increases.
Proposed HUB to Serve Dwyfor
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BCUHB proposes establishing a hub hospital at Ysbyty Alltwen, Porthmadog, but there is no evidence that a single Hub at Alltwen is sufficient to serve all of Dwyfor. Imposing patients from Ffestiniog and district onto the Dwyfor Hub at Ysbyty Alltwen, by closing the beds, minor injuries, X-Ray and some clinics in Ffestiniog, would over burden the local healthcare infrastructure considerably and cause unnecessary readmissions.
Hubs Failure to Serve Rural Areas BCUHB bases its planning on patients being able “by car" to reach a hub in 40 minutes, but that time span has no basis in WHO advice and in any case many older people have to travel by bus and it is impossible for patients in Aberdaron to get to the Porthmadog hub in less than two-and-a-quarter hours by bus. BCUHB also proposes that who currently use the Ffestiniog Memorial Hospital should in future use the Alltwen hub instead – but even more tortuous journeys would be needed from the rural area that Ffestiniog covers. The Porthmadog hub is supposed to cover an area some 40 miles long, but it does not have the capacity to serve the large rural Welsh uplands area.
Non-conformity with Welsh Government’s Rural Health Plan BCUHB’s plans do not use community hospitals to bring services closer to rural communities. Instead of bringing services closer, the proposals denudes large areas of the Welsh uplands of services they could enjoy. The Rural Health Plan has not been used as a point of reference for BCUHB’s planning.
Blaenau Ffestiniog BCUHB has identified Dolgellau as its hub for Meirionnydd, yet it proposes many north Meirionnydd residents should receive their care from Dwyfor – though anyone who understands the geography of the area will appreciate the strategic importance of Ffestiniog Memorial Hospital. BCUHB seems to have a strategy of selecting hospitals to close rather than meeting the health needs of its population; and it seems to be trying to transfer some of its costs to the ambulance trust to local authorities. In this context, DLP puts forward a modified proposal for three acute hospital and eight focus hubs.
Health Needs of the Ffestiniog and Welsh Uplands and the NHS Potential No statistical evidence has been published relating to the health needs of the Ffestiniog and Welsh uplands community, but Blaenau Ffestiniog is one of the most deprived areas in Wales and over the next 20 years the number of people in North Wales over 75 years of age will nearly double. With such demographics, the demand for hospital care services for the residents of Blaenau Ffestiniog can be only grow – so Blaenau Ffestiniog will need community hospital beds for residents’ recuperation, step down and rehabilitation, respite, palliative and end of life care. Ffestiniog Memorial Hospital needs to be improved, not dismantled. The NHS estate in Ffestiniog has considerable potential for delivering quality services to its hinterland and could be easily developed as a model of rural health care delivery for Wales. The GPs and other NHS staff in the area are capable of embarking on good practice rarely seen elsewhere: the Primary Care Centre and the Memorial Hospital form essentially one estate and the community and GPs would support the introduction of additional services.
Nursing and Residential Homes The very limited nursing and residential homes in the Ffestiniog area do not offer any alternative to the community hospital, for the nearest nursing home is in Porthmadog and there are waiting lists for entry to nursing care homes in Dwyfor and Meirionnydd.
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Capital Finance Availability BCUHB has identified a need for £35M capital funding from the Welsh Government to develop its services, but it has suggested that no finance would be available to refurbish the Ffestiniog Memorial Hospital building as a more modern community hospital! It appears that BCUHB wants to close the hospital and gain a capital receipt.
Older People’s Mental Health BCUHB’s proposal to close inpatient beds and establish care in the community will not produce an integrated network of care and the proposals’ impact on Dwyfor and Meirionnydd is greater than on other areas because of the area’s rurality and poor transport. No evidence supports BCUHB’s contention that there are too many mental health beds in the localities and there are reports that few residential homes are qualified to look after elderly mentally ill patients. BCUHB has not published its detailed bed modelling analysis or any survey of the beds that are accessible to older persons with mental health illnesses – so its plan is really a "trust to luck" and there is no commitment to pooling of NHS and local authority budgets or teams. The BCUHB proposal gives every appearance of the abandoning older mentally Ill patients to their own or their families’ care arrangements.
Neonatal Intensive Care Services BCUHB has decided not to develop a specialised neonatal intensive care service centre within North Wales on financial grounds, but full financial and clinical arguments have not been published. The proposal to commission services from Arrowe Park is a model that Welsh ministers ridicule regularly and there are clinical disadvantages of the proposal – in terms of the loss of skills in North Wales that will impact adversely on the local neonatal units. BCUHB has not described what additional arrangements it proposes for providing transport for babies and mothers’ close families or what arrangements have been made for family accommodation.
Vascular Services The clinical proposal is that the surgery should be limited to either one or two sites, but BCUHB has decided to consult only on a single site. The impact on Dwyfor residents will be very different if the service is centralised at Ysbyty Gwynedd rather than Wrexham Maelor. If BCUHB proposes to deliver the service from a location other than Ysbyty Bangor, what additional arrangements does it propose for providing patient transport and what arrangement does it propose to make for conducting pre and post-operative clinics in Ysbyty Bryn Beryl and Ysbyty Alltwen? The consultation on vascular services is inadequate.
Wrexham Plaid Cymru (WPC)
WPC argues that all neonatal intensive care services should be retained in North Wales because of deficiencies at Arrowe Park and access difficulties. (ORS)
Neonatal Intensive Care WPC objects to the proposal to provide neonatal intensive care services from Arrowe Park because clinicians favour keeping the services in North Wales. Arrowe Park is deficient because it does not meet national standards; it is uncertain whether there will be sufficient specialist doctors there; it has a lower
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nurse/cot ration than Glan Clwyd; and BCHUB would render itself susceptible to future price increases if it commits to buying services there. If Welsh units are downgraded then all intensive care babies in North Wales will suffer in standards of service. Moving some of them to Arrowe Park will exacerbate the problem of breastfeeding and the travelling demands will cause problems for many and add to the emotional strain. WPC suggests that managers of intensive care units in North Wales should co-ordinate much better as there are different systems in place currently and there is no sharing of staff between Glan Clwyd and Wrexham. For example, it is possible to train nurses as Advanced Neonatal Nurse Practitioners, as happened at Glan Clwyd.
Blaenau Ffestiniog Hospital Defence Committee (BFHDC)
The BFHDC has campaigned actively because it very strongly opposes BCUHB’s proposed closure of the Memorial Hospital and argues that it should retain its 12 inpatient beds and that a further five (already removed) should be reinstated, as well as the minor injuries service. (ORS)
Introduction BFHDC made a detailed submission to BCUHB in the form of a report responding to Dr Ed Roberts’ review of the Memorial Hospital. The Defence Committee argues that that there should be no further erosion of services from the Ffestiniog Memorial Hospital and it says that although the Wales Rural Health Plan’s key themes are “access, integration and community cohesion” closing the 12 beds at Blaenau Ffestiniog Hospital would move care further from people homes. Rather than improving access, integration and cohesion, it would jeopardise the health needs of rural communities.
Strategic Context BCUHB outlines the challenges it faces in the implementation of its 5-year plan in the light of the service, demographic, financial and other constraints it faces. In this context it proposes to establish integrated locality teams and over time change community hospitals to community campuses. This suggests that beds at Blaenau will close in order to accommodate integrated locality teams, but the proposals are vague. How will BCUHB recruit staff for these enhanced services considering that there are senior nurse shortages; and what will be the cost of the enhanced services? Why have staffing levels not been maintained at Blaenau? We were promised that the Memorial Hospital would not lose any beds until the Health Board ’s plans had been fully implemented.
Methodology for Review The review of Blaenau Gwent hospital conducted by Dr Roberts took little account of the views of local residents, GPs, hospital and community staff, the CHC, the Hospital League of Friends, councillors and the Defence Committee. Moreover, as the vice-chair of another health board, the author was hardly independent.
Hospital Service Profile The profile provided by Dr Roberts is incorrect and incomplete. Contrary to what Dr Roberts says, the Defence Committee firmly believes that: nursing and palliative care beds are needed in Blaenau; local people wish to maintain the hospital, preferably with the reintroduction of the 5 male beds and enhanced
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services; the GPs in the practice would be unable to commute to Alltwen to deliver care to their patients; relatives of patients would find it much more difficult to visit Alltwen than Blaenau Hospital; Blaenau people do not accept that the Health Centre is ageing and with only limited accommodation; bed occupancy is typically higher than show in Dr Roberts’ report; closing beds there will increase bed-blocking elsewhere; and the reduced use of the minor injuries service was due only to its reduced operating hours. The Blaenau minor injuries unit serves important local needs and there will be expense in transferring patients to Ysbyty Alltwen or Ysbyty Gwynedd when the service is withdrawn. Many minor injuries cases when sent to Alltwen are sent on to Ysbyty Gwynedd (without receiving treatment at Alltwen because no doctor is available there). This is worse for patients and puts strain on the ambulance service. The quoted cost of £800K per annum to run the Ffestiniog Memorial Hospital is actually very inexpensive, especially as the services of dedicated doctors are obtained for as little as £28K per annum. Dr Roberts’ report gives little information about the costs of Ysbyty Alltwen and there is no discussion of its capacity to deal with extra patients. The Defence Committee suggests that patient safety may be compromised by the closure and transfers to other hospitals. Finally, it asks if agreements have been reached with the GPs contracted to cover minor injuries and inpatient services at Alltwen during the daytime? Overall, it seems that Blaenau Ffestiniog has suffered from a sequence of changes which have eroded its Memorial Hospital services and the community is now very distrustful of the BCUHB. For example, the Defence Committee believes that the profile of the Memorial Hospital in Dr Roberts report was unduly influenced by BCUHB’s agenda to close the hospital. A section by Councillor Linda W Jones (the managing director of a care company and member of Gwynedd’s Care Scrutiny Committee) adds that closing the Memorial Hospital will result in the need for the provision of care for 12 patients 24/7 in their own homes – which would be at a substantial cost. She points out that there are no nursing care homes in the Blaenau Ffestiniog area, so there are no opportunities for residents to buy services near to home. Hence, the closure of the Memorial Hospital would lead to further deprivation and a threat to patient safety. The Defence Committee submission also includes a letter from four local GPs commenting on the profile and options for the Memorial Hospital.
Conclusions: Options Appraisal The Defence Committee rejects Dr Roberts’ conclusion that Option 1 (“doing nothing”) is unrealistic; in fact, the Committee believes that Option 1 with improvements would be the ideal way forward. In contrast, Options 2 and 3 both discount the views of local people and simply match BCUHB’s agenda. The Defence Committee agrees with local stakeholders that the hospital should retain its 12 inpatient beds and that a further five (already removed) should be reinstated; and it also believes that the minor injuries service is also worthy of being reinstated. Overall, the Defence Committee considers that Dr Roberts’ report is superficial, inconclusive and flawed, and his status as the vice-chair of another health board in Wales means he is not truly independent.
Community Hospitals Association (CHA)
The CHA believes the proposals for community hospitals, minor injuries units, X-Ray facilities and hub hospitals jeopardise healthcare by reducing both access community capacity, leading to a greater not lesser reliance on specialist acute services. (ORS)
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Overall Impression The CHA believes the proposed changes will have a devastating effect on healthcare services in North Wales: community hospitals such as Llangollen and Flint will close; minor injuries units will be lost at Chirk, Colwyn Bay, Mold, Ffestiniog, and Ruthin; X-Ray facilities will close in Mold, Ruthin, Bryn Beryl, Eryri and Tywyn; Ffestiniog hospital will lose its inpatient beds; and Prestatyn and the Royal Alexandra hospitals will close prior to a replacement community hospital. These proposals reduce access to local health care and reduce community capacity – leading to a greater not lesser reliance on specialist acute services. The proposal to create “hubs”, with fewer local hospitals providing more services has been unsuccessful elsewhere and involves people travelling further to the hubs. Instead, BCUHB should build on good practice and utilise community hospitals more fully. Nonetheless, the CHA is reassured by BCUHB’s commitment to establishing new services before closing any services – though it says there will need to be negotiation with communities regarding the definition of suitable alternative services, as these would need to be accessible by public transport and have sufficient capacity.
Rationale for Change While the triple aims of improving the health of the population, the experience of the patients and controlling cost are laudable, they do not in themselves imply the closure of community hospitals. In fact, community hospitals are the best placed to develop a public health campaigns, and patients value them highly.
Building on Good Practice BCUHB should build on such good practice such as the Deeside Palliative Care Drop-in Service, a Macmillan- led service based in a community hospital setting. Community hospitals are centres of integrated care, with partnerships between acute, primary care, community services, and social services, as well as collaborations between the NHS and voluntary sector; and they have an important role in providing intermediate care, rehabilitation, palliative care, as well as clinics and diagnostic and treatment services. It is encouraging that there has been investment in new community hospitals at Holywell, Deeside and Alltwen; and the proposal to build a new community hospital with a wide range of facilities and 30 beds on the Royal Alexandra site is an appropriate development.
Information It would have been helpful to have had maps of both the current and proposed hospitals with their population sizes and distances. It would also be helpful to have clearer statistics on bed usage. The CHA questions BCUHB’s assertion that patients lose their independence in hospitals, may be prone to infection, and take longer to recover once home. Closing minor injuries units seems likely only to increase current pressures on A&E departments.
Consultation The strong public reaction against the consultation paper has been demonstrated with campaigns in many areas, including public meetings, marches and petitions; and Community Health Councils and Town Councils in some areas are party to the campaigns. The CHA believes that codes of practice on consultation require that people are offered the status quo as one of the options.
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National Specialist Advisory Group – Mental Health
The RCPW supports the move towards community rather than inpatient care, but wants to know how sustainable 24-hour emergency mental health care will be provided. [This submission is the same as the one from the Royal Colleage of Psychiatrists in Wales] (ORS)
Integrating Physical and Mental Health Care The NSAGMH supports the move towards community care with less reliance on in-patient models and believes the new approach will facilitate the integration of physical and mental health, but the strategy document does not make clear how better integration will be achieved with local authorities, third sector and the criminal justice system.
Specialist Mental Health Services Inpatient care is increasingly reserved for people who are very unwell and/or have highly specialised needs, but the plans for this specialist area are not specified; and it would be helpful to learn of the proposals to deliver a sustainable 24-hour emergency mental health service.
Workforce and Academic Linkage Recruitment for therapists, pharmacy and psychology is strong in Wales and perhaps these professional groups could taking on newer extended roles. The NSAGMH would like to know how BCUHB plans to improve the psychological skills of all its workforce and develop a tiered approach to psychotherapies. There is a need to plan for the likely retirement of 30% of the senior mental health nursing workforce. There is scope for further developments with academic and professional training bodies.
Estates Mental health services should be provided from buildings of equivalent standard to high quality primary and general health care.
North Wales Social Services Improvement Collaboration (NWSSIC)
The NWSSIC supports the strategic changes that BCUHB is making and accepts the proposals for vascular and intensive neonatal care services; but it objects to closing/downgrading community hospital. It accepts the principle of hubs, but questions the choices made. There should be a more detailed business case with costs, timetables and continuity of care during organisational change. There should be clarity and joint planning about the impact of health service changes on social services. (ORS)
The social services directors constituting the NWSSIC accept the need for changing services and are also critically reviewing their services. There are a number of strategic points that NWSSIC makes.
Rationale for Service Changes NWSSIC welcomes the proposed changes to EMI and the development of community services closer to people’s homes; but there needs to be a clear evidenced base for what is required. For example, there are still concerns about the lack of detail about how a three-site model of services at the general hospitals will be sustainable in the current financial climate and how compatible this is with the development of true
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community services for which finances need to be released. The NWSSIC is concerned that the proposed model is not sustainable and there will be the need for further radical reforms within the next year or so. It is also concerned that, to fund the new service provision, some existing services will be closed as, but it would be more prudent if some invest-to-save funding was available to aid the transition. The NWSSIC supports the development of enhanced care (ECS), but it the consultation document should have included a timetable and how costings for the roll-out have been calculated. ECS and health services closer to home will only work with robust community staffing, but currently across North Wales such staffing is patchy. The absence of robust business or budgetary plans makes it difficult to see how the change are to be made in relation to key milestones, budgetary requirements, plans for disinvestment and reinvestment and what the impact of these changes will be either in the short term or long term. The NWSSIC supports the concept of hospital hubs, but question the robustness of the evidence for why some hospitals have been chosen rather than others – for example, Deeside/Mold andRuthin/Denbigh.
Carers’ Issues Community care will lead to greater expectations on carers, but again detail as to the potential impact is absent. It is essential that future arrangements for assessments and for practical support for carers is discussed and funded between local government, health and voluntary sector support services.
Transfer of Responsibilities The NWSSIC proposes jointly agreeing performance measures to capture current baselines so that changes to activity and cost can be observed and reported on together. An agreement is required which clarifies that whilst patients are receiving HECS, or other new forms of service which substitute for acute services, they are the sole responsibility of BCUHB, as if they had been admitted to hospital.
Specialist Centres The NWSSIC accepts the case for establishing specialist centres for complex vascular or specific orthopaedic services; and it also supports the provision of specialist neonatal services at Arrowe Park, on the basis that the cost is significantly less than that required to develop the service within North Wales. The proposal is supported on the grounds of improved safety, quality and efficiency, but more detail is required to demonstrate how parents and families will be supported.
Strategic Planning There should be on-going dialogue to discuss the proposed changes in a constructive way so that the impact of these are known, jointly planned and delivered in a joined up way. There should also be an agreed approach to the transition from one set of services to the new alternatives, in order to ameliorate any deleterious impact on social care services. There is a need for county-focussed senior manager, convening joint strategic planning meetings to address these, linked to locality leadership teams.
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Community Hospitals and Minor Injuries WPC also objects to the closure/downgrading of community hospitals because there is no guarantee of capital to build the proposed new health centres and there is no room in private nursing homes to take the extra burden. An ageing population needs more community beds to avoid bed-blocking in acute hospitals. Closing minor injury services will put extra pressure on acute hospitals and ambulances; and travelling further to treatment will add to the strain on patients and their families. In general, the extended care at home scheme is too expensive and will not save money.
Key Submissions from Assembly Members and Members of Parliament
Rebecca Evans AM (RE)
RE is doubtful about aspects of the consultation process and raises a number of questions about the data used to justify the outcomes of BCUHB’s planning process. (ORS)
Consultation Process During the consultation process, in the Dwyfor locality, BCUHB held discussions only Pwllheli while there were none in Porthmadog, Criccieth, Penllyn (such as Abersoch or Aberdaron) or in the Nefyn or Trefor/Llanaelhaearn areas; and the total of 150 places for the three sessions at Pwllheli was inadequate for a population approaching 30,000. Moreover, the consultation on vascular surgery cannot be adequate when BCUHB has not yet identified a preferred site from which to deliver the service – for the impact on Dwyfor residents will be very different if the service is offered at Ysbyty Gwynedd or Wrexham Maelor.
Dwyfor Issues If vascular services are not centralised at Ysbyty Bangor, what additional arrangements would there be for patient transport; and what arrangement will there be for pre- and post-operative clinics in Ysbyty Bryn Beryl and Ysbyty Alltwen? If some specialist treatments are to be centralised, how is it justifiable to reduce community hospital beds? Where will patients receive nursing care after operations? Dwyfor residents dislike outsourcing neonatal intensive care service to Arrowe Park, particularly when it previously seemed likely to be repatriated. The clinicians’ preference for a specialised neonatal intensive care service centre within North Wales appears to have been rejected on financial grounds, but what was the financial case? If the service is outsourced to Arrowe Park, what arrangements are proposed for providing transport to Birkenhead for the baby and mother’s close family – and for family accommodation at or near Arrowe Park? What charges will family members face? There is no justification for the conclusion that there are too many beds in the locality. For both older people’s mental health and for community hospitals in Dwyfor and Meirionnydd, what is the detailed bed- and nursing modelling analysis? What data justified the closure or restricted hours of minor injury units? For example, what monitoring has been done on additional demand on the ambulance service following the withdrawal of the minor injury service from Ffestiniog Hospital? What contractual arrangement does BCUHB have with GPs in Blaenau Ffestiniog to provide services in Ffestiniog hospital and arrangements are proposed for the patients from Ffestiniog who may be admitted to Ysbyty Alltwen?
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There is no hub proposed between Porthmadog and Denbigh, the heart of rural North Wales. In producing plans for the number and location of hubs, what was the specific evidence base that justified 40-minutes travel time as reasonable? How many hubs would be required for a 20-minutes travel standard? What pilots have been done for enhanced care service in rural areas and how were they evaluated. What agreements have been reached with the various local authorities to support the primary and community care strategies? Previously, in introducing the HECS service in Prestatyn and Rhyl, some 50 WTE nursing staff from the Royal Alexandra Hospital were redeployed, but how many of them are still employed by BCUHB today? What is the proposed staff redeployment plan and is a better staff retention expected rate this time?
Janet Finch-Saunders, AM for Aberconwy and Shadow Minister for Local Government (JFS)
JFS says funding cuts are jeopardising patients by leading to undue centralisation of services and undesirable outsourcing of level 3 neonatal services. Mental health and other services should achieve a balance between care in the community and access to local inpatient beds; and Llandudno hospital should continue as a major facility. (ORS)
Introduction JFS says that, due to the Welsh Government’s cuts to the Health Budget, the Welsh NHS faces a funding gap of £440m over the two years to 2013-14 and in Wales the NHS faces the toughest funding settlement in the UK. The consequent funding challenges facing BCUHB, and its £64.4m funding gap, mean that changes to services must be considered. Although the consultation process has been both accessible and open over the past two months, it is regrettable that some issues have not gone to consultation – for example, commissioning of major trauma services from the University Hospital of North Staffordshire in Stoke and the regionalising of specialist cancer services and some orthopaedic services would have been welcome.
Locality and Community Services JFS is opposed to downgrading services at any local district hospital and is concerned at the proposed reduction of 24/7 consultant-led A&E services across the board. The proposed closure of some minor injury units may result in increased pressures on other local hospitals and it is unclear how such increases might be managed, particularly if there are staffing difficulties.
Older People’s Mental Health JFS opposes the closure of the older people’s mental health units at Dolgellau and Bryn Beryl, which will reduce the number of inpatient beds for this specialist need. Local and easily accessible services for mental health issues can avoid more specialist interventions, but community-based support is not always the most appropriate choice, so inpatient beds are needed – and both patients and families should have a choice of care. Assurances are needed that BCUHB will be able to provide the therapists and community-based trained staff needed to fulfil the additional support needed for "at home" based care, but reductions in beds may mean that patients must travel much further to access the specialist hospital care and there will be more pressure on carers, local social services and local authorities’ budgets – so proposals for better transport are required.
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Neonatal Services There is considerable opposition to the removal of Level 3 neonatal intensive care services from North Wales to the Arrowe Park, where the facilities might be insufficient to provide care for the additional intake from North Wales, and where there is half the required ratio of nurses to cots. There will be considerable travelling for parents and babies, disruption to families. Instead of out-sourcing additional investment is required in Welsh services.
Vascular Services There are concerns about the proposed consolidation of emergency and major arterial surgery at one acute hospital in North Wales, mainly based on delays consequent on transfers and increased travelling.
Llandudno Hospital It seems that the endoscopy service is to be transferred to Ysbyty Gwynedd Llandudno, despite the refurbishment there. The issues in not mentioned in the consultation document, but the provision should be reinstated is reinstated at Llandudno Hospital, in the context of the £48m investment there; and there should be no other losses of services. It is vitally important that Llandudno Hospital will continue as a major strategic facility.
Llyr Gruffydd AM (LG)
LG objects strongly to BCUHB’s proposals for neonatal intensive care and community hospital services. Both proposals will worsen standards and access for patients. (ORS)
Neonatal intensive care services LG says that BCUHB has known about the problems facing intensive care neonatal services for years, but nothing has been done about them. Clinicians favour keeping the services in North Wales because Arrowe Park fails to meet the national standards, may not have enough specialist doctors, has a poor staff/patient ratio, and has smaller capacity than Wrexham and Glan Clwyd. Moving babies there will cause travel problems (particularly for those without cars) and disruption and stress for families, and it will jeopardise breast feeding. LG suggests that the managers of the intensive care units in North Wales should co-ordinate more and invest in staff to provide a level 3 service that will attract back to Wales babies currently born in Chester and Shrewsbury. Expertise and capacity could be enhanced in North Wales by training nurses as ANNPs to take the burden, as has happened in Glan Clwyd. There is also no certainty about the Arrowe Park contract price, for it could be increased in subsequent years. The intensive care babies who stay in North Wales will have an inferior service because the clinical expertise at the units will decrease. Community Hospitals Capital to build the proposed new health centres is uncertain, so no community hospitals should be closed until new services are fully in place. Private nursing homes in Llangollen lack capacity for additional residents. Closing minor injuries services will put more pressure on the emergency departments at the main hospitals and more stress on patients and their families who will have to travel further. With an ageing population,
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more community beds will be needed. In any case, the HECS, the new community service, in Prestatyn is too expensive to be used everywhere. The closures and downgrading will not save money, for there will be additional ambulance and social services cost if community hospitals close. LG also enclosed a number of anonymous submissions.
David Hanson MP (DH)
DH passes on the concerns of Flint Town Council about the closure of Flint Community Hospital and also asks questions about Mold Hospital. (ORS)
Flint Community Hospital The Flint Town Council is concerned about the following issues. By how much is the health service budget being reduced and what reduction will BCUHB suffer? How much will be saved by closing the Flint Community Hospital? Are there proposals to reduce front line staff, senior officers and administration staff? What is Community Facility? What are the plans for the Clinic and will it be part of any potential change? Who is responsible for proposal to close Flint Community Hospital? How will the proposals provide better all-round services?
Mold Hospital DH requests information on a number of questions. How many people currently use the minor injuries unit at Mold? To where will services relocate if it is closed? Would the closure increase pressure on Wrexham Maelor Hospital (rather than the proposed services at Holywell or Deeside)? Has BCUHB assessed the public transport network? What assessment has been made of the improvements required to the existing service at Mold'?
Ann Jones AM (AJ)
AJ passes on the objections of “Cuddles” about the outsourcing of level 3 neonatal services to Arrowe Park. (ORS)
AJ met with the “Cuddles" parents support group for the neonatal unit at Glan Clwyd and listened to their concerns, which raised several questions: Why were level 3 neonatal services not centralised at Glan Clwyd following a 2005 review? What are the financial benefits of outsourcing to Arrowe Park, which has a worse staffing ratio than Glan Clwyd? What will be the implications for the ambulance services and families? Will Arrowe Park provide a bilingual service to mothers? How is the proposal compatible with ‘care closer to home’? Members of "Cuddles" believe that the proposed changes would be a retrograde step since Arrowe Park cannot offer a “Gold Standard Unit". If implanted, there is a danger that expertise in the neonatal and special baby care will be lost.
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Elfyn Llwyd, MP (EL)
EL says Tywyn’s services should be protected due to its remoteness and visitor numbers. (ORS)
There is no good reason for downgrading the Tywyn Minor Injuries Unit or the X-Ray Unit. Tywyn's distance from other hospitals means it is important that these services remain for residents and visitors when the area's population increases ten-fold.
Sandy Mewies AM (SM)
SM passes on residents’ objections to the proposals for Flint hospital and Mold minor injuries and X- ray services. There is no objection in principle to hubs, but their location is important.
Flint Community Hospital SM outlines questions and some points made by constituents at recent surgeries – for example. What is the status of the Jones report? Following the Jones report, how can the BCUHB propose the closure of the hospital? Flint hospital costs less than £1M per annum and affordable. Many people did not receive the consultation leaflet. There is no business plan giving financial details for Flint. Closure will impact on the economy of Flint citing and there will be transport costs to Holywell. Flint’s population is projected to increase. Will League of Friends money go to central resources? Closing Flint will increase bed-blocking elsewhere. Alternative services need to be in place before closure. SM also summarised respondents’ comments in other submissions. Most of them spoke of the esteem in which they hold the hospital and its inpatient beds and the MIU. They spoke of exemplary care received by loved ones in the past. Transport is a recurrent concern because journeys by public transport to Holywell can be arduous for older and infirm people and costly for those making regular visits who may be on low incomes. Those using their own transport could face congestion on the A55 during holiday and peak times and that similar problems occur when travelling to Deeside or to Wrexham. Regarding the MIU, people who have previously visited Wrexham had faced long waits for attention which exacerbated the journey length. The present location is felt to be most convenient. Regarding beds, several people and organisations felt the cost of less than £1m per annum was reasonable and that the building in Flint had been left to decline. In regard to Primary Health Care provision, GPs in Flint have expressed a wish that this moves ahead as provision will replace badly over-crowded surgeries. An area of concern is the Borough Grove Health Clinic about which something should be done. People have said that hospital care will always be required by some patients either because their needs are very complex or because they live alone and cannot depend for support on relatives or neighbours.
Mold Minor Injuries and X-Ray Unit Major objections have been raised about the proposals for Mold, mainly based on the transport issues between Mold and Wrexham or Deeside. Regarding transfer to Deeside in particular it has been asked why the Deeside patients could not transfer to Mold? The MIU and X ray departments are very well used and transfer of patients to other centres will create congestion there. There are many schools in the area who use these services and also visitors to the town; and the extra strain on the ambulance service has also
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been raised. This group also point out that those unable to attend the units are as likely to visit a GP practice as travel elsewhere. The usage figures of the Mold units which seem not to reflect the real situation.
Strategic Points SM says that there is no objection in principle to the provision of hubs, but locations are important and advance training but will sometimes be required, and some additional posts. Palliative care should be analysed in detail. Whatever the Board decides must be safe and sustainable to meet the needs of an ever- growing population and be easy to access. The timeline in existing documents is frighteningly long and will have to shorten considerably to give confidence in the process.
Darren Millar AM (DM)
The submission accepts the proposal for vascular services, but criticises plans for neonatal services while also objecting to proposals for minor injuries and X-Ray services at Colwyn Bay and Ruthin. (ORS)
Neonatal Intensive Care Services AM strongly opposes the relocation of longer-term neonatal intensive care services from North Wales to Arrowe Park. With an annual birth rate of around 7,500 births, North Wales should retain its own neonatal intensive care unit. There are concerns about quality of care and staffing ratios at Arrowe Park and its services do not meet national standards. There is also a potential for conflicting standards of care between Wales and England in the future. The claim that only 36 babies a year would be affected is disputed by those currently providing these services. BCUHB has given insufficient weight to the travelling difficulties for families, particularly those using public transport, and to nationality issues for mothers no longer able to have their babies born in Wales. BCUHB’s own clinical reference group would prefer to develop a single long-term neonatal intensive care unit in North Wales.
Minor Injuries and X-Ray Services There is strong opposition to closing the minor injuries unit at Colwyn Bay Community Hospital and minor injuries and X-Ray services at Ruthin Community Hospital. BCUHB appears to be using data for whole-year attendances at other hospitals and comparing this to a period in which MIUs of the hospitals in question were closed for a period of three months. Poor signage at Colwyn Bay and Ruthin has contributed to lower attendances there than at Llandudno. Signage issues may be contributing to the growing use of emergency departments at district general hospitals and the reduction in patients using MIUs. The emergency department at Ysbyty Glan Clwyd is already incredibly busy and regularly fails to meet waiting time targets, so closing minor injuries units in Colwyn Bay and Ruthin is likely to increase pressure there. Moreover, closing minor injuries could lead to the loss of other services when there are plans for housing growth in both Conwy and Denbighshire.
Issues specific to Colwyn Bay The commitment to provide additional services in the community is welcomed, but these services should not be used as an excuse to reduce inpatient beds in community hospitals, particularly given the ageing demographics in Conwy and Denbighshire. Should the proposed MIU closure go ahead, then Colwyn Bay
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will be the only major town in North Wales without an MIU service – but coastal regeneration in the area will only increase demand and the town has an elderly population with transport difficulties.
Issues specific to Ruthin Ruthin Community Hospital serves a population from many miles around and this wider catchment seems to have been overlooked by BCUHB. The choice of Denbigh Infirmary as the hospital hub for south Denbighshire is inappropriate due to its proximity to Ysbyty Glan Clwyd whereas Ruthin Community Hospital would be a better location. Public transport in rural Denbighshire is poor and access to the MIU and X-Ray services at Denbigh Infirmary is likely to become even more difficult. Weather is also a significant challenge in south Denbighshire and even those with their own transport face challenges. If services at Ruthin Community Hospital were to close, then accessing MIU and X-Ray services further from home would be more difficult than in densely populated urban areas with better transport links. The loss of X-Ray services at Ruthin will also result in the loss of outpatient clinics and undermine the viability of the specialisms in inpatient services which have been developed over the past few years. Orthopaedic inpatient transfers to Ruthin instead of the DGH are likely to be affected. It is inconsistent to retain X-Ray facilities at other hospitals, which see fewer patients. Rather than closing services at Ruthin Community Hospital, BCHUB should expand the range of outpatient clinics which operate from the hospital in order to make secondary care services more accessible for the people of south Denbighshire.
Vascular Services There seems to be no general opposition to the proposals for vascular services and Glan Clwyd is ideally placed to be the single centre.
Older People’s Mental Health The proposals for older people’s mental health are welcomed, but BCUHB should give more thought to how the transition to these services can be achieved: it is important to retain mental health inpatient beds at their current levels whilst new services are being established.
Consultation Process DM is concerned by the way the public consultation has been conducted. The decision to consult on preferred options has led some to believe it is a fait accompli. It is disappointing that there were failures in the Royal Mail’s delivery of the public information these leaflets in parts of North Wales, including in Colwyn Bay. A major criticism of the consultation process has been the need to ‘ring and book' a place at the events: these should have been complemented by open public meetings, which the public much prefer. DM is disappointed that the Health Board declined invitations to send representatives meetings organised by councillors and AMs.
Aled Rhys Roberts AM (ARR)
ARR accepts the need to reform healthcare to, but he feels that more evidence and implementation planning is required before changes can be justified in practice.
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Need for Reform ARR sees the challenge facing BCUHB (especially in terms of budget pressures and catering for an ageing population), but he requires additional details before accepting some proposals. He accepts, though, that there is no justification for further investment in resources (including X-Ray) where there is a lack of demand. More Evidence Required ARR requires more detail about plans to centralise some services, particularly in terms of the capital funding available for new centres in Llangollen, Rhyl and Flint. Services should not be removed before specific timetables and assurances of financial support are received from the WG. In particular, there is a need for support from GPs for Enhanced Care at Home services, but there has been a lack of detailed implementation planning with local government. Neonatal Intensive Services ARR cannot support outsourcing level 3 intensive neonatal services to Arrowe Park: he is unconvinced that such services cannot be provided within North Wales. He believes the Wales Deanery will not provide training where there is no level 3 provision, so there is a danger that Level 1 and 2 Neonatal Services will suffer. He says that the proposal is not supported by clinical staff and that insufficient information has been provided on transport arrangements for families and on how services in England will prioritise Welsh patients compared with English ones. He says that BCUHB’s performance has not been acceptable and it should confirm that it will comply with UK neonatal service standards after any changes are implemented.
Chris Ruane, MP (CR)
CR expresses concerns about the conduct of the consultation. (ORS)
CR passes on concerns about the pre-registration requirement for attendees at the public meetings and says that consultation events should be clinician-led and contextualise proposals within the wider vision of the aims of health improvements over the next 10 to 15 years.
Antoinette Sandbach AM (AS)
AS The distribution of information about the consultation proposals has not been effective in all cases and so the response timetable should be extended. Level 3 neonatal services should be retained at Glan Clwyd, not outsourced to Arrowe Park, and community hospitals should not be closed on the basis of current evidence. (ORS)
Distribution of Information Because the residents of Llangernyw did not receive notification of the changes being recommended by BCHUB, the timetable for responses should be extended.
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Health Care Service in North Wales
Introduction There is strong public opposition to many of the proposals has been evident, particularly in Flint, Colwyn Bay, Prestatyn and Rhyl. Future plans should be progressed with the support of local communities.
Neo Natal Services AS fundamentally opposes the removal of all neonatal care from North Wales and does not believe Arrowe Park is an effective alternative. There will be problem for patients from rural and western areas, with the possibility that mothers will be separated from their babies, and families will be disrupted. Public transport to the Wirral is very difficult. In any case, Arrowe Park cannot offer better care than Glan Clwyd (it does not meet national guidelines for nurse staffing); moving level 3 services will undermine training for Senior House Officer Doctors; Arrowe Park will be more expensive. These and other concerns have been raised by the Advanced Neonatal Nurse Practitioners, based at Glan Clwyd. Should the proposal go ahead, there will be grave consequences, including that the downgrading of services across North Wales will mean a loss of specialist doctors. As well as travelling difficulties there will be issues about children’s nationality and Welsh speaking. AS has been circulating a petition to retain neonatal services at Glan Clwyd hospital and Cuddles have a petition as well. Public anger at these proposals has been palpable.
Community Hospitals Local facilities should not be closed until a full business case for the alternatives has been approved and the new sites identified and constructed. If facilities are eventually closed then any funds from land sales should be shared with the communities concerned.
Ken Skates AM (KS)
The submissions supports health service reform and the new health centre in Llangollen, but seeks information to set the record straight and to ensure that all avenues are explored before changes are implemented at Chirk and Llangollen. (ORS)
Llangollen Community Hospital KS supports the proposals to reform health services in a way that will deliver greater consistency. He supports building a new health centre at Riverside Lodge, but he raises a number of questions in order to counter local anxieties. For example, what are the beds currently used for and how many staff are there? When would the hospital be closed and what would happen to the site? What progress has been made in buying the Riverside Lodge from the Welsh Government and when could work start on the new health centre? When would the new health centre open and what services would be there? Do GPS support the new services there? How would any lacunae between the hospital closing and the new centre opening be bridged? Will there be job losses? Will there be savings if BCUHB buys in beds in residential homes and/or Chirk Hospital?
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KS also says that because the new health centre would be located on the edge of Llangollen it would need improved access and a dedicated bus service to/from town centre. He also asks for a guarantee that existing services in Llangollen will continue until the new facility is opened.
Chirk Hospital KS says that, having spoken with many nurses and doctors, he is convinced that MIU staff skills are not being sufficiently tested or maintained by low attendance numbers at Chirk. However, he is concerned about the consolidation of MlUs in hospital hubs where there are also A&E services because some people might see accessing A&E as a shortcut to receiving treatment and could therefore call emergency services in order to by-pass hospital queues. Overall, he believes it is important that every avenue is explored prior to MIU closure, including the potential of rotating MIU staff regularly from quiet to busy units so they can continuously refresh their skills; but, if this is not viable, it could be beneficial to engage GPs in the provision of minor injuries treatment.
Joyce Watson AM (JW)
JW reports the objections to the closure of Blaenau Ffestiniog hospital, which will lead to considerable access problems for local people. (ORS)
Blaenau Ffestiniog Hosptial JW reports local views that, while people can understand the need to prioritise spending, they did not see that care in the community could be adequately delivered without services and beds at Blaenau Ffestiniog Hospital. When Ysbyty Alltwen was built, there were assurances that Ffestiniog Hospital would not be reduced. The hospital is 30 miles from Bangor and at the heart of an elderly rural community living in small terraced houses that are unsuitable for in-home nursing; and the nearby working quarry, factory, schools and mountain bike trail all necessitate a community health centre. When the minor injuries unit was closed during the summer, the ambulance Service reported significantly more calls-out. There is a common perception that Ysbyty Alltwen cannot always deal with minor injuries, so people are going to Bangor Community Hospital, thus distorting the figures for local need. Travel is a major problem, with uncertainty over the future of bus services. Finally, the nearest nursing home is in Porthmadog and capacity is already stretched.
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Analysis of Other Submissions
5.7 ORS has reviewed all of the submissions and categorised them for ease of analysis and to identify key themes. Based on ORS’ classification, the number of submissions per category is below: Special Interest (including Voluntary and Community) Groups – 74 GPs and other Health Professionals – 21 BCUHB Staff – 36 County Councillors – 20 Town and Community Councils/Councillors – 36 Residents – 535 5.8 The key themes are reported in the tables below.
Submissions from Special Interest Groups (inc. Voluntary/Community Groups)
Figure 48: Summary of submissions from Special Interest Groups (including Voluntary/Community Groups) – total of 74 submissions, in addition to those summarised as key submissions above
Contributors: Key Themes and Arguments Special Interest Groups MOLD COMMUNITY HOSPITAL Against closure of X-Ray and Minor Injuries Units at Mold Community Hospital Domestic Abuse Safety Unit Shotton MIU well-used by large population Ysgol Gynradd Bryn Coch Prompt and excellent service provided Nercwys Voluntary Aided Primary Distance to other hospitals (Wrexham/Deeside) School Transport costs/poor public transport links to other hospitals Mold Community Hospital Palliative Mold on major bus route – accessible and convenient Care Patients Increased pressure on Ambulance Service and other hospitals (already Mold Hospital League of Friends (3 busy/long waiting times) submissions) Parking issues at Wrexham Maelor Ysgol Gymraeg Glanrafon Particularly negative impact on elderly and infirm Gwernaffield Women's Institute Disruption to local schools/children Padeswood Residents Local people raised funds for equipment, which should remain in community Welsh Presbyterian Church, Mold use Mold WI (2 submissions) Mold Hospital League of Friends’ offer to buy an X-Ray machine should be Sychdyn WI accepted. FLINT COMMUNITY HOSPITAL Against closure of Flint Community Hospital Flint Over 50s Action Group (2 Well-used by large population submissions) Distance to Holywell and Deeside Flint Over 50s Forum Transport costs and poor public transport links to Holywell and Deeside - Knights Green Residents' Association especially difficult for elderly patients or those with no relatives/friends to Castle Heights Residents' Association take them Castle Kids Club Increased pressure on Ambulance Service and other hospitals (already Gwernaffield WI busy/long waiting times) Cytun - Churches Together Flint and Difficult to park at larger hospitals District Community hospital needed given size of (growing) population Royal British Legion, Flint Branch Convenient for patients/visitors Committee People may ignore minor injuries or miss appointments as they do not want Parish of Flint to/cannot travel elsewhere Bolingbroke and Richard Heights Loss of inpatient beds – and insufficient provision at Holywell Residents' Association Pressure on hospices and nursing homes. Flint Mountain Women's Institute Lack of detail in consultation document regarding Primary Care Resource Centre.
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Contributors: Key Themes and Arguments Special Interest Groups RUTHIN COMMUNITY HOSPITAL Against closure of X-Ray and Minor Injuries Units at Ruthin Community Hospital Ruthin Hospital Action Group Distance and transport costs to Glan Clwyd/Denbigh Ysgol Brynhyfryd, Ruthin Provides valuable service for schools in the area League of Friends of Ruthin Hospital Increased demand at other hospitals/on Ambulance Service Vital for consultation and clinics. Must ensure GPs willing to deal with injuries before closure. Questions about research done into making Ruthin the 'hub' – services wider catchment area than Denbigh. NEONATAL INTENSIVE CARE SERVICES Most against provision of Neonatal Intensive Care Services from Arrowe Park Bliss (charity for premature babies) Distance and travel costs – especially for those in West Cuddles Increased travel distances increased risk to babies/mothers Merched y Wawr Uwchaled Practical/emotional strain on parents Difficult for parents - especially those unable to stay at Arrowe Park - to bond with babies Difficult for extended family to provide support due to distance Excellent care at existing hospitals Need to keep services in Wales (parents should have right to have babies in Wales/interact with staff in Welsh) Arrowe Park does not meet BAPM standards More cots in Wrexham/Glan Clwyd than at Arrowe Park One-to-one care in Wrexham/Glan Clwyd (one-to-two in Arrowe Park) Arrowe Park could increase contract costs in future ‘Other’ babies will receive worse service in North Wales due to fewer specialists Potential negative impact on recruitment to remaining services – and de- skilling of BCUHB staff. Some support Staffing levels within North Wales Neonatal Service do not meet standards Develop services in North Wales expensive and depends on attracting doctors with skills/expertise Number of babies needing intensive care not enough to sustain North Wales service Better outcomes if care is centralised so proposal is most acceptable solution. BUT Arrowe Park must meet standards After-care must be provided close to home Existing services must receive investment for 'other' babies Neonatal Transport Service must be effective Must consider financial, emotional, practical impact on families - with appropriate support i.e. financial help, accommodation for skin-to-skin contact. BRYN BERYL HOSPITAL Against closure of X-Ray service at Bryn Beryl Hospital Y Ffor Pensioners' Club Convenient/accessible local service Long journey to Ysbyty Gwynedd/Alltwen Good personal experiences. COLWYN BAY HOSPITAL Against closure of MIU at Colwyn Bay Community Hospital Bay of Colwyn Chamber of Trade Difficult journey to Glan Clwyd or Llandudno The Glyn Community Association New developments being built increased population Closure will have major impact on schools. BLAENAU FFESTINIOG MEMORIAL Against closure of Blaenau Ffestiniog Memorial Hospital HOSPITAL Very well used Blaenau Ffestiniog Disabled Club Excellent staff.
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Contributors: Key Themes and Arguments Special Interest Groups TYWYN COMMUNITY HOSPITAL Against closure of X-Ray unit and reduction of MIU opening hours at Tywyn Tywyn Hospital Appeal Fund (3 Community Hospital submissions) Distance and travel costs to other hospitals (especially for elderly and frail Ysgol Penybryn, Tywyn patients) The Alexandra Nursing Home, Tywyn Inadequate public transport links to hub hospitals Ysgol Ywchradd Tywyn Well used by local schools and residential care homes Hilsboro Residential Home, Tywyn Will lead to loss of other outpatient clinics Llys Cadfan Residential Home, Tywyn Increased demand on Ambulance Service Rotary Club of Tywyn Another community service lost South Meirionnydd Older People's X-Ray machine purchased through local fundraising and should not be moved Forum elsewhere Talyllyn Railway and Council Will affect tourist trade – must cater for increased numbers of holidaymakers Committees associated with the in summer. railway Vicar of the Tywyn Group of Churches NORTH DENBIGHSHIRE Notes of public meetings held. (Royal Alexandra Hospital, Rhyl and Prestatyn Community Hospital) Prestatyn Community Hospital Action Committee (2 submissions) GENERAL COMMENTS General opposition to some or all proposals (reflecting concerns reported above). Merched y Wawr Colwyn District Opposition to closure of community hospitals generally Welsh Women's Aid Distance and cost of travel to ‘specialist’ centres Gwynedd Carers' Partnership People can be treated in own locality near loved ones Together Creating Communities Local hospitals offer more personal service Learning Disability Group, Prestatyn Will increase pressure on acute hospitals Dolgellau & District Branch of Merched No assurance capital is available to build proposed health centres y Wawr No room in private nursing homes St David's Hospice Ageing population requires more community beds for rehabilitation and to Bretton Residents' Action Group avoid bed-blocking (shortage of beds at acute hospitals) Merched y Wawr Llansannan Cost to Ambulance Service/Social Services. Blood Bikers Wales Some support for proposals Nightingale House Hospice Need for change in current economic climate and to ensure robust services for Cragen Llyn a Mon the future Age Concern North Wales Central Rhyl/Prestatyn – support providing new facility in place before closure of Age Well Amlwch and Llangefni existing ones Soroptimist International Bangor and Widespread support for centralisation of vascular services (at Glan Clwyd) District Some support for providing Neonatal Intensive Care Services from Arrowe Presbyterian Church of Wales Park – better patient outcomes Boots UK Older People’s Mental Health – providing there is sufficient support for patients/carers. Merched y Wawr Colwyn Area Support for care closer to home, but also some concerns The Bishop of St Asaph, Gergory K Cameron Staffing levels – services already stretched Xpress Publishing Cost of Enhanced Care at Home service Cancer Network Patient Forum Support available for carers Wrexham Local Service Board Rurality of North Wales Blaenau Ffestiniog Memorial Hospital IT software needs to be improved – as does communication between all Defence Committee agencies Increased pressure on social services, GPs and district nurses Important that community workers can speak Welsh Community services must be in place before secondary care services reduced GPs ready/willing to take on extra responsibility?
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Contributors: Key Themes and Arguments Special Interest Groups Concerns about consultation process Inclusivity of public meetings Payment for focus groups Wording of questions in consultation questionnaire Consultation period too short Decisions appear to have been made Lack of detail on proposals. More needs to be done to recruit doctors to Wales. End of life care needs greater emphasis, as does care of bereaved relatives in community. Proposals will have an adverse effect on adults with learning disability not fair to have to travel for treatment as have additional health needs.
Submissions from GPs and Other Health Professionals
Figure 49: Summary of submissions from GPs and Other Health Professionals – total of 21 submissions
Contributors: Key Themes and Arguments GPs and Other Health Professionals VASCULAR SERVICES Against centralisation of Vascular services on one site Victoria Surgery, Holyhead (2 Quality and safety likely to be compromised submissions) Excessive travel distances/costs Waunfawr Surgery, Caernarfon Ambulance service already overstretched The Surgery, Chirk Proposals do not consider impact centralisation would have on other aspects of vascular provision Would cost significantly more to establish than two-site model. NEONATAL INTENSIVE CARE SERVICES Against proposal to deliver NICU from Arrowe Park GP (unknown location) Travel distance/poor transport links GP (Denbigh) Welsh people should be cared for in their own country Nurse (Bronglais Hospital) NICU should be in North Wales at Glan Clwyd. Head of Social Services (Children) Minority support for proposal, providing transport links and community services are strengthened. BRYN BERYL HOSPITAL Against downgrading of services at Bryn Beryl Hospital Meddygfa Rhydbach Travel distance (and costs) to alternative hospitals Nefyn and Botwnnog Surgeries Limited public transport services GP (Dwyfor) Convenience for elderly population Loss of X-Ray adverse effect on clinics and will not attract services to the hospital Detrimental to efficient use of inpatient/outpatient services Will lead to inequality of care. TYWYN COMMUNITY HOSPITAL Against reduction of X-Ray service and MIU at Tywyn The Health Centre, Tywyn Tywyn should be Hub with full X-Ray and Minor Injuries Services GP (Tywyn) Distance to other hospitals Viable service. ERYRI HOSPITAL Opposed to closure of X-Ray facility at Eryri Hospital Meddygfa Waunfawr Additional demand on acute hospitals GP (Felinheli) Travel distance to alternative hospitals Impact on elderly population Further threatens reduction in local services. MOLD COMMUNITY HOSPITAL General opposition to closure of MIU and X-Ray department at Mold Community Bradley's Practice, Pendre Surgery and Hospital Grosvenor Medical Practice Negative effect on those with families, the elderly and those on low incomes
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Contributors: Key Themes and Arguments GPs and Other Health Professionals Travel distance and transport costs Existing staff work together well Important local services lost forever for minimal financial gain Concerns about capacity of King Street District Nurse clinic to take on additional work - waiting times excessive Consultation data inaccurate. FLINT COMMUNITY HOSPITAL Support hospital ‘hub’ model for Flint Holywell Hospital in better position to The Laurels Surgery, Allt Goch Medical provide good service. Centre, Eyton Surgery Some concerns over equality of care/reduction of beds (should retain a few). Support primary/community care proposals. BLAENAU FFESTINIOG MEMORIAL Opposed to closure of Blaenau Ffestiniog Memorial Hospital. HOSPITAL X-Ray Department critical to practice good medicine in the Community. Meddygon y Blaenau Distance and poor transport links to Ysbyty Gwynedd. Proposals will/already are having detrimental effect on practice. RUTHIN COMMUNITY HOSPITAL Opposed to closure of Ruthin MIU Plas Meddyg and Mount Street Transport issues for elderly surgeries Public transport must be enhanced to support change. Maintain primary care support services at Ruthin Hospital. Maintain out-of-hours service at Denbigh. GENERAL COMMENTS Changes expensive and ineffective. GP (Beaumaris) Proposals for care in the community will lead to elderly and frail patients being GP (Conwy) cared for at home by equally frail and elderly partners. Velindre NHS Trust Opposed to proposed provision of NICS from Arrowe Park Distance from certain parts of North Wales Social factors need to be taken into account.
Submissions from BCUHB staff
Figure 50: Summary of submissions from BCUHB staff – total of 36 submissions, in addition to those summarised as key submissions above
Contributors: Key Themes and Arguments BCUHB staff NEONATAL INTENSIVE CARE SERVICES Against proposal to deliver NICU from Arrowe Park Falls Coordinator, BCUHB – 2 Increased travel distances will result in increased risk to babies and mothers submissions Time-consuming transfers from certain areas to Arrowe Park Occupational Health employee, BCUHB Could lead to isolation of mothers Consultant Ophthalmologist, Stanley Public transport to Arrowe Park expensive, time-consuming and difficult Eye Unit Excellent care at existing hospitals Neonatal Nurse, Ysbyty Glan Clwyd Arrowe Park currently offers nothing more than Glan Clwyd or Wrexham Maelor – and apparently not enough capacity for North Wales babies De-skilling of North Wales staff and downgraded service at North Wales hospitals Could impact on neonatal training for nurses Need for Welsh-speaking staff for those who wish to speak the language. NICU should be centralised at one unit in North Wales (or even at Liverpool Women’s Hospital). BRYN BERYL HOSPITAL Against downgrading of services at Bryn Beryl Hospital Locality Matron, Bryn Beryl & Alltwen Concern about poor public transport and distance/travel cost to other Clinical Practitioner, MIU, Bryn Beryl hospitals Senior Pharmacist - Primary Moving inpatients for X-Ray at Dolgellau will be distressing Care/Community Hospital Services Proposed rollout of more services demand for X-Ray services will increase
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Contributors: Key Themes and Arguments BCUHB staff (Dwyfor) Service underused before 10am and after 9pm but need to provide MIU Anonymous submission during GP out-of-hours. X-Ray at Bryn Beryl busier than Dolgellau could have it at Dolgellau three days a week and Bryn Beryl two days a week. ERYRI HOSPITAL Opposed to closure of X-Ray department at Eryri Hospital. Radiology Department, Eryri Good service for elderly requiring continuous treatment Physiotherapist, Eryri Provides valuable service to acute unit Associate Specialist, Medicine/Care of Cost of transfer for X-Ray the Elderly, Eryri Must be successful outpatient clinics that require X-Ray facilities (i.e. new COPD clinic removed if no X-Ray service on site) Will have a negative impact on physiotherapy/rehabilitation Transfer to Ysbyty Gwynedd will take too long and will lead to increased delays Detrimental effect on quality of care More personal service. FLINT COMMUNITY HOSPITAL Opposed to closure of Flint Community Hospital Nurse, Flint Hospital Palliative beds required in Flint for care that cannot be provided at home Team Secretary, Flintshire CAMHS Distance to Hollywell (especially for elderly population) Public transport to, and location of bus stop in, Holywell is poor. MOLD COMMUNITY HOSPITAL Against closure of MIU and X-Ray service at Mold Community Hospital BCUHB employee (Planning) Excellent personal experience Blood Borne Virus Nurse, BCUHB MIU should be available in each locality Proposals favour some communities over others. RUTHIN COMMUNITY HOSPITAL Against closure of X-Ray department at Ruthin Community Hospital Nurse Practitioner, MIU, Ruthin Negative impact on elderly population. Staff Nurse, MIU, Ruthin Already no beds available at Glan Clwyd and Wrexham Will increase Ambulance Service costs Distance and difficult travel to alternative hospitals Impact on relatives who will have to take time off work to transport patients. CHIRK COMMUNITY HOSPITAL Concern about lack of ‘hub’ for North East Wales. Nothing to cover Wrexham Cardiology and Cardiac Physiology population Chirk Hospital should be classed as hub. Service Manager, Wrexham Maelor VASCULAR SERVICES Importance of having necessary support services e.g. adequate transport service Medical Records Manager, Glan Clwyd for medical records (current service between three acute sites can be slow). CEFNI HOSPITAL Keep all current services at Cefni Hospital Pharmacist, Ysbyty Gwynedd Excellent service Increased pressure on Ysbyty Gwynedd. There needs to be better communication and links with social care, especially for dementia patients. PRESTATYN COMMUNITY HOSPITAL Opposed to closure of Prestatyn Community Hospital BCUHB employee, Prestatyn CH Better care at smaller community hospitals Concern over travelling issues for elderly Care at home does not work for everyone Will increase bed blocking at main hospitals. TYWYN COMMUNITY HOSPITAL Against closure of X-Ray unit and MIU at Tywyn Hospital Clinical Practitioner, MIU, Tywyn Very well-used service Geographically necessary to have services in Tywyn – too great a distance to other hospitals Proposed reduction in opening hours inadequate, especially to cover out-of- hours period Service underused and staff skills being wasted
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Contributors: Key Themes and Arguments BCUHB staff Will lead to loss of other services i.e. orthopaedics Pressure on other hospitals, Ambulance Service and hospital transport Inaccurate data used to support proposal. GENERAL COMMENTS Support for proposals Quality and Practice Devt. Nurse, Rational, sensible, forward thinking and cost-effective. Corporate Nursing Opposition to proposals Nurse Metrics Lead, Ysbyty Gwynedd Cost-savings likely to be minimal Retired Consultant Surgeon YGC Closing MIUs may worsen patients’ health across North Wales. Consultant Child and Adolescent Need for more local services in smaller hospitals (e.g. Ultrasonographers at Psychiatrist, CAMHS Ysbyty Gwynedd happy to support this and can rotate/perform X-Rays if Psychological Therapist, CAMHS required). Associate Specialist Oral/Maxillofacial General comments on: Surgery Improvements needed to CAHMS service i.e. Ultrasonographer, Ysbyty Gwynedd Clinic in Llangollen/Corwen Theatres employee, BCUHB Room at Blaenau Ffestiniog Memorial Hospital and Tywyn Community Administration employee, BCUHB Hospital Mental Health employee, BCUHB Systems for easy access to other health records BCUHB employee (location unknown) Tele and video conferencing facilities. Need for thorough basic training for all front-line nursing staff Need for more money to be spent on services and less on management Need for more communication between staff and clearer information for patients.
Submissions from County Councillors
Figure 51: Summary of submissions from County Councillors – total of 20 submissions
Contributors: Key Themes and Arguments County Councillors MOLD COMMUNITY HOSPITAL General opposition to closure of MIU and X-Ray department at Mold Community Cllr Bateman Hospital Cllr Hilary McGuill Hospital easily accessible by public transport (easier to access than Deeside) Cllr Chris Bithell Distance and travel costs to Wrexham/Deeside Cllr Cindy Hinds Impact on families/friends who have to take time off work to take patients to Cllr Nancy Matthews Wrexham/Deeside People may ignore minor injuries or miss appointments as they do not want to/cannot travel elswehere Additional burden on Wrexham Maelor No MIU at Deeside currently - would be cheaper to have it at Mold Mold has large catchment area and many businesses MIU well used by local schoolchildren. Mold Hospital League of Friends’ offer to buy an X-Ray machine should be accepted. TYWYN COMMUNITY HOSPITAL Against proposal to close X-Ray services and reduce MIU at Tywyn Cllr Anne Lloyd-Jones Concern over transport and travel distance Cllr Mike Stevens Excellent existing service – should be expanded and improved. FLINT COMMUNITY HOSPITAL Opposition to closure of Flint Community Hospital Cllr Rita Johnson One of largest towns in Flintshire Proposed new Primary Care Resource Centre has no funding currently. COLWYN BAY COMMUNITY HOSPITAL Against proposed closure of MIU at Colwyn Bay Community Hospital. Cllrs Carlisle and Cossey Request for information about what will be provided at the hospital in future.
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Contributors: Key Themes and Arguments County Councillors BRYN BERYL HOSPITAL Against downgrading of Bryn Beryl Hospital. Cllr Angela Russell Negative effect on vulnerable people Concern over distance to travel elsewhere. Consultation period should have been longer. ROYAL ALEXANDRA HOSPITAL, Against proposed closure of Prestatyn Community Hospital – at least until new PRESTATYN COMMUNITY HOSPITAL, facility in place. RUTHIN COMMUNITY HOSPITAL AND Questioned why alternative sites within Prestatyn disregarded in favour of NEONATAL INTENSIVE CARE SERVICES moving facility to Rhyl. Denbighshire County Council & Royal Alexandra is in poor condition and, as it is a Grade II listed building, will be Prestatyn Conservative Groups costly/difficult to renovate. Against proposal for NICS at Arrowe Park Increase risk to new mothers/babies Remove parents’ right of parents to have their children born in Wales. Ruthin Community Hospital Geographical area covered by Ruthin so wide significant case for retaining both Denbigh and Ruthin as joint hub for South Denbighshire area. NEONATAL INTENSIVE CARE SERVICES Opposed to proposed provision of NICS from Arrowe Park AND GENERAL COMMENTS Does not have required staff/facilities Cllr Marc Jones Ratio of staff/cots better in North Wales currently Wrexham Independent Group Distance could impact on mother’s ability to breastfeed If capacity reached - will be transferred De-skilling of staff at North Wales facilities. General Against closure of local hospitals/X-Ray departments/MIUs. GENERAL COMMENTS General opposition to some or all proposals. Cllr Eryl Jones-Williams Consultation process flawed Cllr David Williams Decisions already made Cllr Cheryl Carlisle People in some areas not sufficiently consulted Cllr Peter Lewis Some support for enhanced care at home proposals – but concern they will not Cllr Carol Ellis deliver desired outcomes. Cllr Carole O'Toole General concerns about Closure of community hospitals additional pressure on emergency services and acute hospitals Travel distances to ‘specialist’ centres Quality of transport infrastructure Need for community services to be in place prior to removal of secondary care facilities. Some support for proposals – especially Vascular Centre of Excellence (preferably in Glan Clwyd).
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Submissions from Town and Community Councils/Councillors
Figure 52: Summary of submissions from Town and Community Councils/Councillors – total of 36 submissions
Contributors: Key Themes and Arguments Town and Community Councils FLINT COMMUNITY HOSPITAL Opposition to closure of Flint Community Hospital Flint Town Council (4 submissions) Essential for people of Flint Mostyn Community Council Services should be improved not removed North Wales Association of Town and Adverse affect on rural community Larger Community Councils Holywell already overburdened – insufficient patient provision. Cllr Vicky Perfect Some desire for clearer understanding of thought process behind closure. Bagillt Community Council Some cautious welcome for Primary Care Resource Centre - providing it is in Pen-y-ffordd Community Council place before existing services removed. MOLD COMMUNITY HOSPITAL General opposition to closure of MIU and X-Ray department at Mold Community Buckley Town Council Hospital Treuddyn & Llanfynydd (Pontybodkin) Distance and travel costs to Wrexham/Deeside Comm Councils Poor access and public transport links to alternative hospitals Gwernymynydd Community Council Additional burden on Ambulance Service (already stretched) Mold Town Council Negative impact on rural community Leeswood Community Council Additional burden on Wrexham Maelor Hope Community Council MIU well used by local schoolchildren. Mold Hospital League of Friends’ offer to buy an X-Ray machine should be accepted. TYWYN COMMUNITY HOSPITAL Against proposal to close X-Ray service and reduce MIU at Tywyn Community Tywyn Town Council Hospital Councillor David Church Distance and travel costs to alternative hospitals Llangelynnin Community Council Limited public transport to alternative hospitals Cyngor Cymued Bryncrug Community Increased demand on Ambulance Service Council/Cyngor Llanfihangel y Pennant Valuable local resource Community Council Negative impact on families/elderly Aberdyfi Community Council Excellent level of service provided currently Caernarfon Royal Town Council Hub at Dolgellau not reachable in 40 minutes Must cater for summer holidaymakers. RUTHIN COMMUNITY HOSPITAL Against closure of X-Ray and Minor Injuries departments at Ruthin Community (AND OTHER PROPOSALS) Hospital Llanfihangel Glyn Myfyr Community Distance and transport costs to alternative hospitals - especially from places Council like Corwen and Cerrig-y-Drudion Llanfair Dyffryn Clwyd Community Serves large and ageing population Council Increased pressure on local GPs and Ysbyty Glan Clwyd. Ruthin Town Council Against provision of Neonatal Services at Arrowe Park - need Welsh-speaking staff. Support vascular proposals – providing: Ambulance Service fully prepared for urgent transfers 'Other' hospitals not downgraded and allowed to develop specialisms in other areas. COLWYN BAY COMMUNITY HOSPITAL Against proposed closure of MIU at Colwyn Bay Community Hospital. (AND OTHER PROPOSALS) Distance and transport costs to Llandudno Hospital Bay of Colwyn Town Council Increased demand on Ysbyty Glan Clwyd (and parking is problematic). Support proposal for enhanced care at home. Support principles for older people’s mental health proposals – but concern over funding, working relationship with Social Services and support for carers. Support neonatal proposals and centralisation of vascular services (at Glan Clwyd as it is central).
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Contributors: Key Themes and Arguments Town and Community Councils DENBIGH COMMUNITY HOSPITAL Proposals for Denbigh Community Hospital supported. Denbigh Town Council ERYRI COMMUNITY HOSPITAL Against closure of X-Ray department at Eryri hospital Llanddeiniolen Community Council Distance and transport costs to alternative hospitals Ysbyty Gwynedd already overloaded. BLAENAU FFESTINIOG MEMORIAL Against closure of Blaenau Ffestiniog Memorial Hospital HOSPITAL Third largest town in Gwynedd Ffestiniog Town Council Many elderly people and people without cars. Distance to Ysbyty Alltwen Essential that new centre up and running before closure. DOLGELLAU COMMUNITY HOSPITAL General opposition to any reduction in services at Dolgellau Hopsital. Cyngor Cymuned Llanelltyd NEONATAL INTENSIVE CARE SERVICES Opposed to proposed provision of NICS from Arrowe Park – expertise moving AND GENERAL COMMENTS further from the area. Dolbenmaen Community Council General concerns about: Cuts being proposed before improvements in place Lack of doctors in the area Effect of proposals on vulnerable people i.e young/ elderly Unachievable ‘urban’ targets being placed on rural areas Importance of transferring information between agencies such as doctors, ambulance service, social services etc. GENERAL COMMENTS General opposition to some or all proposals. Broughton & Bretton Community Hospital departments should communicate and work together better. Council More funding required for Mental Health Services. Cllr Douglas Madge, Deputy Mayor, Cross-border issues Bangor Welsh patients should retain ability to be treated in England if they so choose Gresford Community Council Importance of Welsh language within health provision Saltney Town Council General concerns about: North Wales Association of Town and Lack of consultation with some affected communities Community Councils BCUHB reneged on alleged promise that more beds would be provided Waunfawr Community Council Loss of services before replacements in place ‘Unacceptable’ loss of MIUs Ambulance waiting times BCUHB’s recruitment issues.
Submissions from Residents
Figure 53: Summary of submissions from Residents – total of 535 submissions
Contributors: Key Themes and Arguments Residents MOLD COMMUNITY HOSPITAL Against closure of X-Ray and Minor Injuries Units at Mold Community Hospital 134 residents Could lead to closure of entire hospital MIU well-used Prompt and excellent service Distance to Wrexham/Deeside – could put patients at risk Transport costs/poor public transport links to alternative hospitals Growing elderly population in area Particularly negative impact on elderly, disabled and children Wrexham Maelor already extremely busy Parking issues at Wrexham Maelor
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Contributors: Key Themes and Arguments Residents Increased pressure on Ambulance Service Disruption to local schools/children League of Friends’ offer to purchase new X-Ray machine should be accepted. LLANGOLLEN COMMUNITY HOSPITAL Opposition to closure of Llangollen Community Hospital 82 residents Distance and transport costs to Wrexham Maelor Poor transport links to alternative hospitals Increased demand on Wrexham Maelor Excellent and well-used service Convenient for patients/families Negative impact on elderly, children and those on low incomes Increased pressure on Ambulance Service Concerns about more care being provided at home Site earmarked for new centre (River Lodge) is inaccessible Existing site should be redeveloped. If proposal implemented, hospital should not be closed until new centre established. FLINT COMMUNITY HOSPITAL Against closure of Flint Hospital 62 residents Distance and transport costs to Holywell Poor transport links to Holywell (bus stop too far away from hospital) Community hospital needed given size of population Convenient, well-used and generally busy Excellent care Negative impact on elderly Increased pressure on Ambulance Service Hospital is being deliberately run down Concern over loss of palliative care Emotional attachment to hospital Existing site should be expanded/renovated. RUTHIN COMMUNITY HOSPITAL Against closure of X-Ray and Minor Injuries Units at Ruthin Community Hospital 41 residents Excellent and well used services Distance and transport costs to Glan Clwyd/Denbigh Poor public transport links to alternative hospitals Provides valuable service for schools Negative impact on elderly/children Increased pressure on GP services Increased pressure on acute hospitals increased delays/waiting times Goes against reassurances that services will be maintained. NEONATAL INTENSIVE CARE SERVICES Most against provision of Neonatal Intensive Care Services from Arrowe Park 33 residents Hospital Distance and travel costs – especially for those in West Increased travel distances increased risk to babies and mothers Difficult for parents who are unable to stay at Arrowe Park to bond with babies – and difficult for extended family to provide support due to distance Excellent care at existing hospitals Need to keep services in Wales (parents should be able to have their babies in Wales/interact with staff in Welsh) Arrowe Park already overstretched Potential negative impact on recruitment to remaining services – and de-skilling of BCUHB staff. Some support (better patient outcomes). BRYN BERYL HOSPITAL Against closure of X-Ray service at Bryn Beryl Hospital 23 residents Distance and transport costs to Ysbyty Gwynedd and other hospitals Ysbyty Gwynedd already over-stretched Convenient, excellent service
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Contributors: Key Themes and Arguments Residents Essential for elderly population Particularly important for ‘isolated’ Lleyn Peninsula. COLWYN BAY HOSPITAL Against closure of Minor Injuries Unit at Colwyn Bay Community Hospital 20 residents A&E services at Glan Clwyd already stretched Increased pressure on Ambulance Service Distance and transport costs to Glan Clwyd Use of MIU will increase due to new attractions in area Serves large population. BLAENAU FFESTINIOG MEMORIAL Against closure of Blaenau Ffestiniog Memorial Hospital HOSPITAL Distance and transport costs to Ysbyty Gwynedd/ Alltwen 13 residents Not providing care closer to home Excellent standard of care Convenient. TYWYN COMMUNITY HOSPITAL Against closure of X-Ray unit and reduction of MIU opening hours at Tywyn 12 residents Community Hospital Distance and inadequate public transport links to other hospitals Ambulance Services already strained Services should be improved not removed. NORTH DENBIGHSHIRE (ROYAL Mainly against closure of the two community hospitals ALEXANDRA, RHYL AND PRESTATYN Lack of rehabilitation facilities COMMUNITY HOSPITAL) 30 inpatient beds insufficient 9 residents Increased demand on Ambulance Service Excellent service Relieve pressure on acute hospitals Concern about Enhanced Care at Home (time available for patients) Services should only be closed when others are in place Some support for closures – expensive to run. VASCULAR SERVICES Concerns over distance to Centre/s of Excellence. 3 residents Excellent care provided at existing centres. CHIRK COMMUNITY HOSPITAL Against proposed changes to Chirk Community Hospital 2 residents Wrexham Maelor A&E and Ambulance Service already pressured Distance to alternative hospitals Elderly less stressed in familiar surroundings. DEESIDE COMMUNITY HOSPITAL Questions around what changes will mean for Deeside and what will be available at 2 residents Deeside Community Hospital Support for provision of more facilities at Deeside Community Hospital. DOLGELLAU AND BARMOUTH HOSPITAL Against proposal to permanently close Uned Meirion at Dolgellau and Barmouth 1 resident District Hospital (loss of respite care and concern over travel costs for patients). OLDER PEOPLE’S MENTAL HEALTH General concerns about proposals for Older People’s Mental Health and support 1 resident available for patients and carers. GENERAL COMMENTS General opposition to some or all proposals. 97 residents Opposition to closure of community hospitals generally Distance and travel costs to ‘specialist’ centres Increased pressure on acute hospitals. Concerns about consultation process Inclusivity of public meetings Decisions appear to have been made Assumes internet access Lack of detail on proposals. Cross-border issues Welsh patients should retain ability to be treated in England if they so choose [and vice versa]
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Contributors: Key Themes and Arguments Residents Hospitals in England slower to treat Welsh patients. Need for more and better health promotion within communities. More needs to be done to recruit doctors to Wales. Concerns about inefficiency and ‘waste’ within BCUHB Some support for proposals Sensible cost-cutting measures Preferable to provide care closer to home (providing it is done with adequate resources) Current services unsafe. Some alternative suggestions for change.
Consultation Questionnaire: Responses from Organisations
5.1 Of the 1,899 open consultation questionnaires received, a total of 55 responses were from organisations. Of course, they have been ‘counted’ in the quantitative analysis reported earlier; but it is also appropriate to consider the 55 responses as a group in this chapter also, since it deals with the views of organisations. Consultation questionnaires were received from the following organisations:
Figure 54: Summary of organisations responding to the Consultation Questionnaire – 55 responses
A group from Flint trying to keep Flint Community Hospital Glan Clwyd Hospital, Cardiology Department Llangollen open Civic Society Abergele Town Council Menai Bridge Town Council Age Concern (Flintshire and Wrexham) Multiple Sclerosis Support Centre, Flintshire and Conwy Alltwen Hospital, Estates Department North Wales 'Waking The Dragon' group Association of Voluntary Organisations in Wrexham (AVOW) Over Fifty forum group on behalf of the Chronic Conditions Management Forum and Parkinsons UK - Arfon and Môn Support Group the Adults Health and Social Care Forum Plaid Cymru, Ruthin Benllech 50+ Club. Plaid Cymru, Edeyrnion, Glascoed, Cynwyd, Corwen Bliss Charity Rhyl Town Council Buckley Town Council St James Church Hall, Mental Health Drop-In Service, Care & Repair Cymru Wrexham Chirk Town Council Save the Cottage Hospital group, Flint Community Hospitals Association for Wales and England The Campaign for The Protection Of Rural Wales (CPTW), Community Pharmacy Wales Clwyd Branch Conwy Town Council The Royal British Legion, Tywyn and District Branch Crossroads Care The League of Friends of Dinas Mawddwy Craig Y Don Medical Practice, Llandudno The League of Friends of Dolgellau and Barmouth Cruse Bereavement Care The League of Friends of Ruthin Hospital Dinner club, Parkfield, Mold, Flintshire Trustees of Denbighshire Voluntary Services Council Dolgellau and Barmouth Community Hospital Trauma and Orthopaedics Unit, Ysbyty Gwynedd Dr J R A Davies & Partners Health Centre, Llangollen Trearddur Bay Community Council Flint Women’s Institute Tŷ Croeso, Dawn Elizabeth House Forum for Voluntary Organisations working with Children, Voice of Gwynedd Young People & their Families (Wrexham) facilitated by Welsh Ambulance Service Trust (South Gwynedd) AVOW
5.2 Whilst responses from groups were included within the overall analysis of the consultation questionnaire feedback, their responses are now shown below in graphical format.
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Healthcare Services Where You Live
Figure 55: To what extent do you agree or disagree with the following priorities for delivering healthcare in North Wales?
Priority 1: Targeted Prevention – Taking action to Priority 2: Enhanced Care at Home promote good health and prevent illness
Base: Those who responded on behalf of an organisation (50) Base: Those who responded on behalf of an organisation (47) 90% of respondents answered the question 85% of respondents answered the question
Priority 3: Moving Care from Acute Hospitals to the Community
Base: Those who responded on behalf of an organisation (48) 87% of respondents answered the question
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Figure 56: In principle, do you agree or disagree that we Figure 57: In principle, do you agree or disagree that the same should focus our resources on providing reliable healthcare services with the same opening times healthcare services at fewer hospitals to make sure should be provided within 40 minutes' drive for as that the services provided are consistently many people as possible in North Wales? available?
Base: Those who responded on behalf of an organisation (47) Base: Those who responded on behalf of an organisation (49) 85% of respondents answered the question 89% of respondents answered the question
Hospital Hubs - Proposed
Figure 58: Do you agree or disagree that the ten hospitals proposed by the Health Board are the most appropriate hospitals to act as ‘hubs’ for healthcare services across North Wales?
Base: Those who responded on behalf of an organisation (49) 89% of respondents answered the question
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Minor Injuries Services
Figure 59: In principle, do you agree or disagree that we Figure 60: Do you agree or disagree with the Health Board's should focus our resources on providing reliable specific proposals for Minor Injury Services? Minor Injuries Services at fewer hospitals to make sure services are consistently available?
Base: Those who responded on behalf of an organisation (50) Base: Those who responded on behalf of an organisation (49) 90% of respondents answered the question 89% of respondents answered the question
X-Ray Services
Figure 61: In principle, do you agree or disagree that X-ray Figure 62: Do you agree or disagree with the Health Board's Services should be concentrated in fewer places to specific proposals for X-ray Services? ensure reliable services?
Base: Those who responded on behalf of an organisation (48) Base: Those who responded on behalf of an organisation (47) 87% of respondents answered the question 85% of respondents answered the question
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Local Services in Blaenau Ffestiniog
Figure 63: Do you agree or disagree that a new facility should be developed at Ffestiniog Memorial Hospital as a base for better community services?
Base: Those who responded on behalf of an organisation (21) 38% of respondents answered the question
Figure 64: Do you agree or disagree that primary care services should be expanded at Ffestiniog Memorial Hospital?
Base: Those who responded on behalf of an organisation (18) 32% of respondents answered the question
Figure 65: Do you agree or disagree that community inpatient beds should be moved from Ffestiniog Memorial Hospital to Ysbyty Alltwen?
Base: Those who responded on behalf of an organisation (20) 36% of respondents answered the question
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Local Services in North Denbighshire – Rhyl and Prestatyn
Figure 66: Do you agree or disagree that a new hospital should be developed on the Royal Alexandra Hospital site which would replace other health service facilities in the area?
Base: Those who responded on behalf of an organisation (23) 41% of respondents answered the question
Local Services in Llangollen
Figure 67: Do you agree or disagree that an extended primary Figure 68: Do you agree or disagree that community inpatient care centre should be developed in Llangollen? beds should be moved from Llangollen Community Hospital to local care homes or Chirk Community Hospital?
Base: Those who responded on behalf of an organisation (25) Base: Those who responded on behalf of an organisation (26) 45% of respondents answered the question 47% of respondents answered the question
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Local Services in Flint
Figure 69: Do you agree or disagree that an extended primary Figure 70: Do you agree or disagree that community inpatient care centre should be developed in Flint? beds should be moved from Flint Community Hospital to Holywell Community Hospital?
Base: Those who responded on behalf of an organisation (25) Base: Those who responded on behalf of an organisation (26) 45% of respondents answered the question 47% of respondents answered the question
Healthcare Services Where You Live – Further Comments 5.3 Respondents were given the opportunity to make further comments with regards to the proposals for healthcare services where they live. Three fifths (60%) of organisations made any further comments. 5.4 The table below shows the top main comments that were made by those who responded on behalf of an organisation.
Figure 71: Further comments made by open questionnaire respondents responding on behalf of an organisation about the proposals for healthcare services where you live?
Number of Responses Main further comments Open Questionnaire (33)
Concerns over travel: - distance - cost 14 - poor road network/concerns over public transport - concerns about family not being able to visit - travelling further will have a negative impact on people living in rural areas
Against idea of hospital hubs for Minor Injury and X-ray Services: - don’t close smaller hospitals 11 - proposals are not cost effective - proposals will lead to a worse level of service
Concerns about resources and increased demand: - X-Ray & minor injuries services will need to be more accessible with open longer hours - GPs wont cope with increased demand 7 - GPs will need more staff/equipment/better facilities to act as Minor Injury/X-ray units • - GPs and NPs will need to play more of a role in treating minor injuries
Base: Number of respondents who made a comment shown in brackets
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Older People’s Health
Figure 72: Do you agree or disagree with these proposals for older people's mental health?
Base: Those who responded on behalf of an organisation (46) 83% of respondents answered the question
Figure 73: Do you agree or disagree with the additional Figure 74: Do you agree or disagree with these proposals for proposals for Conwy and Denbighshire? Gwynedd and Anglesey?
Base: Those who responded on behalf of an organisation (23) Base: Those who responded on behalf of an organisation (33) 41% of respondents answered the question 60% of respondents answered the question
5.5 Respondents were given the opportunity to make further comments with regards to the proposals for older people’s mental health. 5.6 More than a third (36%) of organisations made any further comments. The table below shows the top main comments that were made by those who responded on behalf of an organisation.
Figure 75: Further comments made by open questionnaire respondents responding on behalf of an organisation about the proposals for older people’s mental health?
Number of Responses Main further comments Open Questionnaire (20)
Concerns over travel: - distance - cost 10 - poor road network/concerns over public transport - concerns about family not being able to visit - keep care local
Base: Number of respondents who made a comment in brackets
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Neonatal Intensive Care Services
Figure 76: Do you agree or disagree with the proposal to provide all Neonatal Intensive Care Services from Arrowe Park Hospital?
Base: Those who responded on behalf of an organisation (42) 76% of respondents answered the question
5.7 Respondents were given the opportunity to make further comments with regards to the proposals for Neonatal Intensive Care Services. More than two fifhs (44%) of organisations made any further comments. 5.8 The table below shows the top main comments that were made by those who responded on behalf of an organisation.
Figure 77: Further comments made by open questionnaire respondents responding on behalf of an organisation about the proposals for Neonatal Intensive Care Services?
Number of Responses Main further comments Open Questionnaire (24)
Concerns over travel: - distance - cost - poor road network/concerns over public transport 13 - concerns about family not being able to visit - keep care local - Extra distance to travel will cause more deaths
Base: Number of respondents who made a comment in brackets
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Vascular Services
Figure 78: Do you agree or disagree with the proposal to provide complicated and emergency Vascular Services at one specialist centre in North Wales?
Base: Those who responded on behalf of an organisation (44) 80% of respondents answered the question
Figure 79: If a specialist centre for complicated and emergency Vascular Services was established, at which hospital do you think that this should this be located?
Ysbyty Gwynedd Wrexham 17% Maelor Hospital 33%
Glan Clywd Hospital 50%
Base: Those who responded on behalf of an organisation (36) 65% of respondents answered the question
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6. Petitions Overview of petitions objecting to the proposals
6.1 Several petitions to object to important proposals were organised during the consultation and this chapter reviews all those of which ORS is aware. We apologise if there have been other petitions of which we have no knowledge, but we have cross-checked our records with those of BCUHB and the ones reviewed in the following paragraphs are all those known about. 6.2 The total number of signatures, across all the petitions we know about, is 12,068. 6.3 The largest petition was submitted to BCUHB about Chirk Community Hospital, but there were also other important petitions about the proposals for Mold, Tywyn, Llangollen, Colwyn Bay and Blaenau Ffestiniog Community Hospitals and Neonatal Intensive Care Services – and about the consultation process (the public meetings in particular) and healthcare services in North Wales more generally.
Summary of Petitions
Chirk Community Hospital 6.4 The following petition, signed by 3,457 people was submitted to BCUHB:
Your help is urgently needed to save the Minor Injuries Department at Chirk Hospital from closure. Patients will be faced with having to travel to Wrexham Maelor Hospital for treatment so act now and sign to save the closure of the Minor Injuries Department. We the undersigned do not agree to the closure of the Minor Injuries Department at Chirk Hospital.
Mold Community Hospital 6.5 A petition with 2,403 signatures was submitted with the following wording:
We, the undersigned, are totally opposed to the BCUHB proposals to close the Minor Injuries and X- Ray Units at Mold Community Hospital. We believe that this will cause considerable hardship and health risks for many and particularly for the elderly and infirm because: 1) Access by public transport to the proposed hub at Deeside Hospital is poor and will necessitate several bus journeys for residents from the outlying areas. 2) The time, trouble and costs of making such a journey will lead to residents calling on the ambulance service which is already under pressure and unable to cope with current demand. 3) It will also result in people ignoring minor injuries which will lead to further complications which will inevitably result in greater expense for BCUHB to treat and for the individual could be fatal.
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Since the Deeside Hospital currently has no MIU it makes more sense to make Mold the hub for this area and update the X-Ray equipment there. Mold has relatively good public transport links with the surrounding areas and people coming into the town for other services.
6.6 A further petition in relation to Mold Community Hospital (as below) was signed by 42 people:
I am writing to ask you to stop the proposals to close the Minor Injuries and the X-Ray unit at Mold Hospital. I do not understand why you have chosen these services as they are so important to the people of Mold. I think I can speak for all my friends and family. The staff and the service we get are wonderful. I do not know what we will do without them. We are very proud of Mold Hospital and we would like you to think again.
Neonatal Intensive Care Services 6.7 A petition about Neonatal Intensive Care Services was submitted to BCUHB by the organisation Cuddles. 1,315 people signed an online version of the petition, and 675 signed a paper version - yielding a total of 1,990 signatures. The petition said:
Betsi Cadwaladr have today released information that they intend closing the Intensive Care Unit within the Special Care Baby Unit at Ysbyty Glan Clwyd and move it to Arrowe Park on the Wirral. Therefore all intensive treatment required for babies under 28 weeks will take place in Arrowe Park. This adds a huge amount of pressure to the children in need of this intensive therapy as well as added pressure onto the parents. A number of issues have been noted as a result of this proposal which include the risk this poses on the baby, the pressure of travelling to the Wirral from across Wales, the lack of equal opportunity as stated within the All Wales Neonatal Standards as the babies may be born in England as well as the possibility of the lack of Welsh-speaking nurses and doctors based at Arrowe Park are just a few of the issues. Please show your support by signing this petition in order for Cuddles Members to put this to the Betsi Cadawaladr Board. Thank-you.
Tywyn Community Hospital 6.8 A petition against the closure of the X-Ray service and reduced MIU hours at Tywyn Community Hospital, signed by 1,249 people, was submitted to BCUHB.
Llangollen Community Hospital 6.9 BCUHB received a petition opposing the proposed closure of Llangollen Community Hospital. 170 people signed an online version of the petition, and 1070 signed a paper version - yielding a total of 1,240 signatures. The petition said:
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Betsi Cadwaladr Health Board (BCUHB) have outlined plans for reconfiguring health services in North Wales. They are recommending closing the Minor Injuries Unit (MIU) at Llangollen. The Board have now started on a 'consultation' process to discuss their recommendations. We believe that losing the hospital beds at Llangollen would only serve to exacerbate the bed- blocking at our District General Hospitals and that it is better to treat our patients, especially the most vulnerable, closer to their home communities. The Board only provide two options for discussion: maintain the status quo or closure. We believe that the board should draw up several alternatives for discussion.
Colwyn Bay Community Hospital 6.10 1,027 signed template letters were received about the closure of the Minor Injuries Unit at Colwyn Bay Community Hospital. The letters stated:
As a resident of the Colwyn Bay area, I wish to object to the proposal to close the Minor Injuries Unit at Colwyn Bay Community Hospital. Colwyn Bay is the second largest town in North Wales. As such, it has need of a properly staffed and resourced Minor Injuries Unit. The proposal to locate the Minor Injuries Unit at Llandudno Hospital would not provide the level of service which the people of Colwyn Bay expect or to which they are entitled.
6.11 A further 76 people signed a different petition, organised by the Colwyn Bay Action Group, against the closure of the Minor Injuries Unit. This said:
Colwyn Bay Action Group petition against proposals by Betsi Cadwaladr Health Board to cut relevant services at Colwyn Bay Hospital. We the undersigned support Councillor Cheryl Carlisle's efforts to halt these proposals.
Ruthin Community Hospital 6.12 92 people signed a petition calling on BCUHB to:
Improve services at Ruthin Community Hospital rather than downgrade services through a policy of centralisation.
Prestatyn Community Hospital 6.13 Clwb-y-Ffrith in Prestatyn organised a petition to protest against the proposed closure of Prestatyn Community Hospital. 78 people signed this petition, which said:
Help us to keep Prestatyn Community Hospital open [known as Chatsworth House]. We need it to stay. Sign below for your objection to closure.
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Blaenau Ffestiniog Memorial Hospital 6.14 18 people signed a petition calling on BCUHB:
To develop Ffestiniog Memorial Hospital as a focus hub hospital to serve the rural community of North Meirionnydd and South Conwy.
6.15 It should also be noted that BCUHB received a petition of 3,891 signatures in July this year, before any decisions had been made on consultation proposals. The wording was:
We the undersigned strongly oppose any plans to close the inpatient beds at the Ffestiniog Memorial Hospital and call for the restoration of the previous beds and the upgrading of health care services in the area.
Healthcare Services in North Wales 6.16 An e-petition was organised by Mike Parry entitled ‘Medical Emergency - Preventing the introduction of a poorer Health Service for North Wales’. This was signed by 168 people and stated:
We the undersigned call on the National Assembly for Wales to urge the Welsh Government to ensure that the proposals contained within the Betsi Cadwaladr University Health Board consultation - Health Care in North Wales is Changing does not result in poorer health provision and unneccessary deaths and suffering. The proposals will have a detrimental effect on most areas of health provision and emergency services and in no way can the proposals be an improvement as is intimated. Already experiencing meltdown, the Health Service in Wales will head towards collapse, if these proposals are implemented in their present form. The current BCUHB consultation proposals in relation to Health Care in North Wales appear to be detrimental to general health provision and the safety of our communities. Accessibility, X-Ray provision, Minor Injuries, Mental Health, the Ambulance Services, the Out of Hours service and the ability of GPs to deliver an integrated service are going to be particularly hard hit by the proposals - as they are diametrically at odds with the Welsh Govt's vision in relation to the documents Together for Health, Setting the Direction, and Delivering Emergency Care Services - it appears also to be at odds with the Compact announced by the Health Minister on the 25th of September 2012.
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Consultation: Public Meetings 6.17 228 people signed a petition to protest against the need to pre-book spaces at BCUHB’s public meetings. The petition said:
The CEO of the Betsi Cadwaldr University Hospital Trust (BCUHT), Mary Burrows when speaking recently about the forthcoming Public Consultation said she wants "everybody to take part in the process". How strange then that the series of public meetings arranged throughout the region in September and October, require the public to pre-book to attend, therefore not a public meeting in the true sense. We the undersigned request that BCUHT make suitable sized venues available in order that anyone who wishes to attend can do so without the need to pre-book.
Need for Interpretation
6.18 The petitions summarised above are clearly important in indicating public anxiety about important aspects of the Healthcare in North Wales is Changing review – and the authority will wish to treat them seriously. Nonetheless, the BCUHB should also note that petitions can exaggerate general public sentiments if organised by motivated opponents; and in this case there has been considerable local (and online) campaigning, particularly about changes to community hospitals and Neonatal Intensive Care Services. Petitions should never be disregarded, for they show local feelings; but they should be interpreted in context. 6.19 One petition with emotive appeal was the one organised by Cuddles (a charity that supports the Special Care Baby Unit at Glan Clwyd Hospital), which makes the following statements:
Betsi Cadwaladr…they intend closing the Intensive Care Unit within the Special Care Baby Unit at Ysbyty Glan Clwyd…This adds a huge amount of pressure to the children in need of this intensive therapy as well as added pressure onto the parents. A number of issues have been noted as a result of this proposal, which include the risk this poses on the baby, the pressure of travelling to the Wirral from across Wales, the lack of equal opportunity as stated within the All Wales Neonatal Standards as the babies may be born in England, as well as the possibility of the lack of Welsh-speaking nurses and doctors based at Arrowe Park…
6.20 Given such an appeal, without a context of fuller information, few members of the public would resist a direct invitation to sign such a petition. 6.21 These observations do not discredit the petitions, but provides a context within which they should be interpreted.
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Table of Figures Figure 1: Open Questionnaire responses per 1,000 residents aged 16+ by Lower Super Output Area (LSOA) – All individual respondents that provided a postcode ...... 37 Figure 2: Household Survey responses mapped by area – All individual respondents that provided a postcode ...... 40 Figure 3: Household Survey responses (unweighted and weighted) and Resident Population by Age, Gender and Local Authority Area (Note: Figures may not sum due to rounding) ...... 41 Figure 4: Response by Age. Comparison between Household Survey, Open Questionnaire and general population ...... 42 Figure 5: Comparison of socio-demographic characteristics for the Household Survey and Open Questionnaire (Note: Figures based on valid responses. Figures may not sum due to rounding) ...... 42 Figure 6: Response by Local Authority. Comparison between Household Survey, Open Questionnaire and general population ...... 43 Figure 7: Comparison of location characteristics for the Household Survey and Open Questionnaire (Note: Figures based on valid responses where a postcode was provided. Figures may not sum due to rounding) ...... 43 Figure 8: Consultation Questionnaire responses to proposals for delivering healthcare in North Wales ...... 52 Figure 9: Consultation Questionnaire responses to proposals for providing healthcare services at fewer hospitals ...... 53 Figure 10: Consultation Questionnaire responses to proposals for providing healthcare services at fewer hospitals by the distance between local and hub hospital ...... 54 Figure 11: Consultation Questionnaire responses to proposals for the same healthcare services being provided within 40 minutes’ drive for as many people as possible ...... 54 Figure 12: Consultation Questionnaire responses to proposals for the same healthcare services being provided within 40 minutes’ drive for as many people as possible by the distance between local and hub hospital ...... 55 Figure 13: Consultation Questionnaire responses to proposals for the ten hospitals to act as ‘hubs’ ...... 57 Figure 14: Consultation Questionnaire responses to proposals for the ten hospitals to act as ‘hubs’ by the distance between local and hub hospital ...... 58 Figure 15: Consultation Questionnaire responses to proposals for focusing resources on providing minor injuries services at fewer hospitals ...... 59 Figure 16: Consultation Questionnaire responses to the specific proposals for minor injuries services...... 59 Figure 17: Consultation Questionnaire responses to the specific proposals for minor injuries services by the distance between local and hub hospital ...... 60 Figure 18: Consultation Questionnaire responses to proposals for services to be concentrated in fewer places ...... 61 Figure 19: Consultation Questionnaire responses to the specific proposals for X-ray services...... 61 Figure 20: Consultation Questionnaire responses to the specific proposals for X-ray services by the distance between local and hub hospital ...... 62 Figure 21: Consultation Questionnaire responses to proposals for a new facility being developed at Ffestiniog Memorial Hospital ...... 63 Figure 22: Consultation Questionnaire responses to proposals for a new hospital to be developed on the Royal Alexandra Hospital site ...... 65 Figure 23: Consultation Questionnaire responses to proposals for an extended primary care centre to be developed in Llangollen ...... 66 Figure 24: Consultation Questionnaire responses to proposals for an extended primary care centre to be developed in Flint ...... 67
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Figure 25: Further comments about the proposals for healthcare services where you live?...... 68 Figure 26: Further comments mainly made by Open Questionnaire respondents about the proposals for healthcare services where you live? ...... 69 Figure 27: Consultation Questionnaire responses to proposals for older people’s mental health ...... 70 Figure 28: Household Survey responses mapped by area, with shaded zones depicting 5km, 10km, 25km and over 25km from named General Hospital – All individual respondents that provided a postcode ...... 71 Figure 29: Consultation Questionnaire responses to proposals for Conwy and Denbighshire ...... 72 Figure 30: Consultation Questionnaire responses to proposals for Gwynedd and Anglesey ...... 73 Figure 31: Further comments about the proposals for older people’s mental health? ...... 73 Figure 32: Further comments mainly made by Open Questionnaire respondents about the proposals for older people’s mental health? ...... 74 Figure 33: Consultation Questionnaire responses to the proposal for providing all services from Arrowe Park ...... 75 Figure 34: Household Survey responses mapped by area, with shaded zones depicting 5km, 10km, 25km and over 25km from named General Hospital – All individual respondents that provided a postcode ...... 76 Figure 35: Consultation Questionnaire responses to the proposal to provide all Neonatal Intensive Care Services from Arrowe Park Hospital ...... 77 Figure 36: Further comments about the proposals for Neonatal Intensive Care Services? ...... 78 Figure 37: Further comments mainly made by Open Questionnaire respondents about the proposals for Neonatal Intensive Care Services? ...... 78 Figure 38: Consultation Questionnaire responses to proposals for providing services at a specialist centre in North Wales ...... 79 Figure 39: Consultation Questionnaire responses to proposals for the location of the specialist centre to be at the one of the following hospitals ...... 80 Figure 40: Household Survey responses mapped by area, with shaded zones depicting 5km, 10km, 25km and over 25km from named General Hospital – All individual respondents that provided a postcode ...... 81 Figure 41: Further comments about the proposals for Vascular Services? ...... 82 Figure 42: Further comments mainly made by Open Questionnaire respondents about the proposals for older people’s mental health? ...... 82 Figure 43: Profile of focus group participants ...... 84 Figure 44: Summary of public meeting attendance by location ...... 162 Figure 45: Summary of orgnisations and interest groups attending public meetings by venue ...... 163 Figure 46: Summary of media attendance at public meeting by location ...... 164 Figure 47: Summary of public meeting presenters by location ...... 164 Figure 48: Summary of submissions from Special Interest Groups (including Voluntary/Community Groups) – total of 74 submissions, in addition to those summarised as key submissions above ...... 226 Figure 49: Summary of submissions from GPs and Other Health Professionals – total of 21 submissions ...... 229 Figure 50: Summary of submissions from BCUHB staff – total of 36 submissions, in addition to those summarised as key submissions above ...... 230 Figure 51: Summary of submissions from County Councillors – total of 20 submissions ...... 232 Figure 52: Summary of submissions from Town and Community Councils/Councillors – total of 36 submissions ...... 234 Figure 53: Summary of submissions from Residents – total of 535 submissions ...... 235 Figure 54: Summary of organisations responding to the Consultation Questionnaire – 55 responses ...... 238 Figure 55: To what extent do you agree or disagree with the following priorities for delivering healthcare in North Wales? ...... 239
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Figure 56: In principle, do you agree or disagree that we should focus our resources on providing reliable healthcare services at fewer hospitals to make sure that the services provided are consistently available? ...... 240 Figure 57: In principle, do you agree or disagree that the same healthcare services with the same opening times should be provided within 40 minutes' drive for as many people as possible in North Wales? ...... 240 Figure 58: Do you agree or disagree that the ten hospitals proposed by the Health Board are the most appropriate hospitals to act as ‘hubs’ for healthcare services across North Wales?...... 240 Figure 59: In principle, do you agree or disagree that we should focus our resources on providing reliable Minor Injuries Services at fewer hospitals to make sure services are consistently available? ...... 241 Figure 60: Do you agree or disagree with the Health Board's specific proposals for Minor Injury Services? ...... 241 Figure 61: In principle, do you agree or disagree that X-ray Services should be concentrated in fewer places to ensure reliable services? ...... 241 Figure 62: Do you agree or disagree with the Health Board's specific proposals for X-ray Services? ...... 241 Figure 63: Do you agree or disagree that a new facility should be developed at Ffestiniog Memorial Hospital as a base for better community services? ...... 242 Figure 64: Do you agree or disagree that primary care services should be expanded at Ffestiniog Memorial Hospital? ...... 242 Figure 65: Do you agree or disagree that community inpatient beds should be moved from Ffestiniog Memorial Hospital to Ysbyty Alltwen? ...... 242 Figure 66: Do you agree or disagree that a new hospital should be developed on the Royal Alexandra Hospital site which would replace other health service facilities in the area? ...... 243 Figure 67: Do you agree or disagree that an extended primary care centre should be developed in Llangollen? ...... 243 Figure 68: Do you agree or disagree that community inpatient beds should be moved from Llangollen Community Hospital to local care homes or Chirk Community Hospital? ...... 243 Figure 69: Do you agree or disagree that an extended primary care centre should be developed in Flint? ...... 244 Figure 70: Do you agree or disagree that community inpatient beds should be moved from Flint Community Hospital to Holywell Community Hospital? ...... 244 Figure 71: Further comments made by open questionnaire respondents responding on behalf of an organisation about the proposals for healthcare services where you live? ...... 244 Figure 72: Do you agree or disagree with these proposals for older people's mental health? ...... 245 Figure 73: Do you agree or disagree with the additional proposals for Conwy and Denbighshire? ...... 245 Figure 74: Do you agree or disagree with these proposals for Gwynedd and Anglesey? ...... 245 Figure 75: Further comments made by open questionnaire respondents responding on behalf of an organisation about the proposals for older people’s mental health? ...... 245 Figure 76: Do you agree or disagree with the proposal to provide all Neonatal Intensive Care Services from Arrowe Park Hospital? ...... 246 Figure 77: Further comments made by open questionnaire respondents responding on behalf of an organisation about the proposals for Neonatal Intensive Care Services? ...... 246 Figure 78: Do you agree or disagree with the proposal to provide complicated and emergency Vascular Services at one specialist centre in North Wales? ...... 247 Figure 79: If a specialist centre for complicated and emergency Vascular Services was established, at which hospital do you think that this should this be located? ...... 247
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