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Reponse from Mark Williams, Welsh Liberal Democrat MP for Ceredigion to the Hywel Dda Health Board consultation: Your Health, Your Future

I welcome the opportunity to respond to this consultation and in so doing, acknowledge the historic challenges faced by the Board referred to in your consultation document on pages 8 and 9. As set out in the Chairmans forward to the document, it is appropriate that the NHS in Wales should be a service which is based around health outcomes which care about people and which provide sustainable, high quality services. The foreword refers to the Welsh Government Minister for Health and Social Services statements in Together for Health. I understand this to mean that the focus in this consultation should not be on service change, but on health processes, such as continuous improvements of services and patient experience and addressing inequalities and inconsistencies. In so far as this is concerned, I feel that it is important to refer to the principles of the Bevan Commission which should be the foundation stone of this whole consultation process. Following the views expressed through the Boards Listening and Engagement exercise earlier this year, I was hopeful that the Board would recognise that there should be a much more transparent approach to performance reporting and a more open relationship with all of the people served by the Hywel Dda Health Board area. In this submission I feel it is also pertinent to refer to the Welsh Governments Rural Health Plan (RHP). Whilst the plan was never intended as an alternative health strategy, it was (and still is), a template for translating the delivery of all-Wales strategies into meaningful service delivery mechanisms tailored more specifically to the needs of rural communities. As you know, the long-term aim of this plan is to achieve a better balance within the healthcare system from one dominated by hospital based medicine to one focused on securing population health improvement. This should be achieved through better community services and earlier intervention and support within the community, thus helping reduce inappropriate demands on secondary care. Whilst these aims would not appear to be at all far removed from many of Hywel Ddas aspirations, the RHP goes on to state that achieving this would have to call for greater emphasis on rural proofing; on more flexibility in finding solutions and that we should not be constrained by existing systems or processes, but that we should find innovative solutions to better care for those living in rural localities. Finally, the RHP also states that: Accessing services is the foundation of effective rural health and is a basic human right. Overall,I am concerned that, the lack of definition and detail within the Your Health Your Future consultation document as to how the Boards aims and proposals are to be developed and carried out, means that both of these tenets of the RHP have been ignored. It is clear that we need a model for change which is bottom-up, patient-centred and needs assessed.

Setting the scene Given the catchment area which the Hywel Dda Health Board serves, in responding to this consultation, one cannot dismiss what is happening across Wales as whole, as obviously this will have an effect on future proposals. In the provision of healthcare, we are already witnessing substantial cuts to community services and within social care, funding and social service provision are being decreased. Coupled with this, the requirement to follow protocols laid down by the Royal College and the Wales Deanery are leading to an increase in the concentration of services at larger hospitals, namely those located along the M4 corridor in the south of the country and along the A55 corridor in the north. There has been a general reduction of peripheral services in Mid Wales. A way forward would be to undertake a needs assessment which would be particularly relevant in terms of measuring the potential of any loss of service from Bronglais Hospital, especially given its geographic importance as a hub for Mid Wales healthcare. We need a health plan which has an emphasis on bringing secondary care close to the people. Indeed, it would seem that the Welsh Government Health Minister has recognised this. I refer to her letter of the 12th March this year to Dr. William Roberts of the aBer Group in which she states: I believe we all share the same ambition. We want Bronglais Hospital to develop as a centre of excellence, providing first class care to the population of Mid and West Wales. A hospital able to recruit and retain high calibre staff. A hospital working closely with community service to enable the delivery of responsive, effective pathways of care Thus, any future proposals must have an impact assessment and we must not forget that duty of care is a legal obligation. The basis for the Ministers vision for Bronglais Hospital as a centre of excellence, providing first class care to the population of Mid and West Wales should clearly be a coherent plan for all of the Bronglais Hospital patient catchment area. Sadly, within your most recent proposals, this still appears to be missing. What is evidential however, is what appears to be a proposal to disinvest in secondary care in order to provide resources in primary care and community care. In so far as Bronglais is concerned, we are witnessing cutbacks to facilities and staff and de-skilling, a reduction to the original planned front-of-house scheme and a critical lack of theatre capacity. This is happening in parallel to the Boards decision to close many community hospital beds which coupled with the erosion of social care impacts on step down care and keeps many chronically ill patients trapped on hospital wards for far longer than they need to be. Clearly, a different strategy is required - one which actually builds up services in Bronglais to support community resources.

Emergency Medical Retrieval Developing the Wales Air Ambulance into a 24/7 emergency medical retrieval service is described on page 18 of the consultation document. The Board outlines that discussions at an all-Wales level are apparently underway about how this will be achieved. The Wales Air Ambulance is currently funded by charitable donations and costs approx. 1,400 per mission. Between July 2011 and January of this year, there were 165 missions into Hywel Ddas area with a prediction of this increasing to another fifty per year. Thus, it is likely that any extra work will need to be government funded and further infrastructure (ie more helipads) may need to be constructed. Plans for this appear to be vague. Care closer to our communities in Ceredigion and Mid Wales Given the uncertainty of future health budgets and the fact that the Hywel Dda Health Board has not been able, year on year, to work within its allocated budget, any move which involves demanding more from community and GP services is highly questionable. Despite trawling through the supporting documents to this consultation which are available on the web, there still appears to be no coherent business plan along with information on processes and methodology as to how any of these proposed changes will be delivered. Furthermore, it is difficult to find any evidence of any real investment in primary and community Care. To this end, I could not support any plans which evidently are going to demand more from community and GP services and these should be dropped. Hywel Dda Health Board has already acknowleded that there are problems with GP manpower. There is an aging GP population who find it hard to recruit and who are already fully stretched. Realistically, the proposal for them to underake minor injuries work, pre-operative assessments and increased care of patients newly released from hospital, at an earlier stage than previously was the case, is frankly undeliverable. Undeliverable in terms of their time and also, against the current economic backdrop. Additonally, there would be a requirement for a major programme of nurse education. Instead, it is clear from speaking with my constituents, healthcare professionals and voluntary health organisations, that what needs to be achieved here for a seamless healthcare delivery is to have secondary care reaching outwards towards the patient, thereby increasing patient contact close to home. This could be achieved through more innovative use of mobile equipment, prioritising close-tohome investigations and access to 24/7 specialist opinion. In order to achieve this, it will be necessary to stop closures to community hospital beds, including full mental health provision. Current capacity in community hospitals must absolutely be maintained absolutely until there is strong evidence of alternative community services.

Retention and development of services at Bronglais Hospital, as the main District General Hospital for Ceredigion and Mid Wales.

Bronglais Hospital needs to have: Full obstetric care Full neo-natal care Full emergency care and back-up An assurance that Planned Care provision be fully resourced

It is clear that Bronglais Hospital needs to be the Regional District General Hospital for Mid Wales. It should be properly resourced, have competent local management, good links to tertiary centres and should be the hub for a seamless rural service. It is essential that Bronglais patients receive compassionate care that meets clinical standards particularly in the case of access to emergency theatres for trauma or caesarian section. The original Front of House scheme provided capacity for Bronglais to be a viable DGH for Mid Wales and this was to specifically address the lack of space and condemned main inpatient theatres. Unfortunately, the current scheme does not allow these issues to be corrected. There is significantly less space being provided and the theatres are only safe for day care and there has been a significant reduction in the number of surgical beds. There is a lack of commitment to any surgery requiring ITU. Together, these factors result in the isolation and disempowerment of hospital medical staff and morale is low. Women and Childrens Services At Bronglais, maternity service has changed without consultation (the 2008 RCOG Report refers). Skills must be retained for the safe delivery of babies in Mid Wales. In turn, paediatrics must support maternity and there must be consultant delivered services. Bronglais should have a Paediatric Unit which should be fully reinstated with the four baby beds as described in the 2008 RCOG report, rather than the overnight provision currently offered. Emergency care Within Ceredigion and wider Mid Wales, it is clear that the Golden Hour argument still applies and geographically, the location of Bronglais is critical and highly significant. The hospitals emergency service must be properly resourced and staffed at all times and have the capability to deal with allcomers. The hospital must not be used as a staging post which can cause unnecessary and lifethreatening delays. It is also important for the hospital to have a CEPOD theatre capacity. To this end, I support Option B in your plans and demand appropriate backup within Bronglais.

Planned Care In respect of this, skills and critical mass need to be maintained in Bronglais General and Orthopaedic surgery should be developed and should have appropriate support services (eg physiotherapy). There needs to be sufficient beds for all services, including general surgery, trauma and orthopaedics, gynaecology and obstetrics and paediatrics. The arrangement of the beds must comply with modern standards separation of discipline and male/female, and appropriate space around beds, etc.

Improvement to outpatient facilities needs to meet modern standards and expectations. Outpatient services need to be delivered within the hospital to best use clinician time and provide training and assessment. This should include outpatient services delivered peripatetically throughout Ceredigion and Mid Wales. Bronglais consulting rooms should provide privacy and patients should not wait in crowded corridors. There should be an improvement plan of other facilities to provide comfort and dignity for patients and staff (eg appropriate facilities for chemotherapy and counselling space, etc). Mental Health Services As a matter of urgency, I would urge the Board to restore the mental health in-patient facility beds at Bronglais Hospital (Afallon Ward), recently closed for staffing reasons. I was most concerned to learn from my representative (who attended the Hywel Dda public meeting held at the Morlan Centre in Aberystwyth last month on my behalf) that this topic was not properly or fully discussed when raised at the meeting. It is undeniable that there is a requirement for such an inpatient facility in Mid Wales and I note from Community Health Council locality meetings that concerns about the staffing situation on this ward were known about by hospital management as long as six months ago. I am therefore surprised that efforts were not undertaken sooner to secure appropriate staffing levels on this ward. In failing to do this, I have little confidence in your statement in the consultation document that your aims are to deliver better care, closer to home and to recruit and keep high quality staff. Making every penny count Whilst the Hywel Dda Health Board anticipates that some savings will be made over the period: 2012 2020, these costings are very vague. There is no detailed methodology or processing explanation to accompany them. It is disappointing that there is an absence of thinking through about how plans will integrate or work in concert. The Boards minutes from the last year reveal that there are obvious concerns regarding the cost pressures that the Board has to deal with in having to operate against a flat-cash resource position and indeed, in even attempting to meet its planned breakeven position. I am particularly concerned that there appear to be no estimates in the increased cost of transport in respect of a move to community-based care, given the extra work and journeys to patients in rural areas which will need to be undertaken by health teams working within the community. Finally, the Board will of course be aware of the recent comments made to the BBC by leading health economists regarding the financial implications of any proposed reconfigurations in the current

economic climate. Professor Malcolm Prowle, a former financial adviser to the World Health organisation has warned that these proposals on a pan-Wales basis have not been properly costed and describes them as .........very much the blueprint of a vision and warns that they may very well be unaffordable.

Mark Williams Welsh Liberal Democrat MP for Ceredigion