Hywel Dda is Squashed between a Rock and a Very Hard Place

Hywel Dda University Local Health Board’s controversial reorganisation proposals, including options to downgrade the general hospitals at Withybush, Haverfordwest and Glangwili, Carmarthen, and to build a new hospital on the Carmarthenshire-Pembrokeshire border, led to widespread public consultation between April and July this year. Results of the consultation have just been released, in a 420-page report.

The main conclusion I can draw is that Hywel Dda, responsible for medical services in Carmarthenshire, Pembrokeshire and Ceredigion, is squashed between a rock and a very hard place, and is being asked to do the impossible — cutting costs while also offering adequate medical care to the ageing population of West Wales.

Shortages of suitably qualified permanent medical staff are endemic in the Hywel Dda region, but a brand new hospital might attract some super-skilled medics. That seems to be part of the theory.

Here in Llansawel, 20 or so miles north-east of Carmarthen, the community council submitted a letter to the consultation. The contents have not made their way into the 420 pages, so here it is.

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June 21 2018

Hywel Dda University Health Board

Opinion Research Services

Freepost (SS1018)

PO Box 530, Swansea SA1 1ZL

Llansawel Community Council’s view on ‘Our Big NHS Change’

Dear Sir/ Madam

Llansawel Community Council, while appreciating the financial constraints affecting Hywel Dda University Health Board, is strongly opposed to the closure of Accident & Emergency and Acute Admissions at West Wales General Hospital, Glangwili, and their relocation to a future new hospital between St Clears and Narberth, for these reasons:

• The new hospital would be 30 to 40 miles from Llansawel, depending on the precise site chosen.
• Up to half the journey would be on narrow minor roads.
• The A40 section of the journey is subject to traffic jams and delays notably at holiday times. This could result in ambulances spending more operational time travelling and therefore reduce the number of incidents each ambulance could attend each day.
• The proposed location of the new hospital would not be easily accessible to those patients or visitors who lack their own transport.
• The argument that the Wales Air Ambulance could attend serious incidents in the Llansawel area might be valid for the 12 hours a day during which the air ambulance operates, but the service is funded voluntarily , not by the Welsh Government, and so should be viewed as supplementary, not a critical element of the core service.

We understand the staffing difficulties experienced by the health board, and appreciate that a new hospital might attract staff, but in our view that magnet effect would wear off after two or three years, and we do not think that building a new hospital is the best way to bring skilled medical personnel to West Wales. Instead, we would seek to persuade the Welsh and UK governments to improve the infrastructure of West Wales, for example by electrifying the mainline railway to Swansea and beyond, and by proceeding with the Swansea Bay Tidal Lagoon. These investments would strengthen the economy of West Wales and make the region more attractive to early and mid-career professionals.

Yours faithfully

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The point is that Hywel Dda cannot, on its own, solve the relative inaccessibility of West Wales, the age profile tipping towards the elderly retired, or the apparent inability of the Welsh Government to revive the regional economy. Given these constraints, the mammoth consultation exercise may not achieve much other than a report emphasising that  people don’t want to travel dozens of miles, in a region with very little in the way of frequent public transport, for urgent medical treatment. And we knew that already.

In 2017-18 Hywel Dda overspent its budget by £69.430 million, or 9% above the £766.027 million allocated. The cumulative overspend over the past three years, rising every year, is £150.242 million. Typically it’s more expensive to employ agency and locum staff than permanent employees. The health board states, in appendix 2 to the 2017-18 report and accounts, that “Recruitment of permanent and temporary clinical staffing (allied health professionals, medical and nursing) continues to present a significant operational risk to the UHB [University Health Board] resulting in continued fragility of day to day service provision, difficulties in managing demand and patient flows, making it challenging to implement any service reconfiguration/improvements, undertake waiting list initiatives, and delivery of the NHS Outcomes Framework”.

The difficulties include “lack of substantive middle grade doctors in A&E”, “lack of Registered Nurses leading to unsafe staffing levels in Emergency Departments”, “lack of capacity in district nursing to effectively treat and manage ambulant patients with leg ulcers”, “shortage in clinical workforce to deliver against the current model of General Practice”, “lack of theatre resource, cardiologist, physiologist, nursing and radiologist leading to long waiting times for cardiac pacing and the disruption to scheduled services”, “fragile dermatology services due to insufficient staffing levels”, and “staffing levels below recommended levels for stroke care giving rise to avoidable harm to patients”.

Why don’t more medical professionals want to settle in West Wales? We can guess at a perceived lack of career progression opportunities, few well-paying jobs for non-medic partners or family members, remoteness from London, and property values growing more slowly than in more affluent parts of Britain, making it difficult for early and mid-career professionals to relocate to South East England, say, should that be beneficial career-wise.

The Welsh Government is making a start on expanding medical education in Wales. Health Secretary Vaughan Gething said on July 6th that 40 new funded medical places will be available from September, 20 in Cardiff and 20 in Swansea. In addition, Cardiff is co-operating with Bangor University to arrange for students to be able to do their whole medical degree in North Wales from 2019, and Swansea is collaborating with Aberystwyth to improve medical education in West Wales. These steps should benefit Hywel Dda in due course — but not yet.

Meanwhile, we have the results of the consultation exercise, carried out by Opinion Research Services (ORS), a ‘spin off’ from Swansea University. ORS says that there is least support for ‘Proposal C’, with main hospitals in Aberystwyth, Llanelli and a new site between St Clears and Narberth, plus planned (not acute or emergency) care in Carmarthen, and a community hospital in Haverfordwest. This option is now unlikely to progress.

The choice, it appears, will be between main hospitals in Aberystwyth and St Clears-Narberth, and three community hospitals in Carmarthen, Llanelli and Haverfordwest (Proposal A) and main hospitals in Aberystwyth, St Clears-Narberth, and Llanelli, plus community hospitals in Carmarthen and Haverfordwest (Proposal B). In addition, there is strong feeling in Pembrokeshire for a new plan to expand medical services in the county (which would be challenging, to use a buzz word, without further cuts in Carmarthenshire and Ceredigion).

The alternatives sit alongside a planned increase in medical services available in local centres such as Llandovery and Cross Hands.

That is, if staff are available, but Hywel Dda cannot solve this tough and worsening personnel problem on its own.

PDR