This booklet has been produced by Abertawe Bro Morgannwg University Health Board (ABMU) We would be happy to send you more copies in Welsh or English or in the following formats: Braille (Welsh or English) Talking Book (Welsh or English) British Sign Language Easy Read (Welsh or English) Large print version (Welsh or English) There is a short film about our ideas and much more information on our website www.changingforthebetter.org.uk and YouTube as well (ABMULHB channel). You can download more copies of this booklet and copies of other associated documents from the site. For further copies or other formats to be sent to you, please ring our helpline (01792) 704019, email us at ABM.C4B@wales.nhs.uk or write to Changing for the Better team, ABMU, One Talbot Gateway, Baglan Energy Park, Baglan, Port Talbot SA12 7BR Illustration & design G John Rees ABMU Production ABMU Medical Illustration Dept. ABMU Health Board 2012
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CONTENTS Who Are We And What Do We Do?... What is This Booklet About And Who Should Read It?... Our Vision For Your Future Healthcare... What Are The Challenges Facing Us?... What We ve Been Doing So Far... Working Together With Other Health Boards... Which ABMU Services Has Changing For The Better Been Looking At?... Which Services Has The South Wales Programme Been Looking At?... Ideas Emerging From The Changing For The Better Work... How GP and Community Services Could Change... The South Wales Programme - A Summary Of Its Recommendations... 7 9 10 14 22 26 27 29 31 44 46 4 CHANGING FOR THE BETTER: Our ideas for your local NHS
Combined Possible Impacts of the South Wales Programme Recommendations... What the South Wales Programme could mean for your hospitals... What Happens Next?... How Can You Have Your Say?... 51 54 60 62...Have Your Say! 5
6 CHANGING FOR THE BETTER: Our ideas for your local NHS
Who Are We, And What Do We Do? Abertawe Bro Morgannwg University Health Board (ABMU) runs your local NHS services in Bridgend, Neath Port Talbot and Swansea, and some specialist services for people from further away. We plan the services provided by GPs, dentists, chemists and opticians as well as community services such as district nursing, therapists, school nursing and health visiting. We also have four main hospitals Morriston, Singleton, Neath Port Talbot and the Princess of Wales, as well as some community hospitals. We provide inpatient and community mental health services and a full range of learning disability services for an even greater population. We help you stay fit and healthy by providing information and support about healthy lifestyles. In all of this we work closely with patients, their families and carers, the ambulance service, local authorities, universities and the voluntary sector....have Your Say! 7
A483 Carmarthen A48 Ystalyfera A470 Merthyr Tydfil A4138 M4 Pontardawe 4 A465 Resolven Reynoldston Llanelli Bishopston 2 NEATH 3 SWANSEA A48 6 Swansea Bay 5 Maesteg 7 PORT TALBOT Ogmore Vale Pontypridd Pyle N 8 BRIDGEND M4 CARDIFF KEY : Gorseinon Singleton Morriston Gellinudd 5 6 7 8 Cimla Neath Port Talbot Maesteg Community Princess of Wales Community Hospitals Main hospitals by county 8 CHANGING FOR THE BETTER: Our ideas for your local NHS
What is this booklet about and who should read it? The NHS in Wales is facing some huge challenges and we think that we need to make major changes so in future our healthcare services are safe, reliable and high quality. There is more information on why change is becoming urgent in Why Your Local NHS Needs to Change which we published in May. You can download it from our website or request a copy (see page 2 for contact details). This booklet describes the work we have been doing around this, and outlines our ideas for future NHS care in ABMU. It also contains a summary of the recommendations of another change project which has been running in parallel, The South Wales Programme, which will have an impact on some of our services. We want to share these ideas with you, and get your feedback to influence the next stage - where we will go on to develop more detailed proposals for the next five years. Over 500,000 people live in ABMU and we employ nearly 17,000 staff. It s vital that as many as possible know about our ideas and the reasons for them, and have a say about how local NHS services can give the best possible care now, and in the future. We tell you how you can let us know what you think at the end of this booklet....have Your Say! 9
Our Vision For Your Future Healthcare We want a local NHS which offers the best quality care possible within the resources we have available. Our ambition is to provide NHS services in Swansea, Bridgend, and Neath Port Talbot that are comparable to the best anywhere. There are a number of challenges at the moment which are preventing this (more on that later), but we believe we can overcome these, and we have a clear vision of where we want to be by 2018. It s not only about improving the way we deliver clinical care. We also want to do more to support our population to stay as healthy as possible by making better informed lifestyle choices. Prevention, after all, is better than cure! We know that where you live within ABMU makes a big difference to how long you live and how healthy you are. So we want the gap between the health of the better off and the poor to reduce significantly. We also know that thanks to advances in health and social care our population is living longer. However that means that the biggest demands on the NHS in future will be caring for frail older people. This means increasing the contribution of primary care (GPs) and community services to help older people maintain their independence and well being. So we want to make sure we offer services and resources to meet this challenge. If you have a chronic condition like diabetes or emphysema, we want to work with you to manage your condition more effectively, so you are less likely to end up in hospital as an emergency admission. 10 CHANGING FOR THE BETTER: Our ideas for your local NHS
We want to involve you in planning the care you need and the way in which services will be provided for you. We will develop our GPs and community teams to give you better information, education and support to help you keep on top of your illness and let you continue to live your life as fully as possible. This will also ease the pressure on hospital beds, for those that really need them. We want to make it easier and faster for you to access high quality NHS services; even though sometimes that might mean you travelling a bit further for certain services. That might sound like a contradiction. But our ideas for reshaping services will actually offer you better access to expert teams while also moving many services normally only offered in a hospital setting closer to your homes. We need to make the most of the skilled staff we have available, particularly some doctors who are in short supply, so we anticipate offering more regional centres of excellence where you will be treated by teams of people who are not only specialists in their field, but who are also very experienced because they deal with many cases. At the moment we have too few staff trying to provide some services on too many sites. It means that in future you will receive the very best care we have to offer, from a service which is both reliable and safe, and which meets all the modern quality standards. We realise that if you have to travel a bit further to one of our other ABMU hospitals to receive such a service, that transport may be a worry. So once you have received your specialist treatment, we will help you go home as soon as possible. Rather than transfer you to another hospital, like a community hospital, for ongoing care, we will instead aim to look after you in your own home. Evidence shows that people get better quicker when they are in familiar surroundings, and they are more likely to keep their independence....have Your Say! 11
We also know from feedback that patients prefer to be treated in or closer to their home. We will do this by providing strengthened community-based and GP services to look after you at home. This could mean, for example, that a team of nurses and therapists will come to your home for several weeks until you are back on your feet. We are also taking opportunities to build state-of-the-art Primary Care Resource Centres which are like 21st century health centres, as and where we can. They not only have primary care services like GPs and dentists, but increasingly are offering services which were once only available in hospital settings like warfarin clinics. Some of our community hospitals may also evolve to play a similar role. However we know that buildings are only part of the story, and so strengthening and supporting the primary healthcare team is a key priority for us, wherever they are based. Modern technology can also play a significant role in shifting the balance of care into GP practices and patients own homes. We spend on average 1641 every year for each person in ABMU; half of this in our four main hospitals (Acute Hospital Care) 12 CHANGING FOR THE BETTER: Our ideas for your local NHS
At the moment we spend a lot of our money on hospital services, but in future we want the balance to change so community-based health services get a much larger share. So while you may have to travel a little further for some services, others will be available closer to, or in, your home with appropriate resources to support this. It s also clear to us that modern healthcare shouldn t be limited by traditional Monday to Friday office hours. So we want to introduce longer working days and weekend working in more of our community services and main hospitals to cut down on the time you spend waiting for treatment. Services also need to be easier to contact and use, for all. We also want to work more closely with social care to provide seamless and integrated services, so you don t need to worry about which agency is providing your care....have Your Say! 13
What Are The Challenges Facing Us? ABMU is facing a number of serious challenges, and we are not alone. In November 2011 the Welsh Government published proposals for the NHS in Wales called Together for Health. In it the Health Minister said that the NHS in Wales is facing its toughest ever challenges. We agree and think that if we just carry on as we are we won t be able to meet these challenges, and the standard of care will deteriorate. We don t think that s acceptable. So here are four of the main issues we need to overcome to achieve our vision for future healthcare: (1) Health Services Based on a 50-year-old Blueprint While NHS services are constantly changing, many are still based on a healthcare system designed in 1962, when the then Minister for Health launched The Hospital Plan. Back then we were still watching black and white TV, there were 240 pennies to the, and man had yet to walk on the moon! It was also a time when life expectancy was shorter - it was unusual to live past your 70s - and there were fewer tests and treatments for illnesses like cancer or heart conditions; so people were less likely to survive them. 14 CHANGING FOR THE BETTER: Our ideas for your local NHS
Now, medical and social care has improved, and people live longer. This brings its own challenges however, as patients are likely to need more care as they grow older and in many cases become frailer. Average spend per year for different age groups: Chronic diseases like diabetes are also on the increase, and we have growing problems with public health issues like obesity. So while NHS care is constantly evolving, the system it works within just isn t keeping up with changing and increasing demands. We can t just tinker at the edges; we need to make substantial changes if we are to meet these healthcare challenges....have Your Say! 15
(2) Doctor Shortages For a few years now there has been a problem with a shortage of some types of doctors in the UK. The worst problems are in Paediatrics; Emergency Medicine (A&E); Anaesthetics; General Medicine and Psychiatry. Not having enough doctors, particularly those in the middle-grade ranks, is making it very difficult to maintain safe medical teams. Some services are increasingly vulnerable because without enough doctors they become unsafe. No-one wants to run services which we know are unsafe, and where patients could come to harm as a result. The way we deliver health care and train doctors has changed. Medical treatments have become more specialised, improving care for patients, but increasingly groups of specialist doctors need to be located together so that they have enough cases to treat to keep their skills up. This improves outcomes for patients, but may mean that there are fewer hospitals which can provide the required number of doctors. The doctor shortage has started to reach a crisis point and has already forced some urgent changes. Neath Port Talbot Hospital was a case in point. We couldn t recruit enough doctors to keep a safe acute medicine service, and in August 2012 we had to move the service urgently to other hospitals. It s not the first time doctor shortages have caused us problems. The Children s Ward at Singleton Hospital merged with the one in Morriston Hospital in 2009 because of a shortage of paediatricians. In 2008 the Minor Injury Unit at Singleton Hospital kept closing at very short notice as we just didn t have enough A&E doctors. In the end GPs stepped in, and we also had to reduce the hours it was open. 16 CHANGING FOR THE BETTER: Our ideas for your local NHS
However the UK also faces challenges with its GP workforce. In England it is estimated that GP numbers need to increase by more than 20% to meet the demands being placed on them, and this is at least as much of an issue in Wales. Difficulties finding GPs who want to provide out of hours care are increasing, and an ageing workforce means that there will be difficult issues to face in expanding care provided in GP practices. A bigger proportion of GP s are female, many of whom are choosing to work less than full time, which can also affect access to services. So doctor shortages have been with us for a while but the problem is getting worse. To find out more about why there is a shortage of some doctors; visit our website for more details: www.changingforthebetter.org.uk (3) Quality of Care Quite rightly patients, their families and the public expect us to meet increasingly higher clinical and quality standards. We know that we do not always have the best outcomes every time at the moment. Creating expert teams who work effectively together is key to delivering better outcomes. One good example is the way we treat patients suspected of suffering a stroke. Patients are now assessed in two of our hospitals instead of four. This has allowed us to create dedicated acute stroke care wards offering clot busting thrombolysis services day and night. This has meant we give better care from the start, with specialist rehabilitation taking place in hospitals closer to home. Over 500 patients have already benefitted from this, resulting in fewer long term complications from stroke and fewer fatalities. However, there are even more potential improvements to stroke care which could be made, which might require further changes to these services....have Your Say! 17
So concentrating specialist medical, nursing and therapies skills has reduced the length of time stroke patients are in hospital and improved their recovery and re-mobilisation rates - with patients returning more quickly to more active lives following their illness. In short, patients have a better outcome, they don t need to be in a hospital bed for so long, and they don t need as much after care. All of this adds up to a service which is better for patients and is also a much more efficient use of NHS resources. (4) Money We are in the middle of a major world-wide economic crisis and the NHS is not immune from its effects. On top of that, our ageing population is adding huge demands on services, as is the growing number of people with long term health conditions. The Wales Audit Office estimates that by 2013/14 there will be a funding gap of 250m to 445m in NHS Wales just to stand still on services. We can t afford to keep going as we are - we will run out of money and some services will collapse. However, experience has taught us that if we have services which are effective (they help people get better faster) and efficient (they don t waste money, staff or supplies) then they will also generally save money. A change in the way a service is run may not cost less up front - in some cases it may even need additional investment. 18 CHANGING FOR THE BETTER: Our ideas for your local NHS
But, if change results in any of the following, then the longer term pressures (including costs) are likely to ease: Patients don t get ill in the first place, or not as ill as they would have before the change Patients receive the best care available, even if that means travelling further Patients spend no more time in hospital than they need to Patients avoid unnecessary complications or infections Patient outcomes are as good as possible which means they recover quickly or are as well as possible The risk of unnecessary harm or death is kept to an absolute minimum. Most of our money is spent treating long term conditions......have Your Say! 19
People often equate the number of beds a hospital has with the quality of the health service it provides. Yet ironically there are more beds in Wales: 3.9 per 1,000 population; than in England: 2.6 beds per 1,000 population, but English outcomes are generally better than ours! So there s much more to it than just pumping money into hospital beds. Many of the potential changes we have in mind are about other ways of delivering care. This will allow us to reduce hospital beds so we can redirect our resources to achieve these changes. We want your views on these ideas because we believe change is essential for us to deliver the best care for you now and in the future. Below are some examples which show how modernising services can improve the quality of care we give and also save money: Enhanced Recovery: This is a new way of treating patients having surgery, using alternative drugs for pain relief which have fewer side effects. It also needs more intense clinical care just before and after surgery. But pain is much reduced and the patient s mobility is increased. It halves the amount of time patients need to be in hospital because they are up and about much sooner. It is expected to save ABMU 1.5 million a year in orthopaedics alone. Our patients have been really pleased with the results. Reducing the need for agency doctors: Because of the ongoing doctor shortage, and because we currently spread some of our services too thinly, we face high bills to pay temporary doctors to fill medical staffing gaps. Last year, 2011/2012, our bill for agency doctors was 3.65 million. Reorganising services so that some are consolidated at centres of excellence would dramatically cut the need for agency staff and give patients better access to specialist teams. It would also support continuity of care for patients. Agency doctors are also not always aware of local 20 CHANGING FOR THE BETTER: Our ideas for your local NHS
policies or agreed care pathways. This means they may carry out additional tests and generally use up more resources than a doctor employed on a regular basis in the service would. Modern community services: Effective community services can stop people needing to be admitted to hospital, or if they are admitted, help them go home as soon as possible. The new Mobile Response Unit in Bridgend attends calls to a telecare service from older people or vulnerable people, for example those with chronic conditions or who are at risk of falls. The team then assess the patient in their home to determine if they need hospital or emergency care. Up to July of this year, 674 call outs have been attended, but only 91 patients needed to go to hospital. So this service not only offers patients the care they need, as they need it - it s also usually in their own homes where most patients would prefer to be, rather than hospital. We want to ensure such services are available to all our patients, particularly outside of normal working hours so that there is an alternative to hospital admission which costs around 180 a day. So to sum up, money is a major factor in the changes ahead; but it s not the only one. Better quality, better outcomes, greater efficiency and effectiveness are just as important....have Your Say! 21
What We ve Been Doing So Far Since the start of the year we ve gathered together a wide range of people to discuss the issues and formulate the ideas in this booklet. No-one has a monopoly on ideas, and we wanted to have as many people s views as possible, especially the clinicians who provide our services, and the patients who use them. So since January, over 340 people including GPs, hospital doctors, nurses, midwives, therapists, public health officers and managers as well as patient representatives, service users, carers, voluntary sector organisations, the local authorities, ambulance service and Swansea University have been working together to develop ideas for doing things differently and better, drawing from our own experience and from across the world. These people have formed the ABMU Changing for the Better programme. The Community Health Council is working with us on your behalf and we have invited experts from across the UK to advise us too. 22 CHANGING FOR THE BETTER: Our ideas for your local NHS
We have based our ideas on: What we know about health and disease in our communities The difficulties we are having recruiting some clinical staff Less money being available in real terms, year on year What you have told us about local NHS services now What we know about the quality of care we provide What standards of best practice and research tell us we should be doing What other health providers in the NHS and elsewhere are doing How advances in technology can help us in the future The likely demand on the NHS in the future and the opportunities for working with partner organisations to meet this The need to make fewer errors when we provide care...have Your Say! 23
We have been talking about the Changing for the Better programme and the ideas coming from it with a wider range of our staff, other partners and patient, carer and voluntary sector groups, and we ve shared details on our website and social media sites, and with the press and media. This means that over the past eight months these ideas have been discussed and changed. We are now ready to share them more widely and get your views on them. Our ideas would mean some major changes to the local NHS. All four of our main hospitals would continue to have an important part to play in providing care that cannot be provided in the community, even with additional investment and advancement in community-based care. However we will need fewer beds as care shifts elsewhere, and the services each hospital provides changes. 24 CHANGING FOR THE BETTER: Our ideas for your local NHS
We are listening!...have Your Say! 25
Working Together With Other Health Boards In addition, some of the problems the NHS faces need solutions from across the NHS in South Wales, not just the ABMU area. We think that by working with neighbouring Health Boards over some services, we can provide better, safer and more sustainable care not only for our patients, but a wider population as well. So we have been working with five other Health Boards, and their clinical staff, on another change project, called Together for Health - The South Wales Programme. The recommendations from this programme could change how some ABMU hospital services develop in the future, so we have summarised them, starting on page 46. If you want to find out even more about the South Wales Programme, the full document: Matching the Best in the World Challenges Facing Hospital Services in South Wales and supporting information are available on our website: www.changingforthebetter. org.uk We have not made any decisions yet, we want your views first. This is your opportunity to influence the difficult decisions we need to make and the detailed plans we will publish in the New Year. You can help to shape these plans. Please consider our ideas carefully and help us by giving your views on what changes we should make, what you agree with, what you don t and what we can improve on. We explain how you can do this on page 62 and look forward to discussing our ideas with you and listening to your views between now and Christmas. 26 CHANGING FOR THE BETTER: Our ideas for your local NHS
Which ABMU Services Has Changing For The Better Been Looking At? The 340-plus participants in the Changing for the Better workshops have focused on seven key groups of services. In each case, we ensured that there was a mix of people involved, including those with no prior expertise in the service as well as specialists. That s because we wanted fresh ideas, backed by experience. One group focused not on a service as such, but on how we can help you improve your health, and stay healthy. We had others thinking about our main groupings of patient services, (some aspects of which are also being considered by the South Wales Programme): Unscheduled Care This is urgent or emergency NHS care where you don t have an advance or scheduled appointment. It includes hospital care delivered in an Emergency Department (A&E) for example, when you have a minor cut or bump, when you think you may have broken a bone, or when you have been involved in an accident. It also includes acute medicine, for when you suddenly become seriously unwell (like a heart attack or stroke) and acute surgery, for when you suddenly need an operation (like appendicitis or for a fractured hip). It also includes emergency and urgent care provided by our GPs, dentists, optometrists and community services (such as district nursing). Planned Care All care which is arranged in advance, such as clinic appointments, tests and scheduled operations....have Your Say! 27
Maternity & Newborn - Care for mothers before, during and after birth and the care of ill babies up to one month old. Children & Young People Planned, emergency care and community services for children and young people from birth to 18 years in all settings (except babies requiring specialist neonatal care). Frail, Older People - Older people who may have several health problems and are more likely to be frail. Long Term Conditions - Diseases that cannot be cured, but can be helped by medicines and other treatments and can often be prevented by a healthy lifestyle. In a number of these areas overlaps between how services could change were identified and so the people involved have worked together to agree the best ideas for services. We already have plans to improve specialist adult and older adult Mental Health services through Changing Mental Health Services for the Better, and plans for Substance Misuse services, Child and Adolescent Mental Health Services and Learning Disability services for adults, so we haven t incorporated these plans into this document. However, clinicians from these services have been involved to make sure that the needs of these patients, who also have a physical illness, are considered. 28 CHANGING FOR THE BETTER: Our ideas for your local NHS
Which Services Has The South Wales Programme BEEN LookING At? As we mentioned earlier, in addition to our local Changing for the Better programme the South Wales Programme has also been underway, and has been looking at some of the specialist services which need regional or multi Health Board solutions. This work has been supported by independent expert advice and involved around 300 doctors, nurses, midwives and therapists from across South Wales. It has considered quality, safety and access to achieve sustainable services. Services Considered by the South Wales Programme: Women in pregnancy and childbirth Newborn babies, infants and children People who are injured in accidents or need specialist medical help in an emergency People who need emergency ambulance and paramedic services Clearly the South Wales Programme mirrors some of the work of our Changing for the Better programme, so we have included a full summary of the South Wales Programme recommendations and their implications for our services, starting on page 46. But first, here are the ideas emerging from our Changing For The Better work......have Your Say! 29
30 CHANGING FOR THE BETTER: Our ideas for your local NHS
IDEAS EMERGING FROM THE CHANGING FOR THE BETTER WORK (1) Staying Healthy and Reducing the Risk of Becoming Ill Our first priority should be to make sure we all stay healthy and reduce the risk of developing ill health. We have great opportunities to work with the public, councils, voluntary organisations, local employers, schools, colleges, Universities and communities to help people make healthy choices. This will only be successful if people want to make changes and are supported, and we also need to set a good example for our children and young people. We support the work of the Welsh and UK governments to improve things which contribute to health, like the quality of our housing, air quality and the economy, and we will work with partner organisations to address these in the ABMU area. We need to be bold and invest for the long term in improving people s health and wellbeing, but we may not see some of the benefits for a number of years. Any reduction in avoidable illness and death because of smoking, being overweight or drinking excessively will be more than worth the money invested over time. We also need to make sure that everyone can find information easily about the help and services available. We provide a wide range of services, as do our partners and the voluntary sector, but some of them are not well known about. Therefore we want to work with partners to develop a single, interactive directory of information which can be accessed by computer, telephone and paper copy which will list support services and how to access them....have Your Say! 31
Our staff and partners should take every opportunity to motivate and support people to understand the risks of the things they do or don t do, and help people to: Stop smoking, particularly when pregnant Eat well and maintain a healthy weight Increase the amount of exercise they take Drink alcohol responsibly Not use illegal drugs Not get pregnant by accident and prepare for pregnancy in advance Keep good sexual health Breast feed their baby Get immunisations and vaccinations when they are due Maintain their mental wellbeing 32 CHANGING FOR THE BETTER: Our ideas for your local NHS
(2) Unscheduled Care Unscheduled care is when you don t have a prior appointment for example, when you attend an Accident and Emergency Department (A&E) or have a medical or surgical emergency or a minor injury. Urgent care is also provided by GPs 24/7 at GP Practices from 8am to 6:30pm on weekdays and by the Health Board s GP Out of Hours Service when your surgery is shut overnight and at the weekend. To achieve timely access to high quality, safe and effective unscheduled care services, we need the following: Senior doctors and clinical staff who are available as needed and can offer full, reliable, cover for longer hours than currently Being able to safely and quickly diagnose what is wrong and decide if you need specialist help, or can be treated locally Seven-day working and consistently high standards The right interface with other connecting services Getting the right care without delays Making sure accurate and up to date information is available about your health to whoever you may see in an emergency As emergencies can happen at any time of day and night we need to be able to provide high quality care around the clock, seven days a week. To guarantee this service we require more doctors and other clinical staff to be available. As treatments have become...have Your Say! 33
more specialised this means we need teams of doctors with different specialist skills. This is a particular challenge when we are trying to run these services across a number of locations. In the past we had general doctors who could treat lots of different types of medical problems. Health care has become more specialised and as a result patients get better outcomes, but this also means that staff are now more specialised, and fewer doctors generalise. To meet the required quality standards we need different doctors for different conditions - e.g. stroke, heart, kidney, respiratory, gastrointestinal; which means we need more of them. However these specialist teams, skills and resources cannot be replicated on lots of hospital sites, because we do not have enough trained specialists, and even if we did, they just wouldn t see enough patients to keep these skills up. So not only is it impractical to have too many specialist centres but patients would not get the highest possible quality of care we could offer either. In ABMU the two Accident and Emergency Departments (A&E) have a chronic shortage of doctors, both middle grade and at Consultant level, which puts them under constant pressure. Shortages are also developing in surgery, trauma and acute medicine - services which have a critical role in supporting Accident and Emergency Departments (A&E). Likewise there are challenges with recruiting to GP out of hours services, which are vital to the whole pattern of unscheduled care services. Although nurses roles have developed to support the delivery of care in a number of ways, there is growing evidence to show that having senior doctors available 24/7 for emergency care, in primary (GP) and secondary (hospital) care, means patients get the care they need sooner and improves their outcomes. 34 CHANGING FOR THE BETTER: Our ideas for your local NHS
There is also increasing evidence to suggest that in serious emergencies like stroke or heart attack, that rapid access to specialist teams is critical to ensure that patients get the best treatment and have better chances of recovery. So as explained on page 17, we have recently remodelled our stroke services in line with best practice. The Welsh Government recommends that stroke services offer: 24 hour local diagnosis Specialised care in centres of excellence within four hours Treatment and diagnostic procedures using latest evidence based techniques 24/7 clot busting thrombolysis round the clock Tertiary centre(s) offering very specialist neuroradiology/surgery There are other parts of specialist emergency medical care that we need to develop in a similar way, including respiratory care, gastroenterology, cardiology and emergency surgery. Traditionally emergency surgical care has been provided by a wide range of surgical teams. Changes in specialisation and training now mean that breast and vascular surgeons should concentrate on a specialist and planned care basis, rather than working on general surgical rotas. In all specialities most patients admitted to hospital following an emergency attendance are elderly. These patients have multiple complex needs and their carers need support to keep them at home for as long as is practical. Recent studies show that about 25% suffer from dementia as well as physical illness. This patient group and their families...have Your Say! 35
and/or carers require alternative methods of care and reconfiguring our service to better provide for them both in and out of hospital is, and will be, a significant challenge. Some elements of Unscheduled Care do not have to be provided in major Accident and Emergency Departments led by doctors. Across the UK there are many examples of nurse led minor injuries services where highly trained senior nurses support patient care needs without them having to travel to a major Accident and Emergency Department (A&E). Neath Port Talbot Hospital provides an excellent nurse led Minor Injuries Unit (MIU). Even though we have recently had to make changes for people with more serious acute medical problems in Neath Port Talbot, the MIU continues to treat minor injuries from the local area and further afield, quickly and effectively without patients needing the services of a major A&E. This is also the case with the MIU at Singleton Hospital. The majority of work carried out by GPs in their surgery, patients own homes and out of hours is unplanned and amounts to over 19 million consultations across the UK per year. The GP OOH (Out Of Hours) service also provides an excellent high quality service to a huge volume of patients who have an urgent need for advice, assessment or treatment. We need to ensure that we build upon this service and link it with other unscheduled care services in the future to help with our 24/7 response. The South Wales Programme (see page 49) has also been examining services which affect patients using A&E services and specialist medical emergency services and its recommendations will have an impact on our hospitals. 36 CHANGING FOR THE BETTER: Our ideas for your local NHS
(3) Planned Care We feel that we are spreading some of our surgical services too thinly, offering the same types of operations and planned care on too many sites. For some time now we have been centralising complex surgical operations onto regional centres, and we think that should continue. (We have already done this in Swansea, at Morriston Hospital.) This will still allow us to provide the more common and less complex operations and diagnostic tests in all of our other hospitals. The vast majority of our patients would continue to be able to have their operations at their local general hospital. It would mean that some patients having more complicated operations would need to travel further for their operation, but the trade off is that the quality of the care provided would be better, as would the outcomes of treatment. We think that the centralisation of these complex operations is important to make sure you get the best care possible. We would also like to use technology better for planned care, from using texting and apps to keep you informed and updated on your care, to reviewing you after surgery without you having to come back to hospital....have Your Say! 37
(4) Maternity and Newborn The birth rate in ABMU is increasing, and whilst some mothers are giving birth at a younger age, others are giving birth much older. Both these, alongside increasing numbers of mothers being very overweight, means increasing complexities in births and the need for more neonatal (newborn) care. Quite rightly there are also rising expectations about the quality, safety and experience for mothers and their babies. We need to ensure we plan services specifically to meet the needs of mothers with other illnesses such as diabetes and epilepsy, which will contribute to better outcomes for mothers and their babies. We also need to help people to plan their pregnancies better and ensure they are as healthy as possible and prepared before they actually become pregnant. Care for mothers-to-be is provided by community midwives who support women in or near to their homes, in collaboration with their GP. Over a fifth of women in ABMU already choose to give birth at home or in a midwife led unit but we know that over half the babies in our area could safely be born at home or in a midwife led unit, so we would like to see the number increase. Where women choose or need to have a consultant to deliver their baby then we want to make sure that their care is as safe as possible by having a consultant obstetrician on the labour ward for more hours of the week than we can offer now. To achieve this we need to consolidate our consultant-led obstetric services, so that we make the best use of the staff we have, offering the highest quality care. Some high-risk mothers-to-be may have to travel to another nearby hospital to have their baby, but they will have better access to senior and experienced staff as a result and therefore the chances of having a healthy baby will increase. The South Wales Programme, page 47, also looks at pregnancy and childbirth services, and neonatal (newborn) care, and its recommendations have an impact on our hospitals. 38 CHANGING FOR THE BETTER: Our ideas for your local NHS
(5) Children and Young People The UK-wide shortage of paediatricians (children s doctors) continues to place a strain on our hospital-based services for children and young people, and we ve been looking at ways to address this. It is likely to mean consolidating some of our consultant-led paediatric inpatient services. Having said that, about 95% of the care that we provide to children and young people is by their GP, consultant in outpatients or teams in the community: health visitors, school nurses and specialist community paediatric teams of doctors, nurses and therapists. This is especially true for children with long-term conditions or disability. We want to build on this work to increase the support that we provide children and their families so that fewer of them have to be admitted to hospital in the future and any hospital stays are a short as possible. We want to see even stronger services in our local communities for children who are unwell. We will continue to create the Children s Development Centre in Swansea on the Singleton Hospital site, bringing together the many services that some children, particularly those with disabilities, need into a single facility. This will mean that we will have a Children s Development Centre in Swansea as well as in Neath Port Talbot and Bridgend. Over the next five years we anticipate developing a single point of access in each locality for all these services and extending access to these services after hours and over weekends. We also want to develop further our assessment and diagnostic service for acutely unwell children across ABMU so that they can be seen quickly by a specialist if needed and treatment started, so that after a few hours they could be back at home with support from a primary care or community team if necessary. The South Wales Programme s recommendations on paediatric services, see page 48, has implications for our services....have Your Say! 39
(6) Frail, Older People The number of people who are older and frail is increasing fast and this is expected to continue. We want to focus on their needs throughout all the services they use. We need to deliver care in partnership with the patient, the community, family, carers, GPs, hospitals, Councils and the voluntary sector all working as a team to support them to stay at or near their own home for as long as possible. The key components of care are: Staying Healthy supporting frail older people to live independently at home, to keep well and reduce the risk of deterioration: e.g. checking medicines prescribed for them; house adaptations, health screening and community activities to reduce isolation. Proactive Community Care pro actively identifying older people at most risk of deterioration so support can be provided before a crisis is reached: e.g. through key workers and the use of technology to alert problems. 40 CHANGING FOR THE BETTER: Our ideas for your local NHS
Preventing Hospital Admission making sure admission to hospital is not the automatic way of caring for frail older people; by making access to integrated services in the community quicker and simpler. Inpatient Hospital Care Ensuring we have specialist staff with skills in dealing with multiple health problems in the frail older person and a rapid treatment approach and speedy discharge home. A very important aspect is to ensure that the 25% of hospital inpatients across all departments, who also have dementia, receive appropriate care. Maintaining the dignity of all patients is essential. Discharge to Assess to ensure the frail older person only stays in an acute hospital while they need acute care, and once well enough for discharge are supported to live as independently as possible whilst their needs are assessed carefully by an integrated care team Maintaining Independence developing support for the frail older person, their families and carers to self care and remain independent for as long as possible. Medicines Management for safer healthcare and to help make the best possible use of medicines. To achieve all this we want to invest in and develop community services by using some of the money we spend currently on hospital services....have Your Say! 41
(7) Long-Term Conditions We are seeing an increasing number of people with chronic illnesses like diabetes and chest conditions. We want to improve our services for them but we also want to empower them to manage their condition more effectively themselves, and to better access community services which can help them. The key components of care are: Helping people take ownership of their health by supporting patients to learn more about their condition, directing them to where they can get help and looking at all their needs - not just the condition - to improve their quality of life. Services for people with long term conditions will usually be provided in the community services will be available 24/7, with rehabilitation close to home and ongoing relationships between patients and community teams to give continuity of care, with hospital staff coming out to work with these teams. Communities strengthened to provide a network of support for individuals, carers and families - working in an integrated way with partners to improve the support available for people with long term conditions. 42 CHANGING FOR THE BETTER: Our ideas for your local NHS
Coordinated Care through collaborative working joining up the care of different teams who look after people s health, sharing their records where this will improve the care they receive. Clear route into the right specialist care when it is required rapid access to diagnostic tests provided in the community with a good discharge process back to a network of support in the community. Improved medicines management reduce the risks for patients by regularly checking the drugs they are taking and ensuring everyone plays a role in the review of medication. To achieve these improved services we will need to save money from hospital services and invest in developing community services....have Your Say! 43
How GP and Community Services Could Change What Have We Got Now? So far we ve spoken a lot about how we see the development of community based services, and we want to expand a little on this. In the ABMU area there are 77 GP practices looking after patients and helping them to access urgent and emergency care when needed. These practices provide daytime care on weekdays. The Health Board then provides a GP Out of Hours service for the rest of the time, based in Morriston, the Princess of Wales and Neath Port Talbot hospitals. We are working closely with GPs to ensure that we can continue to provide good access to their services. This is where the vast majority of healthcare is delivered for all of the groups of patients identified earlier in the document. We need to make sure we are strengthening the wider primary health care team, including links with others such as pharmacists, end of life community nurses, health visitors, district nurses, chronic condition nurses and community mental health teams. We run outpatient clinics in all our main hospitals and in other settings such as the new Primary Care Resource Centres. The Resource Centres offer a central facility for some GP surgeries and also some clinics (e.g. baby clinics run by health visitors). Increasingly other services are provided too such as blood tests, some investigations, outpatient clinics and rehabilitation services and we want to build on this whenever the opportunities arise. 44 CHANGING FOR THE BETTER: Our ideas for your local NHS
We are working with groups of GP Practices, community staff, voluntary sector services and hospital staff to form community networks which will help us to plan and coordinate your care in future. This will ensure you get as much of the care you need in or close to your home, and spend as little time as possible in a hospital bed. Also the growing numbers of Primary Care Resource Centres are a base for a number of GP Practices and associated community services as well as some of the services we provide in our hospitals at the moment. At the moment we have four community hospitals Gorseinon Hospital, Cimla Hospital, Gellinudd Hospital and Maesteg Hospital. Because our community resource teams help patients to go straight home with good support we have stopped using the beds in three of our other community hospitals already and we think that as this develops further we will no longer need any beds in community hospitals, as we will care for you at home or in other settings instead. Some community hospitals could change to become a place for community clinics, tests, or other services rather than for staying as an inpatient. It may also mean a reduction in their overall number if we are able to provide the services differently in the community....have Your Say! 45
The South Wales Programme: A Summary Of Its Recommendations Over the last few months the South Wales Programme has considered a number of the same services examined by our Changing for the Better programme. 300 senior clinicians from across South Wales have considered all the evidence and made many important recommendations. Here is a summary of their main recommendations; and we follow with an analysis of how they would affect some of ABMU s services. The map below shows the relevant area of South Wales area included in this programme. 46 CHANGING FOR THE BETTER: Our ideas for your local NHS
South Wales Programme Key Recommendations Women in Pregnancy and Childbirth: That the number of consultant-led obstetrics units in South Wales should reduce so that clinical and training standards can be met, and services can be located in the same hospitals as critical support services Most clinicians agreed that ideally a consultant-led obstetric unit should have around 6,000 babies delivered there per year Most clinicians agreed that emergency gynaecology should only be carried out in hospitals with consultant-led obstetric services Community midwifery and all antenatal and postnatal care should be provided as close to patients communities as possible Low risk births can safely be supported to happen at home or in Midwifery-led units (whether in the same hospital as consultant led obstetrics or not) Most clinicians agreed that ideally a Midwife Led Unit should have around 500 babies delivered there per year...have Your Say! 47
Neonatal (newborn) and Paediatric (children s) Services: There needs to be sufficient, appropriately skilled staff in each centre with paediatric beds There should be only 2 or 3 highly specialised neonatal units as there are not sufficient doctors to cover more units to the required standards There should remain only one tertiary paediatric centre and one paediatric intensive care unit for South Wales, in Cardiff There should be between 2 and 5 consultant-led paediatric units operating 24 hours a day, 7 day a week providing a full range of children s services including inpatient beds and the majority of clinicians supported the idea of 4 Consultantled paediatric units across South Wales There is strong support for paediatric Assessment Units being provided in all hospitals that currently have paediatric beds 48 CHANGING FOR THE BETTER: Our ideas for your local NHS
People Who Are Injured in Accidents or Need Specialist Medical Help In an Emergency Major A&E sites require a range of specialist services to be operating 24/7 on the same site Major A&E sites must have senior clinicians making decisions 24/7 Major A&E sites are unlikely to be efficient if coping with more than 100,000 attendances each year Most emergency specialist gastroenterology/cardiac work should be done at hospitals with a major A&E Population density and travel time to get to major A&E sites are key factors, but to achieve standards of care the number of major A&Es will need to reduce There is clinical agreement that the number of major A&Es should reduce, with most agreeing there should be between 3 and 6 Surgical emergencies should only be treated on hospital sites operating a range of specialist services 24 hours a day, 7 days a week (i.e. with a major A&E) Over time, Consultant surgeons who specialise in vascular and breast surgery should not be included in general surgery medical cover as increasingly they do not have the generalist skills required for all the different patients needing treatment Work is underway to look at a major trauma (multiple injuries) service for South Wales. It could be on a single site or across UHW, Cardiff and Morriston Hospital, Swansea working together...have Your Say! 49
People Who Need Emergency Ambulance and Paramedic Services The aim should be to take patients to the best hospital to meet their needs, not necessarily the closest one Standardisation of services across hospitals will help ambulance services to be clear where best to take different patients A helipad next to every Major A&E is essential Paramedic and pre-hospital care needs developing because increasingly patients can start their treatment when these services reach them, rather than when they get to hospital Helicopters may not be able to fly all night or in some weather conditions, so other means of transport and travel times for these are still important Once acute care is provided, transferring the patient back to a more local hospital is important 50 CHANGING FOR THE BETTER: Our ideas for your local NHS
Combined Possible Impacts of the South Wales Programme Recommendations Emerging from the South Wales Programme is the idea that there are a range of specialist services which need to be located together into Regional Centres in order to optimise the quality and safety of services to be achieved. The services which need to be located together are: Major Accident & Emergency Department Consultant-led Obstetric deliveries Inpatient paediatric beds and associated services Highly specialised neonatal units All levels of critical care Surgical Emergencies Specialist emergency Gastroenterology & Cardiology There has been significant work over past years on the key and specialist roles which University Hospital of Wales, Cardiff; Morriston Hospital, Swansea and the planned new Specialist and Critical Care Centre (SCCC) for Gwent fulfil for their areas and beyond in South Wales. Investment has taken place, or is planned, on the basis of developing this status. The work of the South Wales Programme concludes that these three hospitals are three of the Regional Centres described above....have Your Say! 51
How Many Regional Centres Could There Be? When the ideas outlined above for each speciality are combined, the summary conclusion is that health boards should consider moving to a model where South Wales has four or five centres for specialist obstetric, neonatal, paediatric and accident and emergency services and that as soon as practicable these should be located on single hospital sites. This conclusion has been accepted by the South Wales Programme Board and commended to the South Wales health boards as the basis for public engagement. As three of these are fixed (Cardiff, Swansea and Gwent), as outlined above, this means that across South Wales there needs to be either one or two hospitals in addition, which are regional centres. As can be seen there are three other hospitals which currently provide these services, (see map), out of which the South Wales Programme has concluded only one or two could continue to do so. 52 CHANGING FOR THE BETTER: Our ideas for your local NHS
Whichever one or two out of Prince Charles Hospital (Merthyr Tydfil), Royal Glamorgan Hospital (Llantrisant) and Princess of Wales Hospital (Bridgend) are supported to be Regional Centres in future, they will provide these services for a larger area and more patients than now and have the services they provide enhanced to ensure they meet all the relevant quality standards. The hospital(s) which do not fulfil the role of a Regional Centre in future would continue to provide a wide range of services for their local population, including: Paediatric Assessment facilities Midwife led unit for low risk births Outpatient facilities Diagnostics and scanning Planned operations Local Accident Centre / Minor Injuries Units...Have Your Say! 53
What the South Wales Programme could mean for your hospitals None of the scenarios under consideration would mean closing any of our main hospitals. But the services available at each hospital would change. Some of these changes are minor but some are much bigger and would mean that the role of that hospital would be very different from now. To help you be clear about the changes we anticipate to our main hospitals, the main services that each provide now are shown in the table on page 55. Morriston Hospital Morriston Hospital has long been a centre for specialist emergency and complex care not only for the ABMU area but also serving people from West Wales and in some cases much further afield. This role has been confirmed in principle by the recommendations of the South Wales Programme. The details of this will depend on the outcome of the South Wales Programme regarding the Princess of Wales Hospital as any changes there may affect the number of patients that Morriston Hospital needs to see. We also need to bear in mind that Morriston Hospital does not have two of the services which would normally be expected for such a centre whilst it has inpatient children s wards it does not have the maternity and newborn baby unit (neonatal intensive care), which are at Singleton hospital at the moment. 54 CHANGING FOR THE BETTER: Our ideas for your local NHS
...Have Your Say! 55