An overview of the planning process, findings and emerging proposals for the future

An overview of the planning process, findings and emerging proposals for the future

South Wales Programme objectives Safe and high quality care for patients which matches the best elsewhere Deliverable by a sustainable workforce Optimise access by ensuring patients receive the right care as quickly as possible

What services are involved? Emergency medicine (A&E) Inpatient children s services Consultant-led maternity care and neonatal care

Why do we need to change? Quality and safety Insufficient senior cover to meet core service standards emergency medicine and obstetrics Inadequate critical mass to meet training requirements paediatrics

Why do we need to change? Workforce issues Recruitment of consultants and retention of CCT holders especially in emergency medicine Ageing middle grade non-training workforce

Why do we need to change? Issues affecting doctors-in-training Recruitment problems and insufficient numbers for 1:11 rotas Poor pass rates and high drop-out rates Trainees not receiving range or intensity of experience Less than full-time training increasing

Why do we need to change? Social and demographic changes Increase in population at all ages in Cardiff, Newport and Swansea Over-80 population is growing and will increase demand for acute services

Why do we need to change? Traditional A&E services are no longer fit for purpose More acute/general medicine patients attending than injuries Still regarded as the main front door to the NHS but becomes a bottleneck Still seen as easiest service to access for care which can often be provided differently and more appropriately

Benefit criteria Feedback during engagement was used to develop six benefit criteria the key issues against which all the options were assessed: Safety appropriate clinical cover to meet standards Quality meeting critical mass and access times standards Sustainability available workforce and infrastructure Access number of people with increased journey times Equity proportionate impact of increased journey times on deprived communities Strategic fit overall fit with national and local plans

Strategic Context Together for Health no DGHs will close but will work together to provide services as a network of hospitals Setting the Direction integration and expansion of service provision in community setting to provide more out of hospital care Clinical Futures well developed in AB centralisation of specialist acute services in SCCC RGH & NHH will become local acute hospitals Changing for the Better increasingly specialist services provided in Morriston changing roles for Singleton and NPT UHW and Morriston working together as a collaborative centre in a trauma network for South Wales

Proposed service models Developed by clinical reference groups (CRGs) each chaired by a health board medical director Clinical membership from all health boards and a range of specialties and clinical professions CRGs met monthly from January 2013 with smaller group sessions outside of main meetings and also reporting back to clinical conferences in February, March and April Building on recommendations from clinical summits and conferences in 2012

Emergency medicine - standards Workforce will meet College of Emergency Medicine standard of 16-hour consultant cover for an emergency department and 24-hour cover for trauma unit Patients needing admission will have senior doctor assessment within two hours; otherwise within four hours Rotas will meet European Working Time Directive (EWTD), New Deal and Deanery training requirements

Emergency medicine key principles and assumptions Flexible deployment of clinical workforce and new service model will be sufficiently attractive to recruit additional doctors Increase in enhanced and advanced nurse practitioner (ENP/ANP) and advanced healthcare professional-led and delivered services in local and regional units Development of more flexible, non-training clinical roles Greater integration between minor injuries, GP out of hours and acute medicine in local hospitals Paramedics to have direct access to specific services through development of pathways operating 24/7 Pathways will be developed with patients, public and service providers to signpost access to appropriate services Adequate capacity in primary and community services 24/7

Local emergency care Nurse-led minor injuries Nurse-led paediatric minor injuries Appropriate stabilisation skills and facilities supported by regional department Selected acute medical take and rehabilitation work ongoing to define this High dependency unit service Out of hours primary care service co-location Diagnostics, including hot lab for pathology, CT scanning and MRI provision Elective activity potential options for moving some elective services under consideration

What services will be in the four or five regional hospitals? Treatment for all children under one All acute paediatric illness Majority of unscheduled surgical admissions Patients requiring critical care (including complex elective care) GI bleeds Chest pain and myocardial infarction Poisonings and overdoses (non alcohol) Major illness, for example stroke

Direct to specialty or primary care To specialty Post-op problem cases Allergies Asthma (acute exacerbation) Diabetes (acute exacerbation) PV bleeds and obstetric cases To primary care Flu Diarrhoea and vomiting Dizziness Skin conditions Urinary tract infections Blocked catheters Constipation

Current A&E/MIU casemix CurrHosp Local Primary Care Regional Str to Medicine Str to Other Grand Total Barry 8026 57 171 286 8540 Morriston 50401 2764 20716 554 15865 90300 Neath PT 24680 931 2611 1174 4856 34252 NHH 35334 1061 9921 175 2283 48774 PCH 36642 2046 12011 2716 5867 59282 POW 35693 1503 12074 2202 9214 60686 PPH 23286 1440 4803 786 3222 33537 R Glam 43735 1803 11415 3901 5189 66043 R Gwent 56904 2168 20954 321 5199 85546 Singleton 6834 423 679 48 1138 9122 UHW 81750 4098 28431 2319 19338 135936 YAB 2732 45 48 173 2998 YCC 7332 96 121 273 7823 YCR 4399 5 55 161 4620 YYF 26446 753 1739 56 479 29473 Grand Total 444194 19193 125749 14252 73544 676932 %age 66% 3% 19% 2% 11% 100%

Inpatient children s Minimum of 4,400 attendances a year care - standards Assessed within four hours of arrival by a senior doctor Consultant presence at times of peak activity Rotas will meet EWTD and New Deal requirements and Deanery training requirements including 1:11 rota Separate 1:8 middle grade rota for neonatal intensive care units (three sites) One tier of 11 middle grade doctors will additionally support the local neonatal units (high dependency)

Inpatient children s care principles and assumptions Flexible deployment of clinical workforce Increase in consultants providing hybridised roles (ie covering out of hours and weekend shifts) to replace reducing training grade workforce Ability to attract CCT holders to new consultant roles More advanced nurse practitioners to support both acute paediatrics and neonatal services Pathways will be developed with patients, public and service providers to signpost access to appropriate services

Local hospital children s care Rapid access/hot slots for urgent referrals Minor injuries Routine outpatient clinics Low risk, routine elective day case surgery (surgical pathway for children is being developed separately) The provision of short stay paediatric assessment services is being further reviewed. Key issues include staffing; safe and effective triage; backup services and transfer implications

What services will be in the four or five regional hospitals? Care for all children under one All paediatric emergency specialist assessment All elective and non-elective paediatric admissions All surgery requiring an overnight stay and selected day case procedures/high-risk case mix

Current paediatric attendances Hospital ED Transfer GP Clinic Other Total %ED %GP or clinic Morriston Hospital 1900 13 4268 36 661 6878 28% 63% Nevill Hall Hospital 1225 87 1900 19 295 3526 35% 54% Prince Charles Hospital 1451 45 1776 43 394 3709 39% 49% Princess Of Wales Hospital 895 928 1416 23 577 3839 23% 37% Royal Gwent Hospital 2106 88 3431 42 23 5690 37% 61% University Hospital Of Wales 2076 95 4543 32 1949 8695 24% 53% Royal Glamorgan Hospital 1784 57 1916 67 469 4293 42% 46% Excl. Surgery

Maternity - standards Minimum of 2,500 deliveries a year Labour ward consultant cover meets best practice: <2,500 deliveries = min 40 hours per week >2,501 4,500 = 60 hours per week 4,501 8,000 = 98 hours per week >8000 = 168 hours per week Rotas will meet EWTD and New Deal requirements and Deanery training requirements including 1:11 tier

Maternity - principles and assumptions Mothers will continue to exercise choice on where to deliver (other than where exclusion criteria apply) Urgent transfers from midwife-led units will access a linked consultant unit unless in an emergency (0.06%) when transfer will be directed to nearest hospital with NICU Flexible deployment of clinical workforce Existing midwifery workforce will support Birthrate+ Increase in consultants providing hybrid roles (ie covering out of hours and weekend shifts) Ability to attract CCT holders to new consultant roles

Local maternity services Free-standing midwife-led units (MLU) for low risk deliveries Early pregnancy (EPAU) and day assessment unit services (DAU) Consultant-led and midwifery-led antenatal and postnatal clinics Agreed protocols for safe intra-partum transfers to an obstetric unit where required

What services will be in the four or five regional hospitals? Consultant-led obstetric services for medium and high-risk deliveries Alongside midwife-led units Early pregnancy (EPAU) and day assessment unit services (DAU) Obstetric inpatient care Consultant-led and midwife-led antenatal and postnatal clinics Emergency and elective Caesarean sections All inpatient emergency gynaecology

Current births by hospital Normal Emer Elec Unspec Forceps Vacuum Other Hospital Birth C/S C/S C/S Cephalic Breech Total UHW 3689 708 606 65 869 272 34 60 6303 Royal Gwent 2167 541 324 202 218 4 8 3465 Singleton 1952 537 485 5 261 142 45 13 3441 Princess Of Wales 1517 383 254 29 140 126 5 9 2463 Royal Glamorgan 1426 307 357 83 97 87 4 4 2365 Nevill Hall 1272 352 226 4 102 154 84 7 2201 Prince Charles 891 307 216 12 155 67 10 1 1659 Total 12914 3135 2468 198 1826 1066 186 102 21897 Excludes midwife-led births at: Neath Port Talbot (450), Ysbyty Ystrad Fawr (330), Aberdare Hospital (145) and homebirths (935)

Where are these services currently provided in South Wales? Powys

The options for consultation Option 1: UHW, Morriston Hospital, SCCC and Prince Charles Hospital Option 2: UHW, Morriston Hospital, SCCC and Royal Glamorgan Hospital Option 3: UHW, Morriston Hospital, SCCC, Prince Charles and Princess of Wales hospitals Option 4: UHW, Morriston Hospital, SCCC, Prince Charles and Royal Glamorgan hospitals

Option appraisal summary Travel times to hospitals from each LSOA (areas of residence) Proportion and distribution of population affected by options Impact of service models on total numbers of patients for each option Impact on access number and % increase in patients with total journey times of >30 minutes Equity - number and % increase in patients with total journey times of >30 minutes for most deprived 20% of population Change in bed capacity predicted for each option Additional doctors required for each option Key risks for each option

Travel times The following maps illustrate: The travel times for the surrounding populations for each regional hospital in each of the shortlisted options The populations impacted (anticipated will access a different hospital for the regional services in each of the shortlisted options)

Option 1: 3 + Prince Charles Hospital

Option 2: 3 + Royal Glamorgan

Option 3: 3 + PCH and POWH

Option 4: 3 + PCH and Royal Glam

Option 1: 3 + PCH population affected

Option 2: 3 + Royal Glamorgan population affected

Option 3: 3+ PCH and POW population affected

Option 4: 3 + PCH and RGH population affected

Travel and flow assumptions For emergency medicine and paediatrics, patients will access the hospital they currently do, if services are not changing For emergency medicine and paediatrics, patients will access their NEAREST hospital by average travel time if services change For maternity, women will access hospital of choice based on service algorithm (from ORS survey data) 100% accuracy of triage 100% occupancy of beds No additional capacity has been modelled to meet additional demand for demographic change (population forecasts have been produced to assess high level impact on specialities)

Impact on patients - Option one: 3 + PCH Activity last year Activity expected to remain Number of patients affected % affected RGH Births 2365 622 1743 74% Paediatric Medical assessment 4293 0 4293 100% Paediatric Medical admissions 1719 0 1719 100% Emergency Medicine attendances 66043 47636 18407 28% POWH Births 2463 418 2045 83% Paediatric Medical assessment 3839 0 3839 100% Paediatric Medical admissions 1605 0 1605 100% Emergency Medicine attendances 60686 37895 22791 38%

Impact on patients - Option one: 3 + PCH changes to emergency flows POWH Total ED attendances in 2012 POW UHW Morriston PCH Primary Care Number of patients affected Number 60686 37895 11634 9292 362 1503 22791 Percent 100% 62% 19% 15% 1% 2% 38% RGH Total ED attendances in 2012 R Glam UHW PCH Morriston Primary Care Number of patients affected Number 66043 47636 11454 5132 18 1803 18407 Percent 100% 72% 17% 8% 0% 3% 28%

Impact on patients - Option two: 3 + RGH Activity last year Activity expected to remain Number of patients affected % affected POWH Births 2463 419 2044 83% Paediatric Medical assessment 3839 0 3839 100% Paediatric Medical admissions 1605 0 1605 100% Emergency Medicine attendances 60686 37895 22791 38% PCH Births 1659 417 1242 75% Paediatric Medical assessment 3709 0 3709 100% Paediatric Medical admissions 1550 0 1550 100% Emergency Medicine attendances 59282 39358 19924 34%

Impact on patients - Option two: 3 + RGH changes to emergency flows PCH Total ED attendances in 2012 PCH R Glam SCCC UHW Other Primary Care Number of patients affected number 59282 39358 13584 2539 1526 229 2046 19924 Percent 100% 66% 23% 4% 3% 0% 3% 34% PoWH Total ED attendances in 2012 POWH R Glam Morriston Primary Care Number of patients affected number 60686 37895 16559 4729 1503 22791 Percent 100% 62% 27% 8% 2% 38%

Impact on patients - Option three: 3 + PCH and POW Activity expected to remain Number of patients % affected RGH Activity last year Births 2365 622 1743 74% Paediatric Medical assessment 4293 0 4293 100% Paediatric Medical admissions 1719 0 1719 100% Emergency Medicine attendances 66043 47636 18407 28%

RGH Impact on patients - Option three: 3 + PCH and POW Changes to emergency flows Total ED attendance in 2012 R Glam POWH UHW PCH Primary Care Number of patients affected Number 66043 47636 8738 4881 2985 1803 18407 Percent 100% 72% 13% 7% 5% 3% 28%

Impact on patients - Option four: 3 + PCH and RGH Activity expected to remain Number of patients % affected POWH Activity last year Births 2463 418 2045 83% Paediatric Medical assessment 3839 0 3839 100% Paediatric Medical admissions 1605 0 1605 100% Emergency Medicine attendances 60686 37895 22791 38%

POWH Impact on patients - Option four: 3 + PCH and RGH Changes to emergency flows Total ED attendance in 2012 POWH R Glam Morriston Primary Care Number of patients affected Number 60686 37895 16559 4729 1503 22791 Percent 100% 62% 27% 8% 2% 38%

Summary of impact on emergency activity by hospital for each option Activity* Current Config 3+PCH 3+RGH 3+PCH+ POWH 3+RGH+ PCH Morriston 81,391 87,664 85,210 82,074 84,946 PCH 49,892 57,630 37,031 55,918 53,843 POW 48,430 36,105 36,105 54,514 36,105 R Glam 55,724 44,212 74,302 44,212 65,178 SCCC 26,382 32,154 26,382 26,382 UHW 111,576 126,710 113,797 115,604 112,250 * Excl primary care and straight to specialty

Summary of impact on paediatric activity by hospital for each option Attendances* Current Config 3+PCH 3+RGH 3+PCH+ POWH 3+RGH+ PCH Morriston PCH POW R Glam SCCC UHW 6,878 9,111 8,139 6,987 8,072 3,709 7,179 0 6,481 5,438 3,839 0 0 6,022 0 4,293 0 9,763 0 7,037 9,216 6,972 8,950 6,968 6,967 8,695 13,250 9,611 10,056 9,000 *Excl Surgery

Summary of impact on births by hospital for each option Births* Current Config 3+PCH 3+RGH 3+PCH+ POWH 3+RGH+ PCH Singleton 3,669 6,327 5,328 4,301 5,305 PCH 1,714 2,881 0 2,686 2,153 POW 3,093 0 0 3,347 0 R Glam 2,417 0 4,749 0 3,665 SCCC 6,180 6,004 6,567 6,004 6,002 UHW 6,422 8,339 6,877 7,193 6,416 *incl MLU and Homebirths

Impact on overall access and equity of access emergency medicine ACCESS - Emergency Medicine 3 + PCH 3 + RGH 3 + PCH + POWH 3 + RGH + PCH Total Patients Total Number > 30 mins 32769 33788 11621 14696 % Increase 247% 258% 23% 56% Most Deprived 20% Total Number > 30 mins 15204 14290 3028 3768 % Increase 676% 629% 55% 92%

Impact on overall access and equity of access - paediatrics ACCESS - Paeditrics 3 + PCH 3 + RGH 3 + PCH + POWH 3 + RGH + PCH Total Patients Total Number > 30 mins 8265 8456 4297 4130 % Increase 134% 140% 22% 17% Most Deprived 20% Total Number > 30 mins 2391 3472 1085 1126 % Increase 190% 321% 32% 37%

Impact on overall access and equity of access maternity ACCESS - Maternity 3 + PCH 3 + RGH 3 + PCH + POWH 3 + RGH + PCH Total Patients Total Number > 30 mins 4064 4064 3023 2638 % Increase 85% 85% 38% 20% Most Deprived 20% Total Number > 30 mins 1123 1385 791 593 % Increase 155% 214% 79% 35%

Bed changes required by option Emergency Medicine Additional Beds UHW Morriston SCCC (total) Royal Glam POWH PCH Total 3 + PCH 127 56 172 0 0 57 3 + RGH 15 33 210 154 0 0 412 3 + PCH + POWH 32 1 172 0 43 44 292 3 + RGH + PCH 5 31 172 90 0 28 326 *takes no account of either substituted activity or potential bed reduction on local sites Paediatrics Additional Beds UHW Morriston SCCC (total) Royal Glam POWH PCH Total 3 + PCH 11 10 20 0 0 9 50 3 + RGH 3 8 25 15 0 0 51 3 + PCH + POWH 4 4 20 0 6 7 41 3 + RGH + PCH 1 7 20 8 0 5 41 *Excluding Surgery

Additional doctors required by option Additional Drs Emergency Medicine Cons Middle Grades Paediatrics Cons Middle Grades Maternity Cons Middle Grades 3 + PCH 2 6.4 4.5 N/A 5.3 17.3 3 + RGH 2 6.4 4.5 N/A 4 6.3 3 + PCH + POWH 12 17.4 4.7 N/A 3.2 28.3 3 + RGH + PCH 12 17.4 4.7 N/A 3.9 17.3

The options All the options have been assessed against the benefit criteria safety, quality, sustainability, access, equity and strategic fit. The option which has emerged from this process as the best fit is a five-site model, option 3: UHW, Morriston Hospital, SCCC, Prince Charles and Princess of Wales hospitals

Key risks Ability to provide appropriate education and support to service users, primary care and WAST to optimise triage Ability to develop effective pathways for taking patients directly to specific services (regional, local and community based) Potential impact of the above on secondary transfer rates Capacity and transferability of existing services to backfill released capacity on local site(s) Impact on other services eg acute medicine, emergency and complex elective surgical services Existing infrastructure has not been tested to assess capacity to accommodate changes to both service models and demand Ability to recruit additional medical workforce (training and non-training) much higher risk for five sites compared to four