The Welsh Government, via Health Minister Lesley Griffiths (Lab, Wrexham) and the local health boards (LHBs) are currently reorganising hospital services across Wales.
In the last few days, the four local health boards that cover southern Wales, launched a consultation on plans to spread services between major hospitals in the region. Some high-level services, such as neo-natal critical care services and accident and emergency services, could be centralised at fewer sites.
I’m not going to focus on the wider south Wales situation now, just on the plans put forward by Abertawe Bro Morgannwg (ABM) local health board , which covers Bridgend, Neath Port Talbot and Swansea.
There are two key documents:
Firstly, ABM’s 5-year plan for 2010-2015.
Secondly, Changing for the Better, which covers the plans for south Wales, and was announced yesterday.
A background: Why they’re doing this
There are three main reasons as I see it.
- Spending cuts – ABM have to make at least £189m worth of savings between 2010 and 2015 (p44) to meet Welsh Government targets, which works out at around £38m of cuts per year. Spread across the southern Wales LHB’s, the figures are even higher. Something needs to be done whilst minimising impacts on front-line services – hence spreading specialist services over a wider area.
- Staff shortages, in particular middle-grade doctors – Some hospitals, in particular Neath Port Talbot, have failed to attract staff in some specialities. A combination of stricter UK immigration laws, EU working time directives, a failure to retain “home-grown” medical students and reductions in spending on (expensive) agency staff has built up to a crisis. The Welsh Government have reacted by launching a series of initiatives to attract doctors to Wales. Obviously, for example, if you had fewer full-time A&E departments, you would need fewer experienced emergency medicine doctors.
- “The Case for Change”: Improving NHS performance – It’s claimed centralisation will lead to improvements in patient outcomes by creating expert “centres of excellence”. This has been controversial, as there were suggestions that the evidence to support this argument wasn’t independent enough, leading to an unsuccessful vote of confidence in Lesley Griffiths a few months ago.
By centralising services, some hospitals (including community hospitals) are going to lose some services completely, or see “downgrades” in what they can offer. That’s the politics of the situation.
Labour are arguing that “creating centres of excellence” would lead to a “more sustainable NHS”, whilst the opposition parties say that “downgrading” could put people at risk, or lead to them having to travel further for treatment that’s no better than they receive currently.This week, Bethan Jenkins AM (Plaid, South Wales West) presented a 5,000 signature petition to the Assembly opposing changes at Neath Port Talbot hospital, while protests have taken place outside the Senedd and elsewhere by groups from other LHBs.
Downgrades/centralisation of maternity, children’s and accident and emergency services are of particular concern across Wales.
Along with the economy, this is probably going to be the issue that shadows Welsh Labour for the rest of the Assembly term – and not in a particularly good way.
You can’t provide the same level of services across all hospitals anymore. People need to ask themselves : Would you rather get heart surgery, for example, from an understaffed, overworked team at your local general hospital? Or would you prefer to get it from a larger, fully-staffed, university-linked, centre of excellence based in one of the major towns/cities?
But the flipside is : If you were involved in a major car crash, or suffered a catastrophic heart attack, would you prefer to go to an A&E department as close as possible? Or would you want to travel (by ambulance or air ambulance) to a “centre of excellence” perhaps up to 30-40 miles further away?
It isn’t easy, is it? Both sides have a point, and that’s the frustrating thing.
That’s why ABM and other LHBs are launching consultations on the issue to gauge public opinion. The Abertawe Bro Morgannwg consultation ends on 19th December and they are hosting public meetings at various venues across south west Wales over the coming months. All the details are available here.Now it’s worth taking a look at the specifics put forward for ABM.
Primary care (GP) services
Expect to hear “Primary Care Resource Centre” a lot in the next few decades. These are large bases with multiple GP’s practices under one roof. One in Port Talbot opened a few years ago, and there’s currently one under construction/planned in Swansea.
They’re able to offer more services to more people in a modern environment, acting as a “one stop shop” for some tests, clinics and treatments in the community. I think they’re a good idea, but it does come across as impersonal compared to the traditional family GP practice. I wouldn’t be surprised if we saw one built in the Bridgend area in the next 10 years or so.
Dental services aren’t covered by this consultation, though there have been very minor improvements there year on year. Oral and Maxillofacial surgical services appear to have been kept at all four main hospitals in the ABM area (see further down), but to varying degrees.
Mental health services
There are separate plans for mental health services, and ABM have invested in new facilities – in particular the Bridgend area – for adolescents as well as walk-in/community care services. Mental health services only get a passing reference in this consultation though.
Community hospitals (Maesteg, Gorseinon, Cimla & Gellinudd) are likely to lose their beds in the medium-term.
ABM want to provide more ongoing care at home, meaning beds in community hospitals would no longer be required. Community hospitals will become “hubs” for some diagnostic and treatment services that could be delivered locally. I presume that could include: chiropody, GUM clinics, mother & baby clinics, speech therapy, occupational therapy, rehabilitation, weight-loss, asthma clinics, some types of physiotherapy.
I think that’s pretty sensible (on paper). Those currently reliant on bed-based services at community hospitals will rightly have concerns, though ABM have already stopped using beds at some community hospitals.
All of this is subject to consultation, and is based off ABM’s original plans from January 2011. Some of this may have already changed as a result of the wider south Wales plans.
Morriston Hospital, Swansea
- Emergencies/Trauma : Regional specialist trauma centre/A&E, Major trauma, Emergency surgery
- Routine Treatments & Diagnostics : Renal inpatients, Dialysis, Paediatric (children’s) inpatients, Chronic pain services, Coronary care, Cardiac physiology, Cellular pathology, Microbiology, Day surgery, Artificial Limbs
- Specialist Services : Medical illustrations, Palliative care, Cardiothoracic (heart & lungs) services, Cardiac intensive treatment unit (ITU), Urology, Colo-rectal surgery, Regional centre of excellence for burns & plastic surgery, Spinal surgery
Princess of Wales Hospital, Bridgend
- Emergencies/Trauma : Full-time A&E department, Emergency surgery
- Routine Treatments & Diagnostics : Dialysis, Dermatology (support), Paediatric (children’s) inpatients, Children’s development centre, HIV/AIDS services, Day surgery, Chemotherapy, Coronary care, Cardiac physiology, Rheumatology, Gynaecology, Cellular pathology, Microbiology
- Specialist Services : Obstetrics (maternity services), Neurophysiology, Neo-natal intensive care, Palliative care, Urology, Colo-rectal surgery, Breast surgery, Burns and plastic surgery
Singleton Hospital, Swansea
- Emergencies/Trauma : Unscheduled general/emergency admissions, Minor injury unit
- Routine Treatments & Diagnostics : Gynaecology, Childrens development centre, HIV/AIDS services, Day surgery, Clinical haemotology, Lymphodema services, Chemotherapy, Cardiac physiology, Rheumatology, Plastic surgery (day surgery), Orthogeriatrics, Cellular pathology
- Specialist Services : Regional dermatology centre of excellence, Obstetrics (maternity services), Neo-natal intensive care, Medical illustrations, Clinical Oncology services (i.e Radiotherapy), Breast surgery
Neath Port Talbot Hospital
- Emergencies/Trauma: Unscheduled general/emergency admissions, Minor injury unit
- Routine Treatments & Diagnostics : Dermatology (support), Children’s development centre, Chronic pain services, Chemotherapy, Orthogeriatrics, Artificial Limbs (as part of neurology services)
- Specialist Services : Neurology centre of excellence, Neurophysiology, Obstetrics (midwife-led), Urology, Breast surgery
Retained at all four sites
- Emergencies/Trauma: Critical/Intensive care (full life support only available at Bridgend & Morriston)
- Routine Treatments & Diagnostics: Medical Assessment capability (downgraded at Singleton & NPT), Radiology (complex services at Morriston only), Pre surgery assessment, Blood sciences (specialists only available at Morriston), Mortuary services (post-mortems only carried out in Bridgend & Morriston)
- Specialist Services : Diabetology/Endocrinology (outpatients only at Singleton & NPT), Gastroentrology/Endoscopy (emergencies only treated at Bridgend and Morriston), Respiratory medicine, Elective (scheduled) surgery, Cardiology, Orthopaedics (to varying degrees), Vascular services (day/outpatients only at Singleton and NPT), Oral & Maxillofacial surgery (to varying degrees), Ear Nose & Throat (outpatients only at NPT), Opthalmology (outpatients only at NPT)
- Undecided : Bariatric (weight-loss) surgery (probably Morriston)
- Not available at any site : Neurosurgery, centralised for Mid & South Wales at University Hosptial, Cardiff
Summary & Conclusions
If you found all the above a little hard to follow, there’s an easier guide in the Changing for the Better document (Appendix 2). I think it’s best to sum up what I think all these changes mean.
GP’s and community health teams are likely to play a much greater role from now on. Maybe that’ll be too much work for them to take on, leading to a collision course between GP’s and the Welsh Government in the next few years. People in their 80s+ tend to cost more to treat, and tend to stay in hospital for longer – that’s a simple fact of life. But one way to reduce costs might be to treat people as much as possible in their own homes, and ABM seem to be moving towards that.
Morriston Hospital and the Princess of Wales Hospital are the “winners”in this, retaining a vast bulk of services.
Morriston is going to be the regional “centre of excellence”. If you’re suffering from something really serious/complicated, then you’ll probably be transferred to Morriston (which happens now anyway). Neurosurgery has been centralised permanently in Cardiff, despite attempts/campaigns to keep services in Swansea.
Keeping services in Bridgend is a no-brainer because of the catchment area and distance from Swansea, but it looks like Neath Port Talbot Hospital in particular has lost out as a result.
Singleton Hospital is playing a lesser role, offering more specialist and diagnostic services, while being the main maternity hospital for Swansea. It’s half way between a community hospital and a full district general hospital.
Neath Port Talbot Hospital isn’t even 10 years old yet, but is certainly the “loser”. That’s been offset (a little bit) by being put forward as a possible centre of excellence for neurology. Not all services have been downgraded – the hospital will still offer many of the services you’d expect. However, if you have something long-term or more complicated then it’s likely you’ll have to travel to Bridgend to receive treatment. 24-hour accident and emergency services are likely to be covered by the Princess of Wales and Morriston hospitals too.
I think improved transport between sites is going to be crucial, especially in distant parts of the ABM area (Ogwr & Garw Valleys in Bridgend, Vale of Neath, Swansea Valleys). Morriston is perhaps more awkward to get to if you don’t have a car, though there is the Swansea Metro bendy-bus. I’m not sure that’s enough. The Welsh Government should seriously consider reopening the Swansea District Line to passenger services – about 1km from Morriston Hospital – at some point in the near future.
The impacts of this could stretch beyond the borders of ABM too. Services could be downgraded at Llanelli’s Prince Phillip Hospital, perhaps based on a presumption that patients could be transferred to Morriston or Singleton hospitals. Add in all the possible centralisations across south Wales and it certainly looks like the start of the “turf war” that Leanne Wood (Plaid, South Wales Central) has cautioned against.