South Wales Hospital Programme – The Evidence

Following on from the announcement of the South Wales Programme – which will change some specialist hospital services across the region – it’s worth getting stuck into the underlying arguments being presented to support the changes.

There’s been a lot of politics, and a lot of protest. We’re all being told to “look at the evidence” and “look at the facts”. So, I’ve decided to do that in as (hopefully) level-headed a way possible.

The Medical Reasoning

Three services are to be centralised on fewer sites in south Wales:

  1. Consultant-led maternity and neonatal servicesSpecialist services catering for pregnant women and newborn babies, including childbirth. Midwife-led services, possibly with coverage by some doctors, will likely continue everywhere.
  2. Inpatient’s children’s services (paediatrics) – Care for children who need overnight hospital stays.
  3. Emergency Medicine – Full-time accident and emergency (A&E) departments and emergency surgery. They’re graded from minor injuries (lowest) to the most serious (Level 3). Level 2 and Level 3 A&E care (life threatening emergencies) will be centralised.

The broad medical argument is that highly-specialised services like these would be better provided by a concentrated number of specialist doctors and consultants. It’ll mean having to travel further for some patients, but it could be of a higher quality, and you might be seen more quickly by specialists – if there’s more of them based at fewer sites.

In areas like emergency medicine, treatments have become better but are more expensive and complicated. Technological improvements mean that, in many cases, consultants can provide “distant” care via video links etc. In Northern Ireland, they’ve even started to use robots.

Also, there’s a big difference between the 80% of people who visit A&E for relatively minor injuries – like falls, minor fractures, flare ups of chronic conditions and cuts – and the 20% with immediate life-threatening emergencies. The changes will affect that 20% only.

The Staff Reasoning

Junior doctors need to see a certain number of patients to build up enough medical experience during training. Like any job, you have to actually practice what you do to become good at it. Due to changes to how doctors work – in particular reduced working hours – junior doctors already have less opportunity to do that.

Under current hospital arrangements, they’re spread thinly and have to cover too many rotas. In some cases, they don’t see enough patients to meet national standards for training, due to be introduced in 2030. That puts off consultants working here too, resulting in staff shortages and not enough cover to provide quality training. For example, It’s suggested there should be a ratio of 1 consultant to every 11 juniors.

Linked to the medical arguments, centralisation could make services “safer” by providing better, experienced supervision for junior doctors, and create a better teaching environment at the same time.

There’s also a chronic UK-wide shortage of emergency doctors. Once again, the argument is that centralising them on fewer sites will enable 24/7 care, without spreading them thinly or expecting them to cover too many shifts for too few patients.

The supporting documents even point to “feminisation of the workforce” – before I’m accused of sexism, it’s there in black and white in the Workforce Modelling Technical Document – meaning more pressure on the NHS to offer flexible hours and family-friendly working practices. The workforce is getting older on the whole too, and it’s unclear if replacements are coming through quickly enough.

The Hospitals

Three sites will definitely keep all specialist services:

  • University Hospital, Cardiff
  • Morriston Hospital, Swansea
  • A new £300million critical care centre near Cwmbran

These will become specialist regional trauma centres, while the Heath is a major teaching and research centre in its own right.

The three sites that are up for discussion in the South Wales Programme are:

  • Prince Charles Hospital, Merthyr Tydfil
  • Princess of Wales Hospital, Bridgend
  • Royal Glamorgan Hospital, Llantrisant

The proposals will have a knock-on effect on other hospitals too, even if they’re not going to see any service changes, simply because of patients moving around from the downgraded hospital(s).

The Proposals

The programme puts forward four options for centralisation:

  • Option 1 – The three regional centres (Cardiff, Morriston, Cwmbran) plus Merthyr.
  • Option 2 – The three regional centres plus Llantrisant.
  • Option 3 (The preferred option) – The three regional centres, plus Merthyr and Bridgend.
  • Option 4 – The three regional centres, plus Merthyr and Llantrisant.

The Impact of Each Option
I’ve based this off the technical supporting documents – the statistics used to draw up the options – which are available here. I’ve rounded some of the figures, while “patients” means anyone using the centralised services.

No change (All sites retain all services)

  • No change to services, no impact on populations or journey times.
  • Would cost at least £21million to retain services as they are.
  • Not considered an option.

Option One (3RC + Prince Charles Hospital)
  • Prince Charles would get an extra 20,000 A&E attendances per year (not including “straight to speciality” attendances), with the rest sent to Morriston (+2,000), Cardiff (+13,000). Royal Glamorgan would see 30,000 fewer A&E attendances, Bridgend 12,000 fewer.
  • Average A&E journey time would increase by 23.2%.
  • Paediatrics redirected to Morriston, Cardiff and Merthyr. Attendances to Merthyr would almost double. Average paediatrics journey time would increase by 21%.
  • Births redirected to Prince Charles, Cardiff, Morriston and Cwmbran from Bridgend and Llantrisant. Would increase average maternity journey times by 14%.
  • Patients in Bridgend county and upper Rhondda would have travel times to hospital of 1 hour+
  • Patients in Bridgend would be expected to use Morriston; patients in Rhondda/Taff-Ely would be expected to use Cardiff.
  • Would cost at least £11.7million to implement.

Option Two (3RC + Royal Glamorgan)
  • Royal Glamorgan would see 19,000 more A&E attendances. Others sent to Morriston (+4,000) and Cardiff (+2,000). Both Merthyr and Bridgend would see at least 12,000 fewer A&E attendances each.
  • Average A&E journey time would increase by 25%.
  • Royal Glamorgan would see 127% increase in paediatrics admissions, while there would be smaller increases at Morriston and Cardiff. Average paediatrics journey time would increase by 23%.
  • Births redirected to Royal Glamorgan, Cardiff, Morriston and Cwmbran from Bridgend and Merthyr. Would increase average maternity journey times by 15%.
  • Patients in Merthyr, Cynon Valley and Powys would expect hospital journey times of at least an hour.
  • Patients in Bridgend and Merthyr would be expected to use Royal Glamorgan. Unclear which hospital southern Powys would use.
  • Disproportionately affects the most deprived populations – in particular the heads of the valleys area – compared to other options.
  • Would cost at least £10.6million to implement.

Option Three (3RC + Prince Charles + Princess of Wales)
  • Prince Charles would see an extra 5,000 A&E attendances, Bridgend 6,000, Cardiff 4,000. Royal Glamorgan A&E attendances would fall by 11,000 and Abergavenny by 10,000.
  • Average A&E journey time would increase by 8.3%.
  • Prince Charles would see 75% increase in paediatrics admissions, Bridgend 57%, Cardiff 16%. Negligible impact on Morriston. Average paediatrics journey time would increase by just over 8%.
  • Births redirected mainly to Prince Charles from Royal Glamorgan, with a few hundred per year to Cardiff and Bridgend respectively. Would increase average maternity journey time by 7%.
  • Patients across south Wales would generally have average hospital journey times of 30 minutes to an hour.
  • Patients in Rhondda/Taff-Ely area would be expected to use Bridgend and Cardiff hospitals.
  • Royal Glamorgan would become a centre of excellence for some planned medical services moved from Cardiff and Bridgend.
  • Would cost at least £14million to implement.

Option Four (3RC + Prince Charles + Royal Glamorgan)
  • Royal Glamorgan would see 10,000 more A&E attendances, Prince Charles 4,000. Morriston would see an extra 3,000. Bridgend would see 12,000 fewer A&E attendances, Abergavenny 10,000 fewer.
  • Average A&E journey time would increase by 10.7%.
  • Paediatrics admissions would increase by 64% at Royal Glamorgan and 47% at Prince Charles. Bigger impact on Cardiff and Morriston compared to option three. Average paediatrics journey time would increase by just under 8%, but distance travelled would be longer by 10%.
  • Births redirected mainly to Morriston and Royal Glamorgan from Bridgend, with a few hundred to Merthyr each year. Would increase average maternity journey time by 5%.
  • Patients in the Porthcawl and Maesteg areas of Bridgend county would have hospital journeys of at least an hour.
  • Patients in Bridgend & Western Vale would be expected to use Royal Glamorgan and Morriston hospitals.
  • Bridgend would become a centre of excellence for some planned services moved from Royal Glamorgan and Cardiff.
  • Would cost at least £13.6million to implement.

Myths and Rumours
  • There’s a hope of retaining all services at all sitesNo, that hasn’t been included as an option. They’ve made their mind up, and the consultation is about deciding which hospital(s) in particular will change.
  • Hospitals, or hospital departments, will closeNo, all hospitals will remain open and intact. It’s specific, specialist services that will be moved. A majority of hospital users will be able to use the same services they currently do.
  • Hospitals will be “downgraded”Yes, I think that’s a fair description of what’s happening, but health boards and Welsh Government are reluctant to use the term for obvious reasons. The downgraded hospital(s) will gain some services – it’s been hinted things like pre-planned day surgery – but that’s unlikely to address concerns.
  • Hospitals will “lose” A&E servicesPartially true. At least one of the three hospitals will see their full-time 24 hour A&E department downgraded to either a part-time (9am-5pm) A&E, or a minor injuries unit. However, 80% of A&E patients should still be able to receive treatment at their local hospital, regardless. The changes affect serious emergencies only.
  • Hospitals will “lose” maternity and children’s services Partially true. Specialist consultant-led services will be centralised, but nurse-led and midwife-led services should remain. So it’s a “downgrade”, not a complete loss.
  • It’s being done to save moneyNot entirely. The changes will actually cost money, depending on which option’s chosen – something in the region of £10-14million. If they wanted to keep all services as they are, they would only need to spend an extra £7million on top of that. So, this is being done for Welsh Government policy reasons, not as the result of any “Westminster/Tory-Lib Dem cuts”.
  • Travel times to hospital will be longerYes, for the people near the downgraded hospital(s), as highlighted via the evidence. Though health boards don’t consider this a risk. It might take longer to get to hospital, but it’s presumed quality of care will improve overall.
  • The proposed changes will impact the most deprivedYes. However, both the Merthyr and Rhondda areas are equally deprived, while Bridgend county contains some of the most deprived individual wards in south Wales. Only options 3 and 4 address this properly.

The Conclusion
Options one and two should off the table because of the significantly greater impact on journey times and the lack of proper hospital cover for southern Powys (in the case of option two). If services are going to be centralised, it’s better to keep them at five sites instead of four.

Option three balances smaller increases in average journey times, with the same lessened impact on deprived communities as option four. It would arguably have less impact on other hospitals too. For example, The Princess of Wales Hospital already receives A&E patients from Neath Port Talbot, so option three would put less pressure on Morriston.

Option four

has many things going for it. It avoids putting extra A&E pressure on the Heath, and is slightly cheaper to implement. Journey times are similar to option three, but it impacts the whole of Bridgend county and the western Vale of Glamorgan (~160,000 people), leaving a huge gap in coverage between Llantrisant and Swansea. It also puts more pressure on Morriston and Cardiff with regard paediatric and maternity services.What this means

So there, I’ve “looked at the evidence”, and it lines up with the preferred Option Three –  Merthyr & Bridgend retain services, Royal Glamorgan downgraded.

But other facts and question marks remain:

  • On average, you will travel longer to hospital for serious blue light emergencies if you’re in the area that sees a hospital downgraded. It’s based on an “average time”, meaning the journey could be longer in individual cases depending on where you are.
  • The ambulance service is unlikely to consistently meet its response targets any time soon, and the Rhondda Cynon Taf area has some of the worst response times in Wales.
  • The journey time statistics are based on “drive time” – presumably private car not public transport (for visiting etc.). Access to car rates in the Rhondda and Merthyr areas are some of the lowest in Wales.
  • Precisely how are the Welsh Government and health boards going to improve public transport to and from hospitals 24/7? They should be planning that now, not during implementation.
  • The same number of patients are going to be treated at fewer sites. How that’s“better” hasn’t been properly explained. It’s unlikely to make an impact on waiting times, and it might even make things worse if extra treating capacity at the centralised sites (not just staff numbers) isn’t there from day one. Will more money need to be spent expanding A&Es at places like the Heath?

Access was weighed as equal a priority as sustainability, but access is going to take the biggest hit, and it’s hard to portray losing specialist services as anything but “bad news.”

However, the quality of care should improve if patients have quicker access to consultants and better trained junior doctors on arrival at hospital. That’ll only work in the long-term if it’s matched with improved recruitment and retention of medical staff. Plaid Cymru recently pointed out the grim picture regarding that.

Patients might want to retain all services at all sites. Some politicians might want that. Maybe some front-line NHS staff want that too.

The fact that’s not happening points mainly towards chronic failures in maintaining staffing levels over the last decade or more, not any significant problems with the services themselves. These proposals are simply the easiest thing to do. What if it doesn’t work and there needs to be another centralisation in 10-15 years time?

Where are the statistics and evidence for : Projected treatment times, ambulance waiting times and turnaround at centralised A&Es? Qualified staff per head of population and per patient? Retention of junior doctors and consultants by the Wales Deanery? Medical errors, and excess deaths, caused by poor training and poor staffing levels? Is there a guarantee national training standards will be met by 2030 through centralisation? What’s the evidence underlining those new national standards?

That’s the sort of evidence we need, and to be explained to the public, to provide a robust case in favour of change. The original “Case for Change” had some of that. Without that now, in this consultation, we’re all doing this blindfolded.

Arguments about training stand up, but if the technology’s there for distant treatment by consultants, isn’t it there for some aspects of training too?

Consultants, the Welsh Government, managers and medical teaching staff have decided from the start they want change. There are clear, valid reasons for change – so I’m not in denial.

In terms of arguments put forward, it’s as though they’re listening to managers – who are looking at things from a top-down view – but not service users. It doesn’t look like they’ve listened to many front-line staff, who’ve warned about overcrowding at A&Es, for example, and – as I’ve said – concerns about things like that haven’t been properly cleared up.

The case for change, as presented, is a largely impenetrable, technocratic mess. We’re just being told that it is “safe and sustainable” not why that’s the case. The evidence is largely about deciding the best option, not the underlying case for centralisation itself, nor considering alternatives (if there are any).

It’s up to Labour to explain and defend their policy – which they’ve had on the cards since at least 2006. It should be simple enough, shouldn’t it? Complete cabinet solidarity and all that? All Labour AMs and MPs rallying around Carwyn and Mark because it’s such a good plan, and the best option?