Building local, safe and sustainable services for

Mid and West Wales:

The Case for Change

Contents

1.    The purpose of this document and who it is for              

2.    Background                                                                   

3.    Our joint Responsibility                                                

4.    Why Change                                                                  

5.    The reasons for change                                                  

6.    How things could be different                                      

7.    The way we will consult and work with communities    

8.    Tell us your views                                                         

1. The purpose of this document and who it is for

This paper has been prepared by the NHS Trusts and Local Health Boards in Mid and West Wales and is written for:

·         patients

·         carers

·         NHS staff

·         community leaders

For the purposes of this document Mid and West Wales is the health service communities of Bridgend, Carmarthenshire, Ceredigion, Neath Port Talbot, Pembrokeshire, Powys and Swansea.

It outlines the reasons why change needs to happen to deliver safer and more effective health services for the people of Mid and West Wales.  It does not make specific proposals about services in Mid and West Wales but sets out a case for changing the way current services are provided.

We are at a critical juncture for the NHS in Wales.  By the end of next year spending on the NHS in Wales will have virtually doubled since the Assembly came into being. The current capital programme for 2005-06 is £150m and by the end of the next financial year (April 2007) we will be embarking on a capital programme of £309m. Since the National Assembly was established the number of staff in the health service has increased by 22,085, a 32.2% rise from the number of people working in NHS Wales in 1997, which was 68,623. In September 2004 there were 90,708 staff employed by NHS Wales.

In March the Assembly outlined a new capital budget for buildings and equipment which will be £146m for 2005-06 and £219m for 2006-07 next year. This compares with £100m in 1999/2000.

Earlier this year the First Minister and the Minister for Health and Social Services set the ambitious target that no-one should wait more than 26 weeks from GP referral to the start of treatment by the end of 2009.

Designed for Life outlined a 10-year strategy to deliver a world-class health service in Wales by 2015. This is what the people of Wales are entitled to receive and this is something that health organisations in Mid and West Wales are determined to deliver.

However, to achieve this vision there will need to be some changes to move from the present uncertain, uneven delivery of care towards a system that delivers high quality services as close to people’s homes as possible.  At the same time we need to make sure that when patients need hospital care they can be certain it will be of assured safety and quality.

Quite rightly, we all have high expectations of our health services.  We want them to be the best quality and available when we need them. 

When change is proposed, people need to know why this is necessary and be assured that vital health services will be secured for them.  NHS staff need to understand what the future holds for them.

The information contained in this paper will give people the chance to think about health services in Mid and West Wales and enable them to contribute to the more formal consultations that will take place in early 2006. 

We hope that you will take time to read the paper and to come along to an event in your area to give your views.  These will be held between now and Christmas.  Further details will be published soon. 

One other document is published alongside this one:

·         Frequently Asked Questions which hopefully will answer some of your concerns.

2. Background

The Welsh Assembly Government’s strategy Designed for Life, published in May 2005, outlines a vision of high quality health and social care services designed around the user. 

To prepare for this, the Welsh Assembly Government has:

·         begun a programme of investment and reform bigger than any seen in Wales since the NHS was founded

·         said that people who use services and those who deliver them must work closely together in re-shaping services

·         said that the concerns and priorities of local communities must be taken into account

·         set aside large sums of money for new hospitals and facilities across Wales

Working with partners, we in the NHS in Mid and West Wales aim to make services more accessible, focusing on patients’ needs and improving health and quality of life for everyone. Our ambition is to create health and social care services that are among the best in the world.

3. Our joint responsibility

It is important that readers of this paper understand that this is not about closing much-loved hospitals.  It would, however, be wrong to assume that some hospitals may not change the types of service they currently provide. Any proposals for change must be worked through locally.  Services will be based upon:

·         a fair assessment of what would be safe and of high quality

·         available resources

·         what local people want

The people of Wales are committed to their local services – hospitals are an important part of their communities. This must be respected and built into any solutions. These solutions must be right and appropriate for communities. Services need to be safer and more sustainable than they are at present.

The public’s expectations and needs for healthcare are changing but so is healthcare itself. Just as there are changes in what patients expect and require from services, there are developments in the way that healthcare is delivered. These are not matters of choice but issues which need to be tackled.

Failure to adapt to this changing situation will mean that our health services will decline and people will get poor and sub-standard healthcare. 

The case for change is outlined in this paper. How we respond to the challenge will decide the future of our NHS and the health of our families and communities.  Five core principles are at the heart of our approach:

·         change is needed if we are to provide the services people need

·         our starting point will be the citizen’s experience of healthcare services and our commitment to safety and quality

·         we will work with staff, patients and partners to develop new ways of delivering services

·         we will focus on redesign, not relocation. Redesign can offer high quality alternatives, expanding options for developing new service that meet local needs and expectations

·         we will take a ‘whole system’ view, bringing together the contribution of hospitals, ­-  primary care, community and social services.

It is important that readers of this paper understand that this is not about withdrawing local services.  Rather it is about looking at everything we do to make sure that safe, high quality services are delivered as locally as possible.

This will create local partnerships to transform our services. Working together we will take decisions to create safe, accessible quality services for the people of Mid and West Wales. The people of Wales are committed to local services. They are an integral part of their local communities. They need to be assured that services being provided are high quality and safe.

4. Why change?

The reasons why change is needed include: 

·         the historical picture

·         changing expectations

·         how services are changing (population changes; disease patterns)

·         maintaining quality

·         changes in the medical workforce (responding to staff shortages and new laws on working hours; changes in clinical training).

How things could be different, include:

·         the use of new technology (telemedicine; short stay surgery)

·         a wider range of higher quality services, provided closer to your home

5. The reasons for change

The historical picture

For many years, Wales has had a large number of district general hospitals, all competing to provide similar services. This has made the health service in Wales inefficient and unable to cope very well with the demands of modern treatment and the expectations of patients.  Neither does it make the best use of health professionals’ time and expertise.

Duplication of effort has resulted in longer waiting times and services in some areas are no longer safe. This is because doctors are not seeing enough patients to gain the experience they need to provide high quality care. There is a danger that unless we act now some services may break down over the next few years.

A large number of health professionals, NHS leaders and expert advisors such as Sir Derek Wanless have agreed that only through change can we really improve services for patients, carers and staff.  We must create safe, modern services fit for the 21^st century.

It is not simply about money.  The NHS is better resourced than ever, but there are financial problems caused partly by the fact that we are trying to prop up services that do not meet safety and quality standards.  This sometimes means that we have to reduce services that communities value and wish to keep in order to provide better quality services for all.

Changing Expectations

Our aim is to have a world class healthcare service.  By careful redesign and prudent investment we can have it here in Mid and West Wales.

This is ambitious but not unreasonable. People rightly have higher expectations of their health and social services.  People want high quality care, close to where they live, and they do not want to have to wait. 

The people of Wales deserve and are entitled to this level of service.  To make it happen the way we deliver healthcare must change.

 

 

 

How services are changing

The world in which the NHS operates will continue to change and healthcare services must change too.  If we do not respond to this our healthcare services will become outdated and unable to provide the high quality services that people rightly expect.  This section outlines the reasons for change, and what their effects on services may be.

Population change and patterns of disease in Wales

The current pattern of hospital services was set up in the 1960s.  Many small hospitals are much older than that.   In recent decades the patterns of illness and disease they catered for have changed significantly. Over time, new communities have developed, the age structure of the population has changed and the way disease is treated has altered. 

But just as importantly, hospital admission is no longer the best way of tackling many conditions.  People should only be admitted to hospital or residential care if it is absolutely unavoidable and would suit their condition best. There is a recognised danger that some people, once in hospital, quickly lose their independence and autonomy.  We can do more for people at home.

Medical advances mean that people with illnesses that were once life threatening can now live longer, healthier and productive lives. Treating long term conditions is now a major issue for health services – conditions such as heart disease, respiratory problems, cancer and diabetes. 

Eight out of 10 consultations with GPs in the United Kingdom, and up to three- quarters of emergency admissions to hospitals are for people with long term conditions.  In Wales, a quarter of the population (800,000) have at least one chronic or long-term condition.  Well over half of over 65s have one long-term condition and many of them have more than one.

People with long-term conditions need to use the health service a lot.

However, the NHS, as it is presently organised, is poorly set up to respond to them.  Their care is often disjointed, and admission to hospitals is often the only option, though care at home could be a better option.

There is evidence that up to four in every 10 hospital beds are occupied by patients who do not need to be in hospital. They could be cared for better in their home. Treating people in their home would free up hospitals to focus on what hospitals should be doing ­- dealing with emergency cases and providing planned treatment such as surgical operations (sometimes called “elective care”).

Hospital care is expensive and is not without risk.  Local care is often more cost effective than hospital - which means that better results can be achieved using the same budget.

In Mid and West Wales, the greatest concentration of long term disease is in Llanelli, Neath Port Talbot and Bridgend. The picture for Pembrokeshire, Carmarthenshire and Swansea is more mixed, while people in Ceredigion and Powys have the best levels of health.

The ageing population of Mid and West Wales is an important factor in planning future services.  An analysis of hospital data shows what many people already know - the older people are, the higher the number of unplanned admissions to hospital.  Often these admissions are for conditions that could be managed at home.

Currently people over 65 account for four out of 10 of all emergency admissions and over well over half of all hospital bed days.

Over the next 20 to 30 years, the number of older people in Mid and West Wales will increase and the number of young people will fall. 

Family and household structures are also changing. The availability of family carers is declining, often as those carers themselves become older or children move away for work. The Royal Commission on Long Term Care expressed concern that any development of community care must take these factors into account.

Key messages in this section: The way services are provided now encourages duplication and inefficiency. People expect and deserve a better service, delivered closer to their homes. The combination of increasing levels of long term illness, pressure on hospital services and lack of home and community-based services will mean that our hospitals will become increasingly unable to do what they are there to do (emergency care and elective surgical care). Hospital services should be only one element in a range of care options available to patients. Hospitals should be part of a pathway of care with many options.

Maintaining Quality

In making decisions on future services, quality is a fundamental issue.  By quality, we mean that services should be safe and effective.  They also need to be in line with users’ expectations and reflect the ways in which people wish to be treated. That is why we have strong, independent monitoring of the quality of care provided – reviews that are published for all to see.

Irrespective of how large or small the hospital, the only criteria should be safety and quality. 

Also it is not always true that large hospitals are cheaper. 

Everyone working in a hospital must work to the best standards possible. This applies equally to large and small hospitals.

There is clear evidence that some highly specialised services can only be provided safely in larger centres.  These include:

·         cardiac surgery

·         neuro surgery

·         renal surgery

·         major cancer surgery

·         major vascular surgery.

These are also the sort of services which benefit most from being located alongside high technology diagnostic facilities.

Evidence also shows that hospitals serving populations of fewer than 250,000–300,000 people are those that have most difficulty in meeting safety and effectiveness standards. This weakness might be offset by linking such hospitals together in networks.

Many of the hospitals in Mid and West Wales treat numbers below this level. This means that the hospitals of Powys, Carmarthenshire, Ceredigion and Pembrokeshire will need to work together to maintain high quality and effective services.

In judging the safety of any service, attention must be given not only to the number of doctors and beds available  but also to how well the system works as a whole. This includes the availability of good diagnostic services (tests, scans, etc), the quality of medical support teams and the co-operation of doctors between hospitals.

Key messages in this section: We have a duty and an obligation in law to ensure that services people use are safe and effective. Most surgery does not need to be centralised into fewer hospitals, if common standards are maintained in all  our hospitals and adequate transfer arrangements are put into place. Some major surgery is better performed in specialist centres to provide a safe service. Hospitals with a catchment population of less than 250,000–300,000 people will need to network together to maintain local access and standards. Working together is just as important a factor in healthcare as funding.

Changes to the Medical Workforce

The medical workforce is changing rapidly. There are three major challenges which we need to respond to:

·         staff shortages

·         the European Working Time Directive (EWTD)

·         changes in medical training.

Staff Shortages

However much we might wish to provide full services in every part of Wales, the reality is that we are dependent upon our ability to recruit and keep staff. It is possible to help attract staff to Wales by offering training and incentives, but the NHS in Wales is competing with the rest of the UK and the world.

The health service in Wales already faces shortages in many staff areas, including radiologists and cardiologists, speech and language therapists, and theatre staff.  Many GPs in Mid and West Wales will soon reach retirement age and a way has to be found to attract new GPs so that communities, particularly in deprived areas, are not badly affected.

Many of our consultants will also retire over the next 10 years. This will cause a problem as many are general consultants, while now consultants tend to be trained as specialists.  The reason for this is that they need to keep abreast of scientific advances so that they have the expertise to provide the best care possible.

European Working Time Directive (EWTD)

In the past, Junior Doctors (that is, those in training below Consultant level) often worked more than 90 or 100 hours per week.  Reducing their working hours to a safe and acceptable level has been a major objective for the NHS since 1991.  It is required in the EWTD to ensure the health and safety of patients and doctors alike.  Compliance with the EWTD is mandatory.  By August 2009 no junior doctor may work more than 48 hours a week.

This poses a number of challenges for the NHS.  Under the directive many hospitals will no longer be able to operate on a 9am-5pm basis. working with junior doctors working overnight to provide on-site cover.  The alternative is shift working - a new concept in the NHS for medical staff. 

In some areas of Wales, concentrating services onto fewer sites may be a solution as this would increase the critical mass of services, that is, services ‘around the clock’.  In other parts, however, this could create unacceptable travel times.  If this is the case, new ways of providing services locally will need to be developed.

One way of responding to this challenge is for future night time and weekend services to be based on multidisciplinary, multi-skilled teams that can meet the immediate care needs of patients.  This will draw on specialist advice and input from network partners, using the best available diagnostic and communications technology.

Importantly, activity in all hospital specialities falls markedly after midnight, with general activity at 5am being only a quarter of what it is at 5pm. The requirement for specialists to work overnight, therefore, is much lower. Consequently, providing a system of 24/7 acute assessment, stabilisation and treatment within a network of hospitals working together would provide a really safe and effective service for patients.

 

Changes in Medical Training

There is need to achieve a new balance. Junior Doctors are doctors in training – they need to have enough experience in the number and types of patients they see.  They also need time to study and undertake their normal duties. 

In larger hospitals, this can be achieved relatively easily as there are enough patients of each medical discipline, such as orthopaedics or chest medicine, to fulfil training requirements, even with shorter duty hours.  However, smaller hospitals lack the range of patients even in the busiest units. This is especially true outside normal working hours. This means that junior doctors will fall below minimum training requirements. 

The Royal Colleges who are responsible for education will no longer recognise that posts in these hospitals meet their training requirements.  No-one will take up the posts, as they will not enable doctors to demonstrate that they have had the experience they need to be fully qualified.

Mid and West Wales, because of its network of small/medium sized hospitals serving small populations, has many more services that are vulnerable to the effects of the EWTD than Cardiff, Swansea and Newport, where there are larger hospitals and populations. 

Medicine is becoming more specialised.  Smaller hospitals will not serve enough people to attract a range of consultants, and will need to link to others in a network of collaborating hospitals.

Recruiting consultants in Wales is already a significant problem.  Plugging the gap with temporary appointments is not a long-term solution.

However, we may have to centralise some services, by working in a network we can maintain other services locally.  In addition we can train other clinicians such as nurses, therapists and paramedics to take on new, extended roles which will maintain safe, local services.

Key messages in this section: Reducing Junior Doctors working to 48 hours by 2009 is a health and safety legal requirement aimed at making sure patients are not treated by overtired staff. This means we have to re-design our services to ensure we maintain services locally. In some cases we can train other staff to take on new roles. We can reshape services to cover peak periods with a different service at quiet times. Some centralisation of services will happen, but we will look at all other options first. Staying where we are now will not solve the challenges of a changing medical workforce. Our training and education strategy need to exploit this opportunity so that we can continue to maintain services locally.

6. How things could be different

Although the service faces considerable challenges, the NHS in Mid and West Wales has an opportunity to develop services to meet the needs of local people.  If grasped this will deliver local services which are effective and safe.

The Use of New Technology

New medical technology is dramatically changing the delivery of health care and will:

·         increase the range and potential of treatments

·         lead to a greater concentration of specialist technology and services. For example, cancer treatment where new equipment will need to be used intensively by specialist teams, working at a common location

·         advances make some technologies cheaper and more widely available, for example, the use of new diagnostic techniques that can replace surgery. These reduce the need for some orthopaedic and heart operations. Home monitoring technology can eliminate the need for patients to stay in hospital 

·         lead to more self-care at home. The technology already exists and is being used in Wales to develop “smart” houses, that make homes safer for people who would otherwise need to be admitted to hospital or to long-term care.

There are two specific areas where the advance of technology is already having a major impact on health services: telemedicine and short stay/day surgery.  In the field of telemedicine, Wales is leading the way.  However, in day surgery we are currently behind other parts of the UK.

Telemedicine

Telemedicine allows rapid access to remote or specialist medical expertise by use of telecommunication and information technologies, no matter where the patient is or where the specialist is. Two examples of this innovative approach are:

·         a patient’s heart rhythms can be monitored and analysed by a doctor who is based in a hospital 100 miles away

·         new digital X-ray systems coupled to broadband technology allow a radiologist to read a patient’s X-ray when he is in another hospital, or in the case of one trial which is currently linking Swansea, London and Newcastle.

Wales is already a national leader in Telemedicine. The use is not theoretical or set in an unrealistic sci-fi future. It is in use now.

In Bronglais, for example, ###################

We need to exploit this technology systematically across Wales.

 Such technology can reduce the need for patients to travel to receive specialist treatment. Currently, some of our local services are under threat. because it is difficult to secure staff with the right skills and justify modern equipment. The result is that either services fall below safe standards or patients have to travel for treatment.

Use of telemedicine could enable us to keep services local, with expert advice ‘brought’ to the patient through technology. If going to a specialist centre is required, the patient need only go for that part of the treatment. The remainder of their care could be carried out more locally. Although they had never previously attended the specialist centre, they would already be known to staff via the telemedicine systems.

Telemedicine can also help us move services away from hospitals. For example, 70%-80% of routine dermatological referrals can be managed remotely using a GP or a nurse-led service linked with a distant consultant-led department providing supervision and management. Telemedicine has been used very effectively in nurse-led Minor Injuries Unit to treat patients without the need to transfer to a full hospital A & E.

Further use of technology could include:

·         monitoring technology for chronic disease in the community, linking family doctor services to hospital care

·         remote medical supervision of nurse led community hospital

·         remote consultations.

Key messages in this section:   Wales is already a national leader in telemedicine. This is already in use now.   Use of this technology could improve services for patients in Mid and West Wales, particularly in rural areas.   In Bronglais Hospital telemedicine has been used for the past five years to support fortnightly multi-disciplinary cancer assessment meetings. Highly qualified health professionals often based in different locations can assess a patient’s condition using new technology. This means patients received the benefits of the highest quality care without the need to travel. We need to use this technology systematically across Wales.

Short Stay Surgery

Changes to surgical techniques, such as keyhole surgery and improvements to anaesthetics, so that recovery time is shorter, mean that up to 75% of a hospital’s routine surgery can be conducted within a twenty-three hour stay in hospital. This can go up to 85% if the time is extended to forty-eight hours.

However, Wales lags behind the rest of the UK, in using day and short stay surgery.

The unprecedented increases in capital budgets announced by the Welsh Assembly Government and the publication of the Best Practice in Elective Care Guide by the Innovations and Care Team provides:

·         the opportunity to develop first class short stay surgery centres is open to Wales

·         the speedy reduction in waiting lists.

Key messages in this section

Technology will help maintain and enhance local services. It will make them more local and more specialist by making consultants “virtually” available. Technology will help patients stay independent and at home for longer. Some technologies, such as for radiotherapy, are highly advanced, specialised and large scale. It makes sense to place these in dedicated centres linked to major surgical units. Developments in imaging and technology will allow us to replace some operations. Investments in facilities and modernisation will ensure we improve short stay and day surgery rates, helping us to eradicate unacceptable long waiting times.

A wider range of higher quality services, provided closer to your home

It is important that we are clear about the quality and accessibility of services people should expect in the future. The successful re-configuration of services aims to ensure safe services are provided as locally as possible. However, we will not stop here. We are committed to providing the highest quality services.

As a result of these improvements, there are 10 commitments that we will deliver for the people of Mid and West Wales:

·         patients will be treated by a service organised on the principles of equity, safety, accessibility and quality

·         free prescription medicine

·         swift access to family doctors: all patients will see a GP within 24 hours

·         emergency treatment will be available when needed and to an excellent standard

·         All major local hospitals will continue to play a vital role in the new NHS Wales

·         95% of Emergency Patients in A&E  will be treated within four hours, and 100% within eight hours

·         all patients will be treated within a maximum of 26 weeks from referral by GP

·         no one will be further than one hour’s travelling time from a comprehensive emergency department, no matter how remote their home. The vast majority of people will be much closer. Where transfer to a specialist centre is needed, this will be no more than two hours’ travelling time: again the vast majority of people will be much closer

·         the local surgery, health centre or local hospital will be the “front door” to a high quality, and well organised service always provided in clean facilities. Networks of hospitals will ensure that the patients will have the continuity of a dedicated specialist team, even if the treatment is on more than one site

·         dignity and respect for the patient will be paramount.

Taken together they describe a modern, accessible and reliable NHS that is the right of every citizen.

7. The way we will consult and work with communities

The proposed consultation process will be governed by the guidelines that we issued last year called Shaping Health Services Locally. This sees a major role for local people, NHS staff and Community Health Councils to be involved in developing and designing services for local people. 

Developing the options for change

“The Case for Change” is the first step in engaging staff and the public. Between now and January 1^st 2006, we will be presenting the case for change, and will be seeking the views of the public. We will be doing this through statutory and voluntary organisations. Community Health Councils have a particularly important role because they are the direct route to the views of the public.

Agreeing the changes

During January 2006 we will consider what people have told us and will prepare detailed proposals for consultation.

These will be published on January 31^st, so that CHCs and NHS organisations can consider them at their formal meetings during February.

Once there is agreement, then we can begin to plan the implementation of our improvements.

If further discussion is required, or there isn’t agreement within Mid and West Wales, then a further round of consultation will take place.

8. Tell us your views

We would welcome comments from the public and NHS staff in Mid and West Wales.

You can do this by

·         attending one of the events which will be publicised soon,

·         e-mail (barbara.bowness@nliah.wales.nhs.uk)

·         writing to Barbara Bowness, NLIAH, Innovation House, Bridgend Road, Bryncae, Llanharan, CF72 9RP