2016/17 2018/19 annex 4 31 - health in wales · 2016/17 – 2018/19 annex 4 hywel dda future...

1

Hywel Dda University Health Board 3 Year Integrated Medium Term Plan 2016/17 – 2018/19 Annex 4 Hywel Dda Future Hospitals Vision Document 31st March 2016

2

Future Vision for Our Hospitals

Principles

The principles that guide the vision for our hospitals are state below, and are the difference

we intend to make for the residents of Hywel Dda.

Prevention and early years intervention is the key to our long term mission to

provide the best health care to our population

We will be proactive in our support for our local population, particularly those living

with health issues, and carers who support them

If you think you have a health problem, rapid diagnosis will be in place so that you

can get the treatment you need, if you need it or move on with your day-to-day life

We will be an efficient organisation that does not expect you to travel unduly or wait

unreasonably is consistent, safe and of high quality, and, has a culture of

transparency and learning when things go wrong

Our Commitment

Hywel Dda University Health Board (HDUHB) has a fundamental commitment to providing

urgent and emergency care at each of its current hospital sites including Bronglais Hospital

(BGH), Glangwili Hospital (GGH), Prince Philip Hospital (PPH) and Withybush Hospital

(WGH). We are driven to improve the outcomes and experience of the population who

access our services, and our service development will reflect this.

We will ensure that robust arrangements are in place for individuals attending our hospital

sites to be assessed locally and to allow them to either receive treatment locally where

appropriate or when necessary be transferred rapidly to a specialist unit if there is clinical

evidence that this would improve the outcome or save lives. We will require work on

planned care and our plans for unscheduled care are under development as part of wider

clinical discussions.

Context

Our four hospitals are situated across a large geographical area, with a mix of significant

rurality and also urban conurbations. There are areas of inequity in both rural and urban

populations in Hywel Dda. BGH in the North and WGH in the West are strategically located

and the poor transport infrastructure in many areas means that our public often rely on the

local services for the majority of their healthcare need.

Our projected population demographic suggests that our population will have a significantly

increasing elderly population which inevitably will mean an increase in chronic disease,

cancer, age related eye problems and the risk of social isolation and need for increased care.

3

Our emergency attendances at A&E have remained at high levels despite significant

investment in community services and admission avoidance strategies, outlining the need

for a step change in community provision and proactive care to meet the likely future need.

We have struggled to meet our performance on key national A&E targets and have difficulty

recruiting to senior A&E posts which demonstrates the importance of our work to develop

clear models for unscheduled care at each of our hospitals based on improved outcomes

and experience.

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,0002013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

2032

2033

2034

2035

2036

0-4 5-14 15-24 25-44 45-64 65-74 75+

Projected population, counts by age group, Hywel Dda UHB, 2013-2036Produced by Public Health Wales Observatory, using WG population projections

Estim

ate

d p

opula

tion c

ount

4

In order to provide urgent and emergency care, it is essential for some specialities to be

present on all four sites 24 hours per day, 7 days per week throughout the year in particular

acute medicine, anaesthetics and support services. We will build service models for all other

hospital specialties from a strong core of acute medicine and anaesthetics. Each of our

hospitals currently have a different range of services based on site, and many clinicians work

on more than one site therefore giving the wider population the benefit of their expertise.

We want to build confidence in the public that we will deal with their clinical issue in an

acceptable timeframe ensuring that you only travel when absolutely necessary, and are

transported safely to the right place to deal with your clinical problem. The development of

the Emergency Medical Retrieval Service has allowed people with serious injury or medical

problems to be transported relatively long distances in a short time period either from one

of our hospitals or from the surrounding community. Hywel Dda supports the All Wales

move towards moving from a 12 hour service to a 24 hour service and would expect this to

support building confidence in local service provision.

None of our hospitals work in isolation, and are part of a wider system of Healthcare which

includes primary, community and social services, the 3rd sector and our partner Health

Boards from which we commission some specialist services. The patient pathway often

involves all elements of the system and therefore smooth interfaces between each part of

the system, and also services within hospitals are essential. We will also review our

commissioning arrangements and ensure that we apply the same standards for outcomes

and experience to these services, so that our population gets the best service possible. We

will also test whether some of these services would be better provided within Hywel Dda.

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

Dec

-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

Dec

-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

Dec

-14

Feb

-15

Nu

mb

er o

f A

tten

dan

ces

A&E Attendances

Bronglais General Hospital

Glangwili General Hospital

Prince Philip Hospital

Withybush General Hospital

5

We recognise that our patients currently wait too long for outpatients, and often are called

for follow ups which are of low value and could have been dealt with in another way, such

as virtually or not at all. Our outpatient and follow up attendances have not changed

significantly in recent years. We are committed to drive down our backlog and also make

fundamental changes to pathways, to ensure that waiting is kept to a minimum.

As our hospital and specialty service strategies develop, service model design will need to

facilitate access to services, and take account of likely future need. For many services this

will require the expanded use of innovative technology such as telemetry and extended or

new roles, such as advanced nurse practitioners and physicians associates.

We have had recent success in recruiting to some long term consultant vacancies (eg.

elderly care at WGH, anaesthetics to WGH and GGH, Respiratory Physician and sexual health

consultant to the Health Board) and have also set up an innovative overseas training

programme at WGH based on the Core Medical Training Curriculum. We have also

developed a new service model at PPH and recruited GPs to assess people with urgent

health problems. There are however significant challenges to recruitment nationally in key

specialties, so our service models need to develop roles for consultants that are attractive

and encourage both recruitment and retention. Our investment in academic and

educational opportunity, and clinical leadership, and opportunities for innovative service

development will be key to this.

Some services are best planned on a regional basis and we will enhance our links with

ABMU through the ARCH programme to help plan and recruit to services such as oncology,

neonatology, neurology and vascular services. We will also work within the Mid Wales

Health Collaborative to explore increased opportunities for joint service models and

recruitment with our partners in the Mid-Wales region.

We will not accept accommodation or facilities that are below the minimum standard, and

recognise that a number of the facilities used for our clinical services and postgraduate

facilities need significant modernisation to provide a quality environment of care, and to

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Nu

mb

er

New Outpatient Attendances Bronglais General Hospital

Glangwili General Hospital


6

attract the future clinical workforce. We are progressing a number of important capital

programmes including Phase 2 neonates, the cardiac catheter lab, and Withybush CDU,

however we are reviewing our capital programme and will look to be innovative in our

identification of capital money.

Process

We are developing the vision for our hospitals by, in the first instance, supporting our

specialty lead clinicians to set out their vision for the specialty and supporting our hospital

clinical leads to develop the strategy for their hospital starting from the core of acute

medicine, anaesthetics and support services. Each hospital vision will be based on the

principles outlined above.

We have held four clinical specialty strategy days where each specialty has outlined its

vision, drivers and SWOT analysis, in the presence of the hospital site leads in meetings

chaired by the Medical Director.

The future vision for our hospitals will be taken forward via a Clinical Strategy Steering

Group, chaired by the Medical Director, supported by Planning and Operational colleagues.

7

[Type a quote from the document or the summary of an

interesting point. You can position the text box anywhere

in the document. Use the Text Box Tools tab to change the

formatting of the pull quote text box.]

Glangwili

Strategy Group

Chair Hospital

Clinical Lead

Purpose - Develop

strategy for

hospital

Prince Philip

Strategy Group

Chair Hospital

Clinical Lead

Purpose - Develop

strategy for

hospital

Bronglais

Strategy Group

Chair Hospital

Clinical Lead

Purpose - Develop

strategy for

hospital

Withybush

Strategy Group

Chair Hospital

Clinical Lead

Purpose - Develop

strategy for

hospital

[Type a quote from the document or the summary of an

interesting point. You can position the text box anywhere

in the document. Use the Text Box Tools tab to change the

formatting of the pull quote text box.]

Clinical Strategy Steering Group (Reporting to Board)

Chair Medical Director

Purpose - Steer the development of the clinical services strategy across sites and specialities

Specialty Task & Finish Groups

Chair Specialty Clinical Lead

Purpose - Develop strategy for

specialty

Primary Care Clinical Strategy

Group

Chair Director of Therapies &

Health Science


Primary Care

MH & LD Clinical Strategy

Group

Chair AMD MHLD


MH & LD

Community Services Clinical

Strategy Group

Chair Director of Therapies &

Health Science


Community Services

8

Bronglais Hospital

Context

Bronglais Hospital is situated in Aberystwyth in Mid Wales, and provides hospital services

for large parts of Ceredigion, Powys and South Gwynedd, in a largely rural area with

relatively poor transport infrastructure. Communities are often relatively isolated, and

therefore access to Health services is an important factor for the local population.

The hospital at Bronglais was built in the 1960s and has seen development, redevelopment and

recent refurbishment The services at BGH have recently been the subject of the Mid-Wales

Study, which led to the development of the Mid-Wales Health Collaborative (MWHC) to

help ensure partner organisations are working together to drive equitable services for the

population of Mid-Wales.

A typical year at Bronglais Hospital

Recent and current Achievements

The clinicians at BGH have been used to innovating to develop services that rely on

relatively fewer clinicians than other centres, who are working at a distance from their

peers, where activity in some specialities is lower than in other centres. Recent National

Clinical Audits for Emergency Laparotomy (NELA) and the National Hip Fracture Database

(NHFD) have shown excellent results. Innovative roles such as a surgical geriatrician have

been developed, and the anaesthetic service is consultant delivered out of hours, ensuring

early access to senior decision makers.

Over 26,000 people attend A&E

Over 3,500 people are admitted to a medical

ward

Over 45,000 people are seen in outpatients

Almost 10,000 people receive an operation

BGH

9

BGH clinicians have led the way in the use of telemedicine services in tele-dermatology,

tele-neurology clinics, and tele-echocardiography reducing the need for patients or

specialists to travel by accessing expertise remotely via modern technology. In addition the

endoscopy service has been JAG accredited for over 4 years

The new £38m front of house investment has provided state of the art facilities including a

purpose built day surgery unit and an integrated unscheduled care service. The

environments in these areas are designed to provide an excellent experience patients

attending them, and for staff working in these areas. We have recently opened Y Banwy our

discharge assessment and reablement service, with an associated discharge lounge

Core commitment

The Health Board is committed to BGH being a thriving hospital integrated with local

community services to provide the vast majority of healthcare needs locally without the

need for travel. It is also committed to it continuing to provide 24/7 urgent and emergency

care, and will build its service models from a strong core base of acute medicine,

anaesthesia and support services.

The HB is also committed to provide as much elective care as possible at BGH, to reduce the

need for patient travel. The Health Board also has the ambition to increase the boundaries

of its current catchment area for BGH further eastwards and northwards.

The Health Board remains committed to the implementation of the recommendations from

the Mid Wales Study.

The MWHC is developing plans to implement the recommendations and there are

innovation groups looking at specific services including cardiology, general surgery and

obstetrics and gynaecology.

Challenges

The population surrounding BGH in Mid-Wales is dispersed over a wide geographical area

with relatively poor transport links. BGH itself is relatively remote from other hospitals, with

car journeys of over 1.5 hours to the nearest hospital at GGH and for the catchment

population, GGH can be as much as a 2:15 hour journey. This emphasises the strategic

importance of BGH for its local population. Local clinical service and transport models need

to take account of the relative isolation.

Recruitment to BGH has recently been challenging in some key medical specialties and in

nursing and therapies and in surrounding GP surgeries, and recent retirements have left

vacancies at consultant level. There has been a reliance on non-consultant career middle

grades to support services. Relatively small numbers of clinicians in each team mean that

any single retirement has a significant affect on that department.

10

Generally medical specialties require a higher number of consultants with a lower case load

compared to peers, and this is an important consideration when considering keeping skills

up to date, and ensuring connection with peers from higher volume sites.

How we will address them

An Innovation Chair for the BGH subgroup of the MWHC was appointed in October 2015,

and the Chair is working with local clinical leaders to help prioritise the development of

sustainable service models, and recruitment of key clinicians at BGH. The Collaborative is

also leading on the development of a Centre for Excellence in Rural Health.

The local clinical leads are working on developing service models that will be sustainable

and provide high quality outcomes for the local population, and be attractive to potential

applicants. The MWHC recognised that service and workforce models will need to be

innovative, including the use of technology such as telemetry in both urgent and elective

care. The Health Board has the ambition for telehealth to be the default for communication

in elective care circumstances, where traditionally a patient would have travelled to another

hospital.

As with all other hospitals in the HB, we will support our clinicians to build its specialty

services starting from ensuring that there is a strong sustainable core service model for

anaesthetics and acute medicine in place. It is however important that the service at BGH is

able to attend to the wide range of presentations that the public will seek advice and

treatment for at the hospital. The vast majority of hospital services and healthcare

interactions will continue to be provided at BGH or in the local community.

Glangwili Hospital

Context

Glangwili Hospital is situated in the town of Carmarthen, in Carmarthenshire and provides

hospital services for Carmarthenshire and large parts of South Ceredigion. It also provides a

significant number of specialist services across Hywel Dda. The surrounding population live

in a largely rural area, with some communities being isolated and having poor transport

links.

11

A typical year at Glangwili Hospital


Glangwili Hospital has seen new development in recent years and has state of the art critical

care facilities, a recently built clinical decisions unit and has seen developments in maternity

facilities with a newly refurbished ante natal clinic and a new midwifery led unit. In addition

a new medical ward has recently opened providing additional beds. Mortuary facilities are

modern and make excellent use of technology to support multi site working such as video

conferencing facilities. In addition microscope equipment allows a number of pathologists

to view the same slide at the same time, facilitating education and peer support.

Service developments include an orthogeriatric service particularly supporting hip fractures

and thoracoscopy and endobronchial ultrasound services although GGH clinicians in a range

of specialties provide services for the wider Hywel Dda population.

Core commitment

The Health Board is committed to GGH being a thriving hospital integrated with local


need for travel. It is also committed to it continuing to provide 24/7 urgent and emergency

care, medicine and surgery and intensive care. GGH will continue to provide a 3 tier rota for

Critical Care and aspires to meet the stardards of a tier 3 unit. GGH will also continue to

provide a range of services including A&E, acute medicine, specialist medicine (including

respiratory, cardiology, endocrinology, elderly care, gastroenterology), general surgery and

Nearly 40,000 people attend A&E


ward


Over 20,000 people receive an operation

GGH

12

specialist surgery, trauma and orthopaedics, full range of endoscopy and day surgery

services, opthalmology, renal dialysis, neurology and urology services.

GGH will also continue to be the specialist centre for a number of key specialties for Hywel

Dda such as ENT, urology and will also remain as the centre for paediatric high dependency

care, neonatal care and high risk obstetrics.

Challenges

Like other hospitals in Hywel Dda, recruitment of medical and nursing staff remains

challenging although is generally less problematic than some of our sites. The activity at

GGH in many specialties has increased in recent years, providing challenges to the services,

workforce and facilities.

GGH infrastructure is generally poor although there has been some recent developments

including a relatively new critical care unit and clinical decisions unit. However much of the

infrastructure requires refurbishment. Parking is also an issue and generates many

complaints from patients, and has resulted in a significant amount of work to resolve the

situation.


As with all other hospitals in the HB, we will support our clinicians to build its specialty services starting from ensuring that there is a strong sustainable core service model for anaesthetics and acute medicine in place. Additionally we will develop a site plan for the hospital that addresses the poor

environment and develop businesses case to address problems as appropriate.

Improvements are being made to parking with the creation of additional spaces, changes to

staff parking and the development of the park and ride service.


Prince Philip Hospital is situated in the town of Llanelli in East Carmarthenshire and its

hospital services are mostly accessed by population of east Carmarthenshire and parts of

West Glamorgan. It also provides some services for all Hywel Dda residents. Its population

live mostly in an urban area, and whilst transport links are generally good, there are some

communities in South Carmarthenshire whose transport linkages are less optimal. There is a

high level of deprivation in some communities in Llanelli and the surrounding area.

PPH also provides a wide range of elective activity through its main theatres, its day surgical

theatres, outpatients, endoscopy, therapies, cardiorespiratory, angiography, radiology and

pathology services.

13

A typical year at Prince Philip Hospital


The hospital was built in the early 1990s, and has seen significant developments in recent

years including the breast unit facility which provides excellent bespoke facilities, and allows

the population of Hywel Dda to benefit from some of the most modern breast healthcare

techniques in the world. Other developments in recent years include the rapid access lung

cancer clinic which is based at PPH, Mynydd Mawr ward, the multidisciplinary frailty service,

the rehabilitation unit and the ring fenced elective orthopaedic unit.

More recently the clinicians have developed an improved new model of urgent and

emergency care for patients with acute medical problems, minor injuries and minor illnesses

who present at Prince Philip Hospital. A new acute medical unit has been developed that

can accept patients either by ambulance, or walk in patients. The assessment of patients

who walk in will be GP and Specialist nurse led and the model has become operational in

2016, and was the subject of a recent Ministerial visit. The clinicians have led the

programme of work as a multidisciplinary team, and have continuously engaged with the

public and their representatives, and partner organisations. The president of the Royal

College of Physicians visited in 2015 and highly commended the clinicians for their work and

the service model they had developed.



ward



PPH

14

The acute medical model at PPH is supported by anaesthetists, and the clinical leads are

working on the most appropriate model to support the unit. PPH does not provide acute

surgery, or acute paediatrics or maternity services and protocols are in place with WAST and

the unit at PPH to manage people who present with surgical, paediatric or obstetric

problems.

Core commitment

The Health Board is committed to PPH being a thriving hospital integrated with local


need for travel. It is also committed to it continuing to provide 24/7 medicine supported by

the new front of house model, and will build its service models from a strong core base of

acute medicine, anaesthesia and support services. PPH will also continue with its role

providing the elective centre for orthopaedics and general surgery for Carmarthenshire as it

does now.

Challenges

The major challenge for PPH will be addressed by the implementation of the new front of

house service model.

PPH needs to achieve JAG accreditation for endoscopy and develop facilities and services to

ensure sustained, uninterrupted elective orthopaedic, urology and general surgery services


The hospital will continue to work with other hospitals in Hywel Dda University Health Board

to develop sub-specialty service models.

The hospital is in the process of transition. Along with the Front of House project, recent

changes within the Health Board have highlighted how Prince Philip Hospital can run

optimally. The development of the Gastroenterology ward on Ward 7 has served a dual

purpose of establishing the sub specialty of hepatology as well as allowing ward 4 to

become a specialist cardiology ward with a cardiac day case unit. Local clinicans believe that

this has led to improved delivery of care to patients within those specialities but

recognisethe impact on elective surgery. Also on a yearly basis, elective orthopaedics and

urology (including USCs) are affected by winter pressures. Local clinicians are looking at

options to sustain these medical models alongside the elective surgical services that PPH

provides. Clinician believe that a purpose built daycase unit with a JAG accredited

endoscopy suite will allow for elective surgery to continue for 52 weeks of the year whilst

allowing the medical patients to be safely managed in specialty medical wards that currently

15

exist. This strategy will also help manage the increased demand on medical services from

the increasingly frail and complex case mix.

Withybush Hospital

Context

Withybush Hospital is situated in Haverfordwest in Pembrokeshire and provides the

majority of hospital services for the population of the County. The surrounding population

live in mix of urban and rural environments. There is significant deprivation in some

communities. Some coastal communities in West Pembrokeshire have relatively poor

transport links to other hospitals.

WGH has a recently built (2010) emergency and urgent care centre which contains the

Emergency Department and an Adult Clinical Decision Unit (ACDU). The GP and social

services out of hours services are based next to the emergency and urgent care centre and

the emergency and urgent care centre is supported by the core services within WGH.

A typical year at Withybush General Hospital


The clinical and management teams work well together to address the safety and

sustainability issues at Withybush Hospital.



ward



WGH

16

Overseas medical recruitment and a robust training and mentoring programme has been

successful and well recognised since the recent loss of core medical trainees

New consultants have recently been appointed including an orthogeriatrician and

anaesthetist. Additionally approval has been given to increase the consultant medical

physicians from 8 to 10 to improve the stability of the acute general medical service. The

endoscopy unit was JAG accredited in late 2015.

The hospital has seen new developments and further ones are planned. A new renal dialysis

unit has recently opened and there are plans for investment in a new chemotherapy day

unit and palliative care ward, in partnership with local charities and fundraisers.

Core commitment

The Health Board is committed to ensure that WGH is a thriving district general hospital

providing essential services for the population of Pembrokeshire and its visitors. It is

committed to providing 24/7 urgent and emergency care from a strong core base of acute

medicine, Care of the Elderly and anaesthetics, including intensive care services.

Additionally the Health Board remains committed to the continuation of emergency general

surgical/orthopaedic assessment, outpatients clinic and local diagnostics. Children are

assessed and treated at the hospital via the Paediatric Ambulatory Care Unit 8am – 10pm

and outside of these times through A&E. The HB is also committed to provide as much

elective and emergency care as possible at WGH, to reduce the need for patient travel.

The need to continue to provide education and learning opportunities for doctors in training

with the support of the Welsh Deanery remains a priority.

Challenges

WGH remains important for the Health Board and the local population.

Recruitment to WGH has recently been challenging in some key medical specialties and in

nursing and therapies and in surrounding GP surgeries. Loss of junior medical staff in

training grades has impacted on sustainable service delivery and new opportunities for

overseas recruitment have been sought. Rising numbers of elderly patient in particular has

seen demand increase and shortages of beds has meant that it has proved impossible to

eradicate the need to open temporary additional bed capacity. The shortage of GPs in core

hours and difficulties in the GP out of hours services is also evident. Supporting patients in

the community in order to both prevent admission and to expedite discharge after essential

medical admissions for emergency care is key and this relies on a robust and integrated

social and community care service and on a 24/7 basis to facilitate discharge and offer

options for admission particularly on weekends.

17


Senior clinicians and managers continue to meet formally as part of the Withybush

Implementation Group and they continue to manage the safety and sustainability issues at

the hospital.

We will continue to recruit additional doctors and nurses to the hospital including our

overseas recruitment and supporting training and mentoring programmes. An increase in

consultant numbers in medicine has been agreed and the Health Board is seeking to appoint

2 new consultants during 2016 and 2 more in 2017.

The hospital will continue to work with other hospitals in Hywel Dda Health Board to

develop models for sub-specialty services such as respiratory medicine. This will enable daily

(Monday to Friday) access to consultants at the hospital. Also there will be joint working on

A&E models to ensure sustainability of these key services.

Bed capacity at the hospital is being addressed with plans being assessed to increase bed

numbers and developments at the hospital continue including palliative care services and

beds, chemotherapy day unit and the relocation of PACU closer to A&E to support the

assessment of children.

2016/17 2018/19 annex 4 31 - health in wales · 2016/17 – 2018/19 annex 4 hywel dda future...

Documents