2016/17 2018/19 annex 4 31 - health in wales · 2016/17 – 2018/19 annex 4 hywel dda future...
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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
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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.
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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
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90,000
100,000
110,0002013
2014
2015
2016
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2018
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2020
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2024
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2031
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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
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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
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-12
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-12
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-12
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g-1
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Jun
-14
Au
g-1
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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
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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
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New Outpatient Attendances Bronglais General Hospital
Glangwili General Hospital
Prince Philip Hospital
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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.
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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
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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
Purpose - Develop strategy for
Primary Care
MH & LD Clinical Strategy
Group
Chair AMD MHLD
Purpose - Develop strategy for
MH & LD
Community Services Clinical
Strategy Group
Chair Director of Therapies &
Health Science
Purpose - Develop strategy for
Community Services
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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
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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.
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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.
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A typical year at Glangwili Hospital
Recent and current Achievements
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
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, 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
Over 5,000 people are admitted to a medical
ward
Over 100,000 people are seen in outpatients
Over 20,000 people receive an operation
GGH
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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.
How we will address them
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
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.
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A typical year at Prince Philip Hospital
Recent and current Achievements
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.
Over 35,000 people attend A&E
Over 4,000 people are admitted to a medical
ward
Over 70,000 people are seen in outpatients
Over 12,000 people receive an operation
PPH
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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
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 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
How we will address them
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
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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
Recent and current Achievements
The clinical and management teams work well together to address the safety and
sustainability issues at Withybush Hospital.
Over 40,000 people attend A&E
Over 6,000 people are admitted to a medical
ward
Over 80,000 people are seen in outpatients
Over 17,000 people receive an operation
WGH
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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.
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How we will address them
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.
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