Minutes:
4.1 The Area Committee welcomed Mr. N. Wood, Chief Operating Officer, Aneurin Bevan University Health Board (ABUHB). Some questions were submitted prior to the meeting.
4.2 It was explained that the Clinical Futures Strategy sets out to develop health services in the Gwent region by delivering most care close to home, by creating a network of local hospitals providing routine diagnostic and treatment services and by centralising specialist and critical care services in a purpose built Specialist and Critical Care Centre (SCCC). Building the 447 bed SCCC has commenced and will open in 2021 and a series of local district local hospitals will then provide a clear model regarding management of ill health.
4.3 Progress so far has seen the building of Ysbytty Aneurin Bevan (Ebbw Vale) and Ysbytty Ystrad Fawr which consolidates the former North Gwent Community Hospitals. It is now necessary to plan how best to use Nevill Hall Hospital, Abergavenny and Royal Gwent Hospital, Newport as local general hospitals.
4.4 In terms of Primary Care (Care closer to home), it was explained that there are 12 Neighbourhood Care Networks (NCN) in the Gwent area with one in North Monmouthshire and one in South Monmouthshire. The NCNs develop local plans to deliver local care, including at local hospitals e.g. Chepstow and Monnow Vale hospitals; an arrangement that will allow local GPs a greater say in developments to deliver models of care closer to home. It is hoped to all elements operational by the time the SCCC opens in 2021.
4.5 It was questioned how these plans have been communicated to residents and responded that the strategic plan was partially driven through the Welsh Government Primary Care Plan in Wales explaining that the Clinical Futures Strategy was consulted upon in 2009 and scrutinised by the Community Health Council. Since that time it was stated that plans are regularly communicated and consulted upon. The example was provided of the local consultation undertaken regarding the move to specialise in breast services in Ysbytty Ystrad Fawr. The Area Committee was reminded of the work of the Public Service Board which considers health policy, the Wellbeing of Future Generations (Wales) Act 2015 and the Social Services and Wellbeing Act 2014.
4.6 The Committee were advised that there is a workforce crisis and lack of GPs in Gwent (common to the rest of Wales) and this is placing pressure on primary care services. A task force has been set up to address this issue which is particularly challenging in North Caerphilly, Blaenau Gwent and Torfaen. It was commented that South Monmouthshire is not too bad in comparison and recruitment has been mainly successful with only one vacancy currently.
4.7 More information was provided that in the region there are 200 nurse, and 40 Junior and Middle Tier hospital doctor vacancies. In Monmouthshire, there is a significant shortfall of domiciliary care with an outcome that some care packages are not available with a consequence that some patients have to stay in nursing homes or hospitals longer than necessary.
4.8 It was explained that the financial situation is the same as rest of wales. The Health Board had a forecast deficit budget of £10m and with savings of 3% this would be mitigated.
4.9 It was confirmed that primary care in a locality is generally delivered by contracted staff at independently contracted GP surgeries. GP practices receive income based on size of population and relative deprivation.
4.10 Staffing at Chepstow GP surgeries as of 01.07.17 was advised as:
Towngate (9162 Patients)
4 GP Partners 2.67 WTE
1 Salaried GP
1 Advanced Nurse Practitioner
2 Nurses
3 HCA
1 Phlebotomist
Mount Pleasant Practice – (8,299 Patients)
4 GP Partners (1 resigning 30.09.2017) 2.89 WTE
3 Salaried GPs
5 Nurses
2 HCA
Vauxhall Practice – (7,388 Patients)
4 GP Partners 2.89 WTE
2 Salaried GPs
1 Advanced Nurse Practitioner
3 Nurses
1 HCA
2 Phlebotomists
4.11 It was noted that not all of the other staff are full time workers and also that the above numbers of GPs meets the aim of 1 per 2000 patients which is a relative guide.
4.12 Information was provided regarding national standards around access to provisions and the principles of 5 As for Access:
· Morning Opening Time 8.00am/Consultation Start Time 8.30am
· Doors to remain open during lunch
· Last Routine Appointment at 17.50pm
· Telephone assess to “Live Person” from 8.00am – 18.30pm
· “Sort it in one call” (ability to make an appointment to be seen in one call and/or my health On-Line (internet booking)
4.13 Further it was explained that, in terms of reasonable access, expectations were:
· Urgent – Offer of a consultation same day (not emergency) –acute presentations that can’t wait for up to 48 hours. This would be dependent on clinical need. The consultation could be face to face, telephone or house visit.
· Soon – Offer of a consultation, within 48 hours, of request.
· Planned – Offer of a consultation, within 2 weeks, of request (unless patient chooses not to).
4.14 It was explained that the above standards are part of a GP surgery delivery plan and they are assessed on their ability to deliver the 5As. It was noted that only one surgery did not achieve the 5As but that the Health Board were not aware of any major risks identified as a consequence.
4.15 It was added that both Vauxhall and Towngate surgeries are considering extended opening hours to 8pm and Saturday morning. A question was asked about the location of the 5As on the Health Board website.
4.16 Anecdotal evidence was provided that it can take 4-6 weeks to obtain a routine appointment at Mount Pleasant Surgery and 3 weeks at Towngate surgery. It was commented that Vauxhall Surgery allows phone consultations in some circumstances.
4.17 A question was asked about FTE staff levels and it was responded that GP practices buy in staff to provide the necessary access requirements. It was added that the Senior GP Lead for Primary Care in the Neighbourhood Care Network (NCN) can address access issues if being compromised.
4.18 It was confirmed that funding for GP surgeries is by Welsh Government formula and is not equated to patient demand. It was commented that an aging population should be taken into account and that repeat appointments should be monitored. It was explained that the General Medical Services Contract sets out the formula and the Health Board has no influence over that. NCNs bid for funding to deal with specific issues in areas. It was added that integrated social care is provided in Monnow Vale Hospital mainly concerning
re-ablement of the elderly and those requiring longer term provision. All provision is based on the needs in region and the example was provided of using resources to provide a district nurse and community nursing who can provide care at home rather than requiring a visit to a local practice.
4.19 A question was asked by a member of the public regarding interaction between town GP practices and whether or not they can share resources. It was responded that locum doctors are often shared and added that all GP practices in this area are members of the South Monmouthshire Neighbourhood Care Network and share best practice and intelligence. In response to a question, it was explained that complaints (e.g. unacceptable delay in obtaining an appointment at a surgery) should be reported to the practice itself.
4.20 The long term issue of the closure of the Minor Injuries hospital in Chepstow was raised and it was queried if there was no demand, noting that patients are directed to the Royal Gwent Hospital where there is no parking and the expectation of a long wait. It was responded that there had been Minor Injuries provision in Chepstow that was seeing less than a dozen people a day which was economically unviable. Members argued that it was not advertised at the time.
4.21 It was explained that emergency care provision was changing across the UK and Wales, and Minor Injury units need to be a certain size for safety, adequate and senior staff. It was explained that the Specialist Critical Care Centre is the best way forward plus Nevill Hall Hospital, Ysbytty Ystrad Fawr and the Royal Gwent Hospital as minor injury units.
4.22 It was also explained that the availability of suitable staff is a problem in the whole UK and a doctor trains for 7 years and a nurse practitioner for 5 years.
4.23 In response to a question, it was explained that residents of Chepstow can attend Lydney & District Hospital for the Minor Injuries Unit. It was noted that there is currently consultation in progress on community hospital facilities in the Forest of Dean. In response to a request for new provision in Chepstow, it was confirmed that this would not be possible.
4.24 A member of the public expressed the opinion that Chepstow is losing out because it has lost the major burns unit, recuperation facilities at Mount Pleasant and that the dementia wards and cardiac rehabilitation that was proposed has gone. It was questioned what the current and future purpose of the hospital is. It was added that the White Paper currently under consultation seeks to silence patients’ opinions on service by proposing the abolishment of Community Health Councils (CHC). Concern was expressed that the Health Board will have no challenge, and also about the arrangements for emergency care until the SCCC opens in 2021.
4.25 It was responded that the White Paper is proposed by the Welsh Government not the Health Board, adding that the Health Board works very closely with the CHC; holding regular meetings and receiving all Health Board consultations to allow it to hold the Health Board to account.
4.26 It was recalled that the plan for the SCCC was put to Welsh Government (WG) in 2008. The delay was to do with WG capital allocation and the business plan was only approved last year with costs rising by an inflationary measure. It was stated that the money was fixed and the Health Board will have to make choices based on the funds available. The priority is to safe services.
4.27 It was agreed that there is a need to establish a plan for Chepstow Hospital such as diagnostics, outpatients, medical assessment unit for elderly (instead of travelling to the Royal Gwent Hospital). This would require access to a named doctor. It was confirmed that the Health Board is working towards this approach for Monnow Vale and also the County Hospital and that there was uncertainty where those hospitals currently sit in the strategy.
4.27 It was confirmed that the Clinical Future Strategy document was on the website http://www.wales.nhs.uk/sitesplus/866/home .
4.28 It was reported that residents believe that services are not being delivered. It was questioned if they have complained to their GP practice or to the Health Board. It was queried how the Health Board monitors the length of appointment delays and responded that practices are independent contractors that provide a service to the local population and that if the Health Board started to see a large number of complaints, it would step in and carry out a review. Access and sustainability is measured for practices and this has not highlighted any issues in South Monmouthshire – this was carried out last winter by an external agency. It was commented that generally patients want to maintain a good relationship with their GP practice therefore won’t complain. It was questioned what the basis of the comments were i.e. seeking routine appointments, what clinical urgency, a general review of health or new condition? It was suggested that the Health Board should consider moving patients away from only seeing a GP and to multi-disciplinary centres with co-located services.
4.29 In terms of Minor Injuries provision, it was commented that levels of staffing were run down before the Unit was closed and then patient safety was then reason to close. It was suggested that the closure puts pressure on primary care in the area.
4.30 Concerns were expressed that there was longer waiting time for operations at the Royal Gwent Hospital and Nevill Hall Hospital than at Ysbytty Aneurin Bevan (Ebbw Vale) Hospital and Ysbytty Ystrad Fawr. It is also a long journey of up to an hour each way for patients from Chepstow to travel to the Royal Gwent Hospital get treatment results with limited parking availability. The parking situation is set to worsen due to the current temporary parking area being the site for the future development of 575 houses in Newport. It was commented that these issues are all due to lack of hospital service provision in Chepstow.
4.31 It was commented that the geographical spread of hospitals is totally uneven and there is less provision compared to England noting that the removal of the Severn Bridge tolls will worsen the situation.
4.32 It was questioned if the Health Board tracks Local Development Plans and planning applications noting the potential for an additional 2500 houses in the area.
4.33 It was explained that the consulted upon plan lays out provision of emergency services at Royal Gwent and Nevill Hall Hospitals, Ysbytty Aneurin Bevan, Ysbytty Ystrad Fawr and the SCCC and this is the approach that is being implemented.
4.34 It was questioned if there was progress in establishing a Medical Assessment Unit for the provision of urgent care Chepstow Hospital utilising GPs in Caldicot and Chepstow.
4.35 It was explained that the minor injury unit at Ysbytty Ystrad Fawr sees 130 patients a day and Ysbytty Aneurin Bevan, approximately 40-60 patients a day. The representative was unable to comment on the comment that staff had been run down in Chepstow Hospital but directed Members to the consultation papers at the time of the closure.
4.36 Regarding Access to GPs in the local area, a number of residents have commented that the 5As have not been met. It was suggested that no proper analysis was undertaken when Chepstow Minor Injury Unit closed. It was responded that the Health Board published a clear plan that was consulted upon, signed off and implemented. There was a review in 2011 of MI units that was consulted upon and the situation is now being moved forward. There is a need for a clear plan for Chepstow Hospital and discussions are in progress to provide a medical assessment unit.
4.37 It was contested that the geographical spread of hospitals was acceptable if the hospitals at Lydney, Gloucester and Bristol are taken into account and was based on population. It was observed that patients don’t think they can access services in England and responded that the National Health Service Act 2006 makes provision that UK citizens can access services anywhere.
4.38 Members stated that they wanted a district hospital in Chepstow and highlighted the demand for men’s health services. It was explained that Public Health Services are looking to improve men’s health services providing the example of promoting early diagnosis of more men’s cancers, to extend life. Consequently, there will be a programme of health screening rolled out over 2 years of a full health check at a specific age; currently being piloted in Blaenau Gwent and North Caerphilly where life expectancy is much lower.
4.39 It was commented that the health of the population in this area is markedly better than other regions in Gwent.
4.40 It was advised that some consultants visit Chepstow Hospital for outpatient appointments and it is planned to develop that service. Ultrasound, X-Ray and some diagnostic services are also provided at Chepstow Hospital. The Health Board is considering what services can be moved to Nevill Hall Hospital as there is more space.
4.41 It was suggested that leaflets and information should be made available to patients/public in the area to explain access to services across the border, complaints and the 5As.
4.42 The Committee was informed that the Royal Gwent Hospital has a new minor injuries building and 96% of patients seen there have been treated and discharged within 4 hours. Additionally, it was explained that Nevill Hall Hospital if the best performing A and E service in Wales. It was added that 90% of patients in this area have a first appointment within 26 weeks as per Welsh Government standards.
4.43 It was questioned if patients requesting appointments are asked if the request is urgent and queried what standards should be delivered. It was responded that there is no legislation but there is guidance on principles of access as to what is urgent. There is a ranked traffic light system used by Chepstow practices based on self-assessment and Health Board assessment. Most recent results indicate “green” based on what has been seen and test calls. The Committee were reminded that GP surgeries are independent contractors, and residents who are dissatisfied need to complain to the practice directly in the first instance.
4.44 It was queried what the Health Board use as a basis when planning for future and responded that the Planning Department would be better informed to answer but that the main basis would be population. It was added that it is part of the remit of the Public Service Board to compile a local plan.
4.45 In response to a question, it was confirmed that provision in a medical assessment unit would be the minor assessment of clinical illness led by a nurse possibly from the local GP practices.
4.46 The Committee requested involvement in what will be delivered in Chepstow Hospital e.g. post-operative recovery. It was explained that local leaders will be deploy for of the five local authorities to develop local plan; engagement will take place in Spring 2018. The Committee were cautioned that there had to be realistic expectations. The representative agreed to contact the NCN and local leader for S. Monmouthshire about topics for consultation.
4.47 A question was asked about mental health services for under 25s and it was confirmed that Claire Marchant and Chris O Connor jointly chair the Mental Health Partnership and this matter is within their remit.
4.48 It was queried by a member of the public, what happened to dementia patients noting that there is a dementia ward in Chepstow Hospital. It was stated that there were no plans to remove dementia services from Monmouthshire at the time of the meeting.
4.49 It was explained that there is no Cardiac rehabilitation but that there is a rehabilitation ward for general recuperation purposes.
4.50 A request was made for a list of the current services provided in Chepstow Hospital for residents’ information. It was confirmed that there will be additions to services provided and they will be communicated in due course.
4.51 Noting the ratio of 2000 patients: 1 GP, it was enquired what the health Board will do to ensure the ration is not exceeded as area and population develops. It was stated that the Health Board would seek to provide an expansion of primary care services. Where or if provision becomes disparate, it would intervene. It was added that when details of new developments are known, the Health Board will actively look at primary care resource centres, with a pharmacy and other locally provided services. This will be reviewed annually. The Health Board will also monitor access in the area and funding can be given to practices to expand or improve but only when there is a crisis.
4.52 In response to a question, it was confirmed that the Health Board employ doctors from all over the world to counter shortages.
4.53 In response to a query, it was explained that analysis of the waiting lists at different hospitals is undertaken on a bi-weekly basis. Currently, no waiting list issues are evident in Monmouthshire. It was queried if can you obtain an appointment quicker in some hospitals than others and explained that admission is under the control of named consultants and is not connected with location.
4.54 It was confirmed that the Clinical Futures strategy has superseded the promised review of the Minor Injuries Unit at Ysbytty Aneurin Bevan so there is no information from that.
4.55 The Chair questioned the use of hospitals and asked if Chepstow Hospital and Monnow Vale could have simple operating facilities. It was explained that Nevill Hall Hospital and Ysbytty Ystrad Fawr have day care theatres and that there are 38 such facilities across Gwent which provides plenty of provision but it is not all local.
4.56 The Chair commented that problems with staffing could possibly be related to learning Welsh compulsorily in schools. It was commented that there is no requirement for Welsh language speakers, however English Language (spoken and written) is a requirement. It was reported that some staff have left or not taken up posts over Brexit concerns.
4.57 The Chief Operating Officer was thanked for his attendance at the meeting and for answering the questions.