HEALTH boards across South Wales - with one notable exception - have voted to concentrate key services at fewer hospitals, to try to protect them and improve quality for patients. Health reporter ANDY RUTHERFORD reports on a process that will begin in within months, even though in Gwent the hospital that will house these services has yet to be built.

AFTER 18 months of public consultation and internal deliberation, South Wales health chiefs have voted on proposals to reorganise four key services - consultant-led maternity and neonatal care, inpatient children's, and emergency medicine (A&E) for the sickest patients - onto fewer hospital sites.

The option voted upon was to concentrate these services onto five hospital sites throughout the region, instead of the current eight.

Those five sites are the proposed Specialist and Critical Care Centre for Gwent, the University Hospital of Wales in Cardiff, Morriston Hospital in Swansea, the Princess of Wales Hospital in Bridgend, and Prince Charles Hospital in Merthyr Tydfil.

Five health boards - Aneurin Bevan, Cardiff and Vale, Abertawe Bro Morgannwg, Cwm Taf and Powys - and the Welsh Ambulance Services NHS Trust have been involved in the project, called the South Wales Programme, designed to ensure the delivery of safe and sustainable specialist services in the region.

All bar Cwm Taf last week voted for the five-site option, with the future role of the Royal Glamorgan Hospital at Llantrisant the bone of contention in that area. Further talks will be held on its future.

It is unfortunate but predictable, given the sensitivities involved, that not all the interested parties could agree a way forward.

For the NHS in Gwent meanwhile, the process has validated longstanding proposals for a Specialist and Critical Care Centre (SCCC), to be built near Cwmbran, to treat the area's sickest patients.

The concept of reorganising services is longer established in Gwent than other parts of Wales, the SCCC idea being consulted upon seven years ago.

The plan will see the aforementioned key services delivered on one hospital site - the SCCC - instead of as currently, the Royal Gwent and Nevill Hall Hospitals.

But Aneurin Bevan University Health Board is warning that some services, and not just those subjected to the recent consultation, are likely to have to be concentrated in one hospital ahead of the SCCC opening.

It will be mid-2019 before the latter is fully operational, by which time factors driving service reorganisation will long since have come into play

Difficulties in staffing rotas are becoming acute now, and reductions in trainee doctor numbers in Wales could trigger a wave of service reorganisations as early as this summer, across South Wales.

Paul Hollard, programme director of the South Wales Programme, the reorganisation project, said it has been driven by concern at maintaining the quality and safety of services, and access to them.

"We have not been meeting clinical standards in some hospitals," he said.

"We do not have enough doctors to provide these services across South Wales hospitals, as they are organised at the moment.

"Training numbers are falling in Wales. Some services are at risk of collapsing because of a shortage of doctors. Staff are working far beyond normal working hours to keep services going."

Mr Hollard believes changes must be made to key hospital services "within a year or so" and ahead of the completion of some capital projects that will be needed to house them.

SERVICES identified as 'fragile' two years ago, when work began on proposals for reorganisation, have become more fragile since.

That is the warning from Aneurin Bevan University Health Board chief executive Dr Andrew Goodall, who said a decision was required on reorganisation because "over the coming months there will be services that will collapse" and the issue of falling training numbers should concentrate minds.

"We need to face a drop in training numbers from August, and that will present a huge challenge," he said.

"But when we talk about changing the future of hospitals, it is not about hospitals closing. We have a responsibility to continue to provide the majority of services in a local setting.

"Difficulties with medical staffing are as relevant to us as other parts of Wales, and Clinical Futures (the hospital services modernisation blueprint for Gwent that gave rise to the idea of a Specialist and Critical Care Centre) foresaw that.

"The most immediate pressure feels like it is on A&E and paediatrics but what is most obvious from the last two years is that fragile services have become more fragile.

"We face genuine difficulties in recruiting medical staff."

At the heart of the recruitment issue is training, and Paul Hollard said good training requires sustainable rotas and supervision of trainees.

"We cannot have an over-reliance on trainees delivering care, rather than being trained," he said.

"Not all hospitals can deliver against the requirements of the curriculum. Trainees must be on fewer sites in the next 12 months, in these four services (A&E, consultant-led maternity and neonatal care, inpatient children's).

The Wales Deanery (School of Postgraduate Medical and Dental Education, based at Cardiff University) commissions the education and training of hospital doctors and GPs.

In a statement on service reorganisation, it stresses that Wales is not alone in having difficulties filling rotas, "however it should be noted that 'fill' rates for Wales are significantly lower than those across England.

"Recruitment gaps impact heavily upon rotas which then puts undue service pressure on trainees, to the detriment of their educational experience. The most important aspect for attracting and retaining trainee doctors to Wales is to improve the training experience for them here.

"To achieve this the Deanery believes training should be undertaken on fewer sites to enable a critical mass of trainees and ensure out-of-hours rotas are robust, with protected time for education and training."

DR Goodall said it is vital the health board continues to talk to patients and public about service reorganisation, a view echoed by Gwent's independent health watchdog.

Aneurin Bevan Community Health Council backs the five-site option for reorganisation, and wants the health board to raise awareness on key issues surrounding it.

Chief officer Cathy O'Sullivan said the public must be reassured that Nevill Hall Hospital has "an important and sustainable future, given the concerns of residents of north Gwent and south Powys about the role and level of service they can expect."

She added that the CHC wants a South Wales-wide campaign to raise awareness of service changes and the need for people to make "appropriate use of the range of A&E and casualty services on the basis of nationally agreed terminology."

There has been confusion over what services are provided at the 24-hour emergency centre at Gwent's newest hospital, Ysbyty Ystrad Fawr, which does not have full-blown A&E status.

Under the service changes, this model of emergency centre is likely to be developed at other hospitals in South Wales.

PROVISION of key services on fewer sites will mean patients travelling more frequently across health board boundaries.

Reorganisation will involve the development of three acute care alliances across South Wales, with one for South East Wales, compromising the existing Aneurin Bevan University Health Board area and its hospitals, overlapping to include Prince Charles Hospital in Merthyr Tydfil.

The aim of ACAs is to encourage closer working between health boards and staff, recognising that cross-border links must be strengthened.

Prince Charles Hospital for instance, is likely to a play a bigger role for people in Heads of the Valleys areas, including Tredegar and Ebbw Vale, when some services shift from Nevill Hall to the proposed SCCC near Cwmbran.

Dr Goodall said strengthening inter-health board relationships is vital for patients and for staff.

"We may look at improving recruitment by having people moving around organisations to improve and widen skills," he said.

Paul Hollard said there may be scope to allocate trainees to ACAs instead of individual health boards, to expose them to a wider range of experience.