Jacob Williams
Friday 15th March, 2013

EXCLUSIVE: Consultation? What consultation?

EXCLUSIVE: Consultation? What consultation?

You’ll have done well over the past couple of months to have avoided the furore surrounding the Hywel Dda Health Board’s reform proposals under the ‘Your Health Your Future’ banner. The proposals coming out of it have been coming under criticism from all corners within the three counties making up the health board’s area, and so, too, has the consultation process.

In a post I uploaded earlier this week I said I had a scoop up my sleeve relating to the consultation process, since which time two developments have emerged in this saga.

Yesterday, in what must have been one of the final letters to have been sent by Lesley Griffiths AM in her role as health minister, the Hywel Dda Community Health Council was informed that their referral of the health board’s proposals was being batted back. That’s right – the Community Health Council, which resolved in good faith to refer the health board’s proposals to the minister for not being up to scratch, were told by said minister that their referral was…not up to scratch!

You couldn’t make it up.

The letter goes on to explain why – the minister wants the CHC and the health board to get back around the table:

“Officials have considered your submission and advise me there are several inconsistencies between the case you make and the National Guidance for Engagement and Consultation on Changes to Health Services.”

“Local resolution must be sought wherever possible and referral to Welsh Ministers should only be made as a last resort. Where particular proposals are judged not to be in the best interest of health services in the area, the CHC must propose alternative solutions for providing safe and sustainable services to their local community.”

The health minister also asks that, if there are any outstanding matters following this further engagement between the HB and the CHC, they then be referred back by 5th April, and additionally requests to be updated of any developments by weekly progress updates in the interim period.

It is my understanding that the CHC deems the minister’s time-frame for reconciliation to be unacceptable and that the executive board of the CHC will be meeting on Tuesday of next week to discuss this latest spanner in the works.

A further twist in this tale came about minutes after this letter was sent when it was announced that Lesley Griffiths was being removed from her ministerial health role to be replaced by Mark Drakeford AM.

This big cabinet shake-up which came as a shock to the media now sees Mrs. Griffiths heading up the local government portfolio. Quite how much effect this political change will have on the plight of the health boards whose proposals have been referred by their respective community health councils, remains to be seen, but one can understand how frustrated the Hywel Dda Community Health Council must feel to be batted from pillar to post, especially when a crucial element of their referral document criticises a lack of co-operation.

It has widely been perceived by the public, if not the officials, that the consultation exercise by Hywel Dda was pointless with no other purpose than to give the impression that their opinions had been taken into account because ‘everything was a done deal.’

The CHC certainly picked up the baton, scornfully criticising the most basic elements of the consultation. The original 27-page referral from the CHC, if you haven’t read it already, is quite a damning document, and makes more than a few highly critical references to not only the questions and wording of the consultation documents, but also how the results from it were collated, processed and decisions arrived at.

The referral, sent by the Chairman of the CHC, Tony Wales on 25th February includes the paragraph:

“The public perception was that there was a considerable gap between the ministerial rhetoric, the ability of the HB to deliver within the widely-recognised constraints of the resource available and their willingness to conscientiously listen and engage. Thus, the belief grew that the HB was set on pursuing a cost-cutting agenda, that the Listening and Engagement exercise was needless, based on a flawed and inappropriate commercial model, and that the outcome was a foregone conclusion.”

(Click here to read more from the CHC's referral request)

It is bullet point six of the referral which interests me, and which leads on to the basis of this ever-so-humble website exclusive:

6. The formal Consultation period ran from August 6th to October 29th 2012 and included an extensive programme of engagement with staff, stake-holders and the public. This process was applauded by the CHC as it resonated with one of its recommendations following Listening and Engagement, viz. a wide range of feedback mechanisms should be used involving less heavy reliance on ‘technical’ (on-line computer-reliant) means. Having stressed that the (open) consultation questionnaire would be the main conduit of public response (C. Wright HB. 01.08.2013) and following a comprehensive campaign by CHC on behalf of the HB to encourage public participation/questionnaire return, 4,422 residents and organisations replied. Additionally, a postal survey (‘household survey’) was sent to 5,000 randomly selected households (the criteria of selection were not shared with the CHC) of which only 14% (697) were returned. At a later date, the CHC were informed by ORS that this (low) return was afforded greater weighting in the final analysis than the 4,422 consultation questionnaires, the rationale for which the CHC continues to dispute. Moreover, it has since been revealed that recipient households were merely sent a summary document and not the full consultation document to inform their decision-making.

As can be seen, the channel for the public to express their views in this consultation was via a questionnaire drawn up by the health board, split into two groups. Both used the same questionnaire, the difference came in the way they were used.

One kind which was known as the ‘open’ survey, was available for anybody to request, fill in and return. The second type, the ‘closed’ surveys, limited to 5,000, were posted to randomly selected addresses within the health board area, and it was these submissions to which far greater weight was attributed in the conclusions of the consultation process.

Little is known about the process by which the health board determined that 5,000 addresses were representative, or how little –if any– weight has been given to the open responses.

Very active and resolute campaigners fighting to retain services at Withybush Hospital in Haverfordwest (SWAT –Save Withybush Action Team) and well-publicised vocal campaigns in Llanelli (SOSPPAN – Save Our Services Prince Philip Action Network) as well as campaigners bidding to save the minor injuries unit in Tenby, all put a great amount of effort into encouraging members of their wider communities to request, fill in and return the freely-available open surveys.

It seems this effort was effectively worthless, and that these campaigners and ordinary members of the public who opposed the plans were instead reliant upon a tiny minority of people returning the exclusive, unsolicited questionnaires, which the CHC claims were accompanied by inadequate supporting information.

As the CHC alluded, the returns to these closed 5,000 surveys across the three counties within the Hywel Dda Health Board were particularly poor – 14%, but now I can reveal a breakdown of all of the results.

The following data, which was obtained via a freedom of information request submitted by Tenby Town Council and shared with jacobwilliams.com, gives a breakdown of the 37 postal code areas within Pembrokeshire, Carmarthenshire and Ceredigion, and the number of addresses targeted with a closed survey, and the corresponding number of returns.

With over 28,000 addresses in the Haverfordwest postal area (SA61 + SA62) which covers from Martletwy-Dale-St. David’s and everything in-between, only 73 closed consultation responses were returned from just 478 surveys.

The entire Whitland postal code with nearly 3,908 addresses was represented by just three surveys. The geographic area listed under the ‘others’ postcode heading with 5,251 residences (greater than the smallest three listed postcode areas combined) returned only fourteen responses.

Find out how well your area was represented in this closed-book survey, and use it to help form your own opinion on whether or not ‘Your Health, Your Future’ amounted to proper consultation:

Hywel Dda Health Board FoI Disclosure

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  • Honest Joe

    I wonder how many of these surveys were sent to holiday homes? I can just imagine swarms of holiday home owners will come over to their retreats for Easter and find a questionnaire waiting for them asking them about a health service they have no clue about, have never used and probably never will use.

  • Simply Stunned

    Is this some sort of joke?

    Pembroke Dock has 9,000 homes, strange that my parents didn’t get a survey!

  • Well, just over 8,073 is the figure given for the Pembroke Dock area postcode (SA72) on this list, which is individual addresses, rather than separate buildings/homes.

    We all know how many bedsits there are in Pembroke Dock, given recent coverage, and I guess that each and every one of them counts toward the 8,073 figure!

  • Valley-Red

    Going slightly off thread, how long before she carries out the same process for local government with probably a worse consultation process, if that is possible?

    Obviously to Welsh government, consulting with the electorate actually means patting them on the head whilst telling them that “we know what’s best for you”.

  • His Holiness Wally

    I’m noting all of this regarding the consultation exercise and perhaps it’s something to return to tomorrow. Do you happen to know what the CHC proposed as alternatives as they are bound to do as part of the process? Mark Drakeford is a very interesting appointment in my opinion, as is the sideways shuffling of Lesley Griffiths.

  • John Hudson

    As all of this is driven by finance, or rather the lack of it, the CHC points to missing financial evidence to confirm that the LHB proposals are viable and sustainable.

    If this information is made available, has the CHC got the proper expertise to evaluate it and set it in context?

    It seems to me that considerable costs will be passed on to Local Authorities, by way of additional social service requirements, and costs to us by way of increased travel costs and our time.

    Who are the CHC Board that represent our views? Who appoints members?

  • Dr Wally

    I agree with Mr Hudson, up to a point, certainly regarding the importance of finance which tends to be downplayed by the LHB and politicians.

    I think your point is very valid about whether the CHC could evaluate it effectively in any event. A very good question in my opinion. Here’s another question, anybody know where else in the British Isles there are 4 district general hospitals to serve a population of 450,000?

    In the late 90s a proposal existed to site a brand new, state of the art ‘super hospital’ around the Whitland area. Such a proposal was viewed as the work of the devil incarnate by much of the CHC’s population at the time, yet had it been built and properly resourced, with appropriate transport support, we probably wouldn’t be in this hopeless merry go round of trying to run unsustainable services with a shrinking financial pot with ever increasing technological advances and so on, at 4 different DGH sites.

    (And before the PRs of this world start running off thinking I am advocating NO hospital of any sort in Haverfordwest, Llanelli, Carmarthen or Aberystwyth, think again. I am not.)

    However, what we have now can’t go on from a clinical or financial perspective and whether the consultation was flawed or not is a little bit of a diversion from the real issues in my very humble and probably worthless (because I do have a different view sometimes!) opinion. I view CHCs as a waste of money themselves.

  • This must be a first, Wally’s saying something I find quite agreeable!

    As I’ve said recently, whilst the report is thoroughly critical – and rightly so – I think the minister is probably right to have batted it back, because it is distinctly lacking in proposals/alternatives/compromises. I think it’s rather telling that such a fundamental omission has been made by the CHC.

    That said, it could well be the case that the CHC feels it has a lack of information and co-operation from the health board to come up with its own alternatives, something which I suspect the (new) minister hopes will be rectified within this short deadline. The relationship between the CHC and HB is well known to be a fiery one.

  • Concerned

    I also happen to think Wally is talking sense. If there had not been so much grandstanding over the Whitland hospital proposals and the project had been discussed sensibly then we may not be in the mess we are now.

    Hopefully the new minister can knock heads together and get agreement and fresh proposals between between the CHC and HD health board.

  • Judy

    I cannot believe that you criticise the CHC, they sent their referral stating that the process of the consultation was a sham, that the HB had not adhered to the Gunning Principles.

    The CHC represents the whole of the Hywel Dda area and are volunteers who spent their time reading technical documents and submissions and inspect the hospitals. Can you say that any of you read all the technical documents that went alongside the consultation?

    Maybe instead of shouting off about them you should join as a member and see what they actually do!

  • Hi Judy,

    If you’re talking about something I’ve said, as opposed to other commenters, what makes you think I’m ‘shouting off’ about the CHC?

    It’s just highlighting what’s happened. What you’ve said is fine, but it’s what is lacking in the referral is where the CHC has let itself down, and which has ultimately led to the current position where the referral is in limbo. The referral lacked alternative proposals, and that’s why the minister batted it back. Do you disagree with that?

  • Dr Wally

    Nice to be out of the firing line for once…but seriously…

    Judy, I also believe that Jacob hasn’t ‘shouted off’ about the CHC, if anyone has, I have. Nevertheless, what do the CHCs in the current Welsh NHS actually add? What I also believe from reading the documents is that the CHC supports (perhaps in a closet way) the closure of the two South Pembrokeshire MIUs and a number of the other proposed changes. They are just stalling and using process flaws to appear to be the ‘voice of reason’. Quite clever, in a limited way. I draw your attention to North Wales also. Didn’t the CHC there object to the HB’s plans initially and then, controversially and mysteriously, changed tack quite dramatically?

    Now, in summary, I believe that the NHS has changed markedly in the last 20 years and the current arrangements cannot continue from a clinical perspective, if nothing else, if you want a first class service. Two counter examples perhaps and someone with more knowledge may point out they are not as good as I think…

    Cardiac care is provided, as I understand it, on a model whereby most specialist care and surgery is actually in the main provided by Morriston Hospital. Diagnostics and first contact stuff is done at Withybush. Bypasses, stents and so on are done in Swansea because they have the expertise and can attract top clinicians and have the throughput (dealing with most of West Wales) to enable them to maintain their clinical excellence and continue to attract top clinicians. The patients clearly benefit from this and there is no real squealing about the travel involved for instance.

    Cancer care similarly is structured in a similar ‘step up and step back’ way whereby disease complication and treatments are provided in the setting which is most appropriate from a clinical perspective and NOT just because it’s near to the patient. That may be a consideration, of course, but it is not the prime mover. There are many examples in my view whereby the people of Pembrokeshire would be far better served by modern models of care and not ones which assumes that everything must be provided locally. Must go now, time to start campaiging for a hospital in Fishguard and Narberth. Why you ask? Because Tenby’s got one…and don’t mention the ‘Tenby Cottage Ward’.

    Jacob, might be time to ban me!

  • A Clark

    Consultation simply involves the proposer stating their case, listening to those affected thereby and then ignoring them. That fulfils the consultation requirements. Whether the proposer actually modifies their case as a result of comments from those affected is in the lap of the Gods.

    Most people expect too much from the consultation process. Yes, I’m a cynic, but then this is modern democracy.

  • David Williams

    First of all the CHC have been refused information needed from Hywel Dda to allow them to make “detailed” alternatives requested by Leslie Griffiths. Also how can you expect non paid volunteers with a very limited budget to come up with detailed alternatives in a short time when Hywel Dda cannot with a much larger budget, loads of paid staff and 6 years working on it.

    They have no answer when asked about cost analysis or risk assessment, no idea about how the ambulance service will cope with additional strain, no idea about how many extra staff will be needed or the cost of moving care out into the community which potentially could cost more.

    Their answer seems to be ‘we will sort it out as we go along’ which inspires a lot of confidence and how many people will be adversely affected or even die while they muddle through?

    The CHC are the patient/public’s watchdog with a very limited budget and therefore are very cost effective. Without them there is no-one to challenge health boards or hospitals when standards slip.

  • David Williams

    Reply to Dr Wally,

    No-one expects to have brain surgery, heart surgery major trauma etc treated at Withybush but Pembrokeshire people have a right to expect not to have to travel up to 45 miles for SCBU or maternity consultant care when urgently needed, especially taking into account our transport infrastructure.

    We do have one too many hospitals in Hywel Dda but they have two in Carmarthen with dual carriage/motorway to Swansea 30 miles away. Draw a 30 mile circle round Haverfordwest, Carmarthen, Llanelli and Swansea and guess where there is a huge overlapping of circles?

    I realise population has to be taken into account but LLanelli, the largest town in Carmarthenshire, is 20 minutes away from Swansea. It appears Carmarthenshire is going to be well catered for while Pembrokeshire is out on a limb even though we have much more risk from energy industry accidents, much more tourist population in summer etc etc. If the SCBU closes within a reasonably short time we will lose paediatrics and maternity consultants with midwife only unit at Withybush.

    If your pregnant wife developed an unexpected complication requiring urgent surgical attention would you want to have to take her 45 miles from St Davids or Fishguard to Carmarthen possibly with snow/ice around or holiday traffic clogging the roads. You can’t wait for an ambulance as they cannot cope at the moment let alone with extra workload having to ferry patients further afield.

    Compare the above scenario with Carmarthenshire who would have a choice of 30 miles west to Haverfordwest or 30 miles east to Swansea (about 20 mins with blues and twos). We want near equality of risk for our children and pregnant mothers.

  • JohnTar

    Surely the primary object of the CHC Referral was to inform the Health Minister (whoever that person might be at whatever time) of the concerns that they (the CHC), and more importantly the tens of thousands of potential NHS Wales users, had about the way that the Consultation was carried out and its end result? It would not have been necessary to detail any alternative opinions that the CHC had about the proposed restructuring of local health services.

    In her response to the referral the then Health Minister mentions the fact that the CHC MUST negotiate change to the proposals with the Health Board, setting a precedent for further dialogue, but then sets a ridiculous time limit for the discussions – which quite frankly makes her appear to be residing somewhere in cloud-cuckoo land when one considers how long just the initial discussions and consultation period has taken to bear any fruit. When one makes any complaint about anything, he, she or they are extremely fortunate if mutual satisfaction occurs without prolonged negotiation, and there are a lot of justifiably angry and bewildered folk involved in THIS contretemps!

    As for your well researched and documented breakdown of the public poll, instituted area-by-area by the Health Board, Jacob; I think that it goes without saying that the tri-counties’ public “scuttle-butt” had the two elements of it pretty accurately nailed down when the Health Board announced its “decision”, with massive inconsistency between its “open” and “closed” components – and THAT is what the Minister should be looking into, NOT entering into verbal flim-flam about the breakdown of political procedure…

  • Dr Wally

    Reply to Mr Williams,

    What do you see as the difference, in maintaining clinical competence, between heart/brain surgery and SCBU then? Secondly, Do the current proposals actually remove consultant maternity care? I apologise if I’ve missed that. Thirdly, what would Pembrokeshire people prefer, a properly run and resourced service or one which constantly struggles to recruit well qualified medics, partly because of exactly where we are?

    Just because you or others may state that we will have a service here doesn’t suddenly mean that consultants will queue up to work in area. Further, the CHC’s own response highlights the problems with recruiting to the Glangwili based model Level 2 Neonatal model and actually uses that as an obstacle and a reason to not proceed. Rather contradictory.

    Finally, I really like this “The CHC are the patient/public’s watchdog with a very limited budget and therefore are very cost effective. Without them there is no-one to challenge health boards or hospitals when standards slip.”

    I can’t say I agree, I can’t see their effectiveness so far.

  • John Hudson

    Can I direct attention to the Local Service Board minutes of 29 January 2013. These are available under the LSB tag on the County Council’s website.

    These seem to underline the value and worth of the consultation and its outcome.

  • John Hudson

    Under item 5 of the Minutes, concerning the Consultation final requirements, CM comments that the focus is now on the financial challenge the changes pose and stated that he would like to see support from Pembrokeshire politicians in moving forward.

    It all seems to be a foregone conclusion. I wonder if our elected representatives will comply with the lead given by unelected officers. The only politician at that meeting was our County council leader.

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