Access to Health Services in Rural Wales - Cael Gafael ar Wasanaethau Iechyd yn y Gymru Wledig

Speech by Kirsty Williams AM delivered to National Assembly for Wales - Cynulliad Cenedlaethol Cymru on Thu 9th May 2002

Having being successful in the draw for the first ever short debate in the National Assembly for Wales, I did not anticipate that I would have to wait three years for the draw to favour me again. However, it was easy to select a topic for this morning's debate: I want to highlight the challenges of delivering and accessing health services in a rural setting.

A minnau wedi llwyddo i dynnu'r tocyn am y ddadl fer gyntaf erioed yng Nghynulliad Cenedlaethol Cymru, ni ddisgwyliais y byddwn yn gorfod disgwyl tair blynedd imi gael y fraint eto. Er hynny, hawdd oedd dewis pwnc i'r ddadl y bore yma: yr wyf am dynnu sylw at yr her o ddarparu a chael gafael ar wasanaethau iechyd mewn lleoliadau gwledig.

We often hear in Plenary and in the Health and Social Services Committee that there is a potential crisis in recruiting GPs in deprived and isolated parts of Wales. That is true, but it is also true for many rural parts of Wales. Given the falling retirement age of GPs and the increasing number of female doctors who are more likely to work part-time, or take career breaks to look after other aspects of their lives, it is a challenge for the whole of Wales. However, it is particularly challenging for rural Wales where the main concern is out-of-hours services and on-call responsibilities. General practitioner practices in Powys and the Powys local health group quote those factors as being the main problem in recruiting new GPs. Applicant numbers have dropped in recent years, and practices in Builth Wells and Talgarth have been anxious about their ability to recruit new partners. One practice in north Radnorshire has had a vacancy since April 2001. The two doctors running that practice have to work a 'one in two' rota, and are on call every other weekend. I am sure that you would agree that that puts a strain on their ability to continue with that work.

Clywn yn aml yn y Cyfarfod Llawn ac yn y Pwyllgor Iechyd a Gwasanaethau Cymdeithasol fod posibiliad o argyfwng o ran recriwtio meddygon teulu mewn rhannau difreintiedig a diarffordd o Gymru. Mae hynny'n wir, ond mae hefyd yn wir am lawer

o'r rhannau gwledig o Gymru. Gan fod oedran ymddeol meddygon teulu'n disgyn ac oherwydd y nifer cynyddol o feddygon benywaidd sy'n fwy tebygol o weithio'n rhan amser, neu gymryd toriad yn eu gyrfa i ymorol am agweddau eraill ar eu bywyd, mae hyn yn her i Gymru gyfan. Fodd bynnag, mae'n her arbennig i'r Gymru wledig lle y mae'r pryder pennaf ynghylch gwasanaethau y tu allan i oriau a chyfrifoldebau ar alwad. Mae practisiau meddygon teulu ym Mhowys a grŵp iechyd lleol Powys yn crybwyll y ffactorau hynny fel y brif broblem wrth recriwtio meddygon teulu newydd. Mae nifer yr ymgeiswyr wedi disgyn yn ystod y blynyddoedd diwethaf hyn, a bu practisiau yn Llanfair ym Muallt a Thalgarth yn bryderus ynghylch eu gallu i recriwtio partneriaid newydd. Mae swydd yn wag mewn un practis yng ngogledd sir Faesyfed ers Ebrill 2001. Mae'r ddau feddyg sy'n rhedeg y practis hwnnw'n gorfod gweithio'n ôl rota 'un ym mhob dau', ac maent ar alwad bob yn ail benwythnos. Yr wyf yn sicr y cytunech fod hynny'n rhoi straen ar eu gallu i barhau â'r gwaith hwnnw.

It was hoped that the new contract for GPs would offer a way forward for stressed professionals looking to cut back on their busy on-call commitments, but the document 'Your Contract, Your Future' has caused a great deal of concern in rural areas. I regret the General Practitioners Committee's decision not to hold a consultation meeting in mid Wales to discuss the contents of the document with rural GPs.

Yr oedd gobaith y byddai'r contract newydd i feddygon teulu'n cynnig ffordd ymlaen i weithwyr proffesiynol sydd dan straen ac sy'n ceisio lleihau eu hymrwymiadau ar alwad prysur, ond mae'r ddogfen 'Your Contract, Your Future' wedi peri llawer o bryder mewn ardaloedd gwledig. Mae'n ofid imi fod Pwyllgor yr Ymarferwyr Cyffredinol wedi penderfynu peidio â chynnal cyfarfod ymgynghori yn y Canolbarth i drafod cynnwys y ddogfen â meddygon teulu gwledig.

We must consider innovative systems to recruit to this challenging area of practice. It is a wonderful opportunity for many practitioners to work in a rural setting with a good infrastructure, good practice buildings, and the opportunity to extend their scope by working in conjunction with community hospitals. However, that advantage poses a problem in arranging out-of-hours rotas as doctors are expected to cover at local community hospitals, as well as deal with their usual patient lists. The new document affords opportunities for organisations, such as the soon to be formed local Powys health board, to take this challenge into account and develop services. We cannot take the commitment of rural GPs to continue to work rotas such as the 'one in two' for granted.

Rhaid inni ystyried systemau arloesol i recriwtio i'r maes ymarfer ymestynnol hwn. Mae'n gyfle gwych i lawer o ymarferwyr weithio mewn lleoliad gwledig gyda seilwaith da, adeiladau practis da, a'r cyfle i ymestyn cylch eu gwaith drwy weithio ar y cyd ag ysbytai cymunedol. Fodd bynnag, mae'r fantais honno'n peri problem o ran trefnu rotâu y tu allan i oriau gan fod disgwyl i'r meddygon ddirprwyo mewn ysbytai cymunedol lleol, yn ogystal â delio â'u rhestrau cleifion arferol. Mae'r ddogfen newydd yn cynnig cyfleoedd i gyrff, fel bwrdd iechyd lleol Powys sydd i'w ffurfio cyn hir, gymryd yr her hon i ystyriaeth a datblygu gwasanaethau. Ni allwn gymryd ymrwymiad meddygon teulu gwledig i barhau i weithio'n ôl rotâu fel yr un 'un ym mhob dau' yn ganiataol.

Access to dentistry has already been alluded to today. Presteigne has not had an NHS dentist since 1999, and, despite receiving the highest possible levels of subsidy to attract a dentist to the area—an impressive £50,000— we have been unable to do so. Shortages in the community dental service mean that even at-risk and vulnerable groups cannot access dental services in this area of Wales. The nearest NHS dentist for patients in Presteigne is Brecon, and I know that similar situations exist in Ceredigion, and that the practice in Brecon has also been touted to the people there. As a resident of Brecon, I am worried that that dentist must see people from a geographic area of well over 100 miles, which also raises the issue of access for local residents who are currently signed up to that dentist. Therefore, access to primary care services is a pressing need for many of my constituents, and we must seriously consider innovative ways of supporting investment that can make a difference in this area.

Cyfeiriwyd at fynediad at ddeintyddiaeth eisoes heddiw. Nid oes deintydd GIG yn Llanandras ers 1999, ac, er inni gael y cymhorthdal mwyaf posibl i ddenu deintydd i'r ardal—y swm sylweddol o £50,000—nid ydym wedi gallu gwneud hynny. Mae prinder yn y gwasanaeth deintyddol cymunedol yn golygu nad yw hyd yn oed grwpiau sydd mewn perygl ac yn agored i niwed yn gallu cael gwasanaethau deintyddol yn y rhan hon o Gymru. Yn Aberhonddu y mae'r deintydd GIG agosaf i gleifion yn Llanandras, a gwn fod sefyllfaoedd tebyg yng Ngheredigion, a bod y practis yn Aberhonddu wedi'i bedlera hefyd ymysg y bobl yno. Fel un sy'n byw yn Aberhonddu, yr wyf yn pryderu bod y deintydd hwnnw'n gorfod gweld rhai o ardal ddaearyddol o ymhell dros 100 milltir, ac mae hynny hefyd yn codi mater y mynediad i'r trigolion lleol sydd wedi cofrestru gyda'r deintydd hwnnw ar hyn o bryd. Felly, mae mynediad at wasanaethau gofal sylfaenol yn daer angen gan lawer o'm hetholwyr, a rhaid inni ddwys ystyried dulliau arloesol o gynnal buddsoddiad a all wneud gwahaniaeth yn yr ardal hon.

Ambulance cover is the second area of great concern to my constituency. In 1999, we successfully introduced 24-hour ambulance cover in Powys. Many of you may be surprised to know that, prior to that, out-of hours ambulance services were covered by staff from their homes. If you made a 999 call out of hours in Radnorshire before 1999, ambulance personnel were woken in their beds and had to get dressed and drive to the local ambulance station to pick up the ambulance before responding to the call. We were greatly cheered by the decision of the Ambulance Trust for Wales to instate 24- hour cover, which is now enjoyed at Ystradgynlais, Brecon, Llandrindod Wells, Newtown and other areas of Montgomeryshire. However, this was done at the expense of the hours of service at Crickhowell, Builth Wells and Bronllys. Therefore, in those areas in east Radnorshire, if you call an ambulance out of hours, it will have to travel from Brecon. With the best will in the world, and even the speediest driving, it is not possible for those ambulance crews to respond to medical emergencies within an appropriate timescale in vast tracks

Y warchodaeth ambiwlans yw'r ail faes sy'n peri pryder mawr yn fy etholaeth. Yn 1999, llwyddasom i gyflwyno gwarchodaeth ambiwlans 24 awr ym Mhowys. Efallai y bydd llawer ohonoch yn synnu bod y gwasanaethau ambiwlans y tu allan i oriau, cyn hynny, wedi'u darparu gan y staff o'u cartrefi. Os gwnaech alwad 999 y tu allan i oriau yn sir Faesyfed cyn 1999, câi'r gweithwyr ambiwlans eu deffro o'u gwelyau ac yr oeddent yn gorfod gwisgo amdanynt a gyrru i'r orsaf ambiwlans leol i nôl yr ambiwlans cyn ymateb i'r alwad. Fe'n calonogwyd yn fawr gan benderfyniad Ymddiriedolaeth Ambiwlans Cymru i sefydlu gwarchodaeth 24 awr, a geir bellach yn Ystradgynlais, Aberhonddu, Llandrindod, y Drenewydd ac ardaloedd eraill o sir Drefaldwyn. Fodd bynnag, gwnaethpwyd hynny ar draul yr oriau gwasanaeth yng Nghrucywel, Llanfair ym Muallt a Bronllys. Felly, yn yr ardaloedd hynny yn nwyrain sir Faesyfed, os galwch am ambiwlans y tu allan i oriau, bydd yn gorfod dod o Aberhonddu. Gyda phob ewyllys yn y byd, a hyd yn oed y gyrru cyflymaf, nid oes modd i'r criwiau ambiwlans hynny ymateb i argyfwng of Brecon and Radnorshire. meddygol o fewn cyfnod priodol mewn rhannau helaeth o Frycheiniog a sir Faesyfed.

We should also be realistic about what can be done about this situation. Increasing 24-hour ambulance cover, for instance to Bronllys, could go a long way to help, but there are areas of my constituency that will never be able to get an ambulance within the magical 8 to 10 minutes. Therefore, we have welcomed the development of the first responder and rapid responder schemes in Rhayader, for instance. However, I am concerned that the all-Wales ambulance trusts do not cover sickness leave in many cases in Powys, and have also failed to respond in a timely fashion to the innovation of the Brecknock and Radnor community health council to develop first responder schemes in areas such as Sennybridge. They have identified funding for such a scheme, and have only asked the ambulance trust to provide training opportunities for volunteers in the use of defibrillator machines; yet it has taken over a year for that to come to fruition. However, I am glad to say that, after some pushing, training for Sennybridge residents will go ahead.

Dylem fod yn realistig hefyd ynghylch yr hyn y gellir ei wneud am y sefyllfa hon. Byddai cynyddu'r warchodaeth ambiwlans 24 awr, i gynnwys Bronllys er enghraifft, yn gymorth mawr, ond ceir ardaloedd yn fy etholaeth na fyddant byth yn gallu cael ambiwlans o fewn yr wyth i 10 munud hud. Felly, yr ydym wedi croesawu datblygu'r cynlluniau ymatebwr cyntaf ac ymatebwr cyflym yn Rhaeadr Gwy, er enghraifft. Fodd bynnag, yr wyf yn bryderus nad yw'r ymddiriedolaethau ambiwlans Cymru gyfan yn dirprwyo yn ystod absenoldeb salwch mewn llawer o achosion ym Mhowys a'u bod hefyd wedi methu ag ymateb yn brydlon i arloesedd cyngor iechyd cymunedol Brycheiniog a Maesyfed wrth ddatblygu cynlluniau ymatebwr cyntaf mewn ardaloedd fel Pontsenni. Maent wedi canfod arian i gynllun o'r fath, a dim ond gofyn i'r ymddiriedolaeth ambiwlans ddarparu cyfleoedd hyfforddi i wirfoddolwyr yn y defnydd o beiriannau diffibrilio; ac eto, cymerodd dros flwyddyn i hynny ddwyn ffrwyth. Fodd bynnag, yr wyf yn falch o ddweud y bydd yr hyfforddiant ar gyfer trigolion Pontsenni'n mynd yn ei flaen, ar ôl rhywfaint o bwyso.

Transport to hospital is a vexed and inconsistent issue. Patients who suffer from cancer conditions are entitled to free transport to their hospital appointments, regardless of their ability to pay for those charges, whereas other patients with chronic, long-term conditions must pay for transport to hospital. For a Rhayader resident travelling to Hereford hospital, the fee would be around £25 per trip. When you consider that people must attend many out-patient appointments at Hereford before receiving an operation, and subsequently receive their after-care there, the bill soon adds up.

Mae trafnidiaeth i'r ysbyty'n fater astrus a dadleuol. Mae hawl gan gleifion sy'n dioddef gan anhwylderau canser i gael trafnidiaeth am ddim i'w hapwyntiadau ysbyty, beth bynnag fo'u gallu i dalu'r costau hynny, tra bo'n rhaid i gleifion eraill ag anhwylderau cronig, tymor hir dalu am drafnidiaeth i'r ysbyty. Yn achos rhywun sy'n byw yn Rhaeadr Gwy a deithiai i ysbyty Henffordd, byddai'r ffi oddeutu £25 y daith. Pan ystyriwch fod rhaid i bobl gadw llawer o apwyntiadau claf allanol yn Henffordd cyn cael llawdriniaeth, a'u bod yn derbyn ôl-ofal yno wedyn, mae'r bil yn tyfu'n gyflym.

That brings me to the issue of access to hospitals in rural settings. In the document, 'Access and Excellence', the Chief Medical Officer for Wales committed herself to developing a healthcare system that was flexible enough to meet the needs of rural and urban Wales. That document also referred to public expectations about what services people expected to be delivered locally.

Mae hynny'n dod â mi at fater y mynediad i ysbytai mewn lleoliadau gwledig. Yn y ddogfen, 'Mynediad a Rhagoriaeth', ymrwymodd Prif Swyddog Meddygol Cymru i ddatblygu system gofal iechyd a oedd yn ddigon hyblyg i ddiwallu anghenion y Gymru wledig a'r Gymru drefol. Cyfeiriodd y ddogfen honno hefyd at y disgwyliadau sydd gan y cyhoedd am y gwasanaethau y mae

People in rural Wales are realistic about what can be delivered in community hospitals. As much as I love Brecon War Memorial hospital, I would not want to undergo brain surgery there—it would not be appropriate. People in rural Wales are prepared to travel to other locations to receive services when they are assured that the outcome will be better for them. However, they are not prepared, for example, to travel long distances for short, 10-minute out-patient appointments. They are particularly keen for out-patient and maternity services to be delivered as locally as possible.

pobl yn disgwyl iddynt gael eu darparu'n lleol. Mae pobl yn y Gymru wledig yn realistig ynghylch yr hyn y gellir ei ddarparu mewn ysbytai cymunedol. Er cymaint y caraf Ysbyty Coffa'r Rhyfel Sir Frycheiniog, ni fyddwn am gael llawdriniaeth ar yr ymennydd yno—ni fyddai'n briodol. Mae pobl yn y Gymru wledig yn barod i deithio i leoliadau eraill i dderbyn gwasanaethau pan ydynt yn cael sicrwydd y bydd y canlyniad yn well iddynt. Fodd bynnag, nid ydynt yn barod, er enghraifft, i deithio'n bell ar gyfer apwyntiadau claf allanol byr, 10 munud o hyd. Maent yn arbennig o awyddus i weld darparu gwasanaethau cleifion allanol a mamolaeth mor lleol ag y bo modd.

The 'Access and Excellence' document also points to the pull of centralisation through a variety of factors, which has led to an iniquitous situation in my constituency regarding maternity services. Last year saw the re-establishment and the reconfiguration of maternity services at Brecon War Memorial hospital. We saw the downgrading of the maternity unit to being midwife-led, and the end of what were regarded as high risk procedures at the unit. While there is an argument about the feasibility of performing emergency caesarean sections at Brecon without the availability of blood supplies and without special intensive care facilities for mother and child, I do not accept the situation in which we find ourselves today regarding maternity services in Powys. From 1 October, mothers giving birth in a Powys maternity unit must leave that unit within 24 hours of giving birth. Members with experience of these matters will agree that this is not acceptable.

Mae'r ddogfen 'Mynediad a Rhagoriaeth' yn cyfeirio hefyd at y dynfa i ganoli drwy amryw o ffactorau, sydd wedi arwain at sefyllfa anghyfiawn yn fy etholaeth i mewn cysylltiad â gwasanaethau mamolaeth. Y llynedd gwelwyd ailsefydlu ac ailgyflunio'r gwasanaethau mamolaeth yn Ysbyty Coffa'r Rhyfel Sir Frycheiniog. Gwelsom israddio'r uned famolaeth yn un sydd dan ofal bydwraig, a diwedd ar weithdrefnau a ystyrid yn rhai risg uchel yn yr uned. Er bod dadl ynghylch ymarferoldeb cyflawni crothdoriadau brys yn Aberhonddu os nad oes cyflenwadau o waed a chyfleusterau gofal dwys arbennig i'r fam a'r plentyn, nid wyf yn derbyn y sefyllfa sydd ohoni heddiw o ran y gwasanaethau mamolaeth ym Mhowys. O 1 Hydref ymlaen, bydd mamau sy'n rhoi genedigaeth mewn uned famolaeth ym Mhowys yn gorfod gadael yr uned honno o fewn 24 awr ar ôl y geni. Bydd yr Aelodau â phrofiad o'r materion hyn yn cytuno nad yw hyn yn dderbyniol.

This week members of the Knighton hospital league of friends, potential mothers, and mothers who have had their babies at the hospital, travelled to the Assembly to hand a petition to the Minister for Health and Social Services outlining their concerns about this policy development. Mums in Knighton who want to stay in hospital longer than 24 hours, must travel to Hereford hospital to have their babies. One mum's partner clocked up an impressive 1,000 miles while he visited her following the birth of their child at Hereford hospital. I am sure that even those of you who represent urban constituencies cannot believe that this is an equitable situation.

Yr wythnos hon daeth aelodau o gymdeithas cyfeillion ysbyty Trefyclo, mamau dichonol, a mamau a roddodd enedigaeth i'w plant yn yr ysbyty hwnnw i'r Cynulliad i gyflwyno deiseb i'r Gweinidog dros Iechyd a Gwasanaethau Cymdeithasol a oedd yn amlinellu eu pryderon ynghylch y datblygiad polisi hwn. Bydd mamau yn Nhrefyclo sydd am aros yn hwy na 24 awr yn yr ysbyty yn gorfod mynd i ysbyty Henffordd i roi genedigaeth. Yr oedd cymar un fam wedi teithio pellter aruthrol o 1,000 o filltiroedd wrth ymweld â hi ar ôl geni eu plentyn yn ysbyty Henffordd. Yr wyf yn sicr na fydd hyd yn oed y rhai ohonoch sy'n cynrychioli etholaethau trefol yn gallu credu bod hynny'n sefyllfa deg.

Knighton community hospital has a first class record. There have been no adverse incidents regarding safety in that maternity unit. It was also the first hospital in Wales to receive a United Nations award for high levels of breast-feeding—it has an exemplary record in establishing breast-feeding in the area. It serves a highly rural population, many people living in isolated farmhouses up in the Teme valley. The choice is stark for them now. Either you go home after 24 hours, often to an isolated environment, perhaps with limited support structures and other young children in the house, or you have your child in Hereford hospital. That is not an equitable situation.

Mae record ragorol gan ysbyty cymunedol Trefyclo. Ni fu unrhyw ddigwyddiadau anffafriol o ran diogelwch yn yr uned famolaeth honno. Hwnnw hefyd oedd yr ysbyty cyntaf yng Nghymru i gael gwobr gan y Cenhedloedd Unedig am y lefel uchel o fwydo o'r fron—mae ganddo record ragorol o ran sefydlu bwydo o'r fron yn yr ardal. Mae'n gwasanaethu poblogaeth wledig iawn, a llawer ohonynt yn byw mewn ffermdai diarffordd yn nyffryn Tefeidiad. Mae'r dewis yn un plaen iddynt yn awr. Un ai yr ydych yn mynd adref ar ôl 24 awr, i amgylchedd unig yn aml, a strwythurau cymorth cyfyngedig efallai a phlant ifanc eraill yn y tŷ, neu yr ydych yn geni'ch plentyn yn ysbyty Henffordd. Nid yw honno'n sefyllfa deg.

This debate is not about having lower standards of safety for people in rural areas, but about delivering healthcare in innovative ways for people in rural Wales. It is about using telemedicine links and specialist nurses, which would mean that the trip to the district general hospital for a 10-minute consultation was no longer necessary. It is about delivering the appropriate service by appropriately trained people in the appropriate place and not giving in to the centralisation that many of the royal colleges favour. They often operate from London and have little regard for the geography and demography of Wales.

Nid yw'r ddadl hon yn ymwneud â chael safonau diogelwch is i bobl mewn ardaloedd gwledig, ond â darparu gofal iechyd drwy ddulliau arloesol i bobl yn y Gymru wledig. Mae'n ymwneud â defnyddio cysylltiadau telefeddygaeth a nyrsys arbenigol, a olygai na fyddai angen wedyn am y daith i'r ysbyty dosbarth cyffredinol am ymgynghoriad 10 munud. Mae'n ymwneud â darparu'r gwasanaeth priodol gan rai a hyfforddwyd yn briodol yn y lle priodol ac nid ildio i'r canoli y mae llawer o'r colegau brenhinol yn ei ffafrio. Maent yn gweithredu o Lundain yn aml ac nid ydynt yn rhoi fawr o ystyriaeth i ddaearyddiaeth a demograffeg Cymru.