1.237 While consultees differed in the extent to which they supported the proposed direction of travel and options for clinical services, there was broad alignment on the practical challenges facing implementation, particularly in a rural context. The themes below represent the most significant issues raised across the qualitative engagement activities.
1.238 Travel and transport emerged as the most dominant theme across all consultation methods. Consultees consistently stressed that long distances, poor public transport, limited hospital parking at all main sites, and rural road conditions present major barriers to accessing care, especially if services are consolidated onto fewer hospital sites. Concerns extended to patient transfers, with particular anxiety about the current strain on the Welsh Ambulance Service University NHS Trust (WASUT) and the feasibility of increased inter-hospital movement.
1.239 Communities emphasised that travel difficulties affect not only patients but also carers, family members and staff. Many felt that sustainable transport solutions must be established before any service changes are implemented. Many consultees were especially vocal about the mismatch between proposed clinical models and the realities of rural geography.
1.240 Workforce issues were consistently cited as a critical risk to the success of any future service model. Staff, councillors, special interest groups and submissions highlighted long-standing recruitment and retention difficulties, particularly in rural areas. Consultees questioned whether centralising services would exacerbate shortages, place additional travel burdens on staff and intensify pressure on already overstretched teams.
1.241 There was broad agreement that new service configurations must be underpinned by credible workforce plans, including local training pathways, incentives for rural recruitment, sustainable rotas and investment in staff accommodation, development and infrastructure. Many staff emphasised that proposed pathways could not be delivered without significant additional workforce capacity.
1.242 Consultees highlighted the ageing condition of many hospital buildings across Hywel Dda, with Withybush and Glangwili frequently described as needing significant investment. Concerns centred on insufficient physical capacity, outdated infrastructure, and limited ability to support major service reconfigurations without phased capital development.
1.243 Parking emerged as a key issue across all hospital sites, with fears that concentrating services on these sites would create unmanageable congestion and further hinder access.
1.244 Some questionnaire respondents felt there might be unacknowledged impacts on services not covered as part of the CSP, such as trauma and emergency care, general medicine, nuclear medicine, anaesthetics, psychology and mental health services; noting that many services overlap or are closely linked to one another, so ought not to be considered in isolation.
1.245 Similarly, staff, councillors and some community groups raised concerns about the interdependencies between acute, specialist and diagnostic services. Many felt that reviewing clinical areas in isolation risked fragmented care, exacerbating service fragility, or destabilising core functions like General Internal Medicine. Several staff members emphasised the importance of understanding how changes to emergency care, stroke, critical care and surgical pathways would interact across sites.
1.246 Regional effects were also noted: neighbouring health boards and councils highlighted the potential impact of change on patient flows, workforce distribution and cross-border pathways, underscoring the need for co-ordinated planning across mid and west Wales.
1.247 While staff, external partners, and some members of the public welcomed digital tools and virtual consultations, there were some concerns that digital solutions cannot replace face-to-face care for many groups. Older people, residents living in more rural areas with poor connectivity, and people with disabilities or limited digital literacy were considered at risk of exclusion if reliance on technology increases without appropriate support. Consultees encouraged a blended model, with digital options complemented by robust non-digital alternatives and improved digital literacy support.
1.248 A recurring theme across engagement with members of the public, service users, councillors and on social media was low confidence in the consultation process and a perceived lack of transparency. A number expressed concern that decisions had already been made, that consultation materials were too complex, and that meaningful engagement was limited by inaccessible formats, time pressures and consultation fatigue.
1.249 There were calls for clearer communication of clinical reasoning, evidence, modelling and cost implications; plain-language updates; and stronger assurance that feedback will shape final decisions. There was also appetite for greater honesty about the constraints facing the Health Board and the trade-offs required to deliver sustainable services.
1.250 While many consultees prioritised local access - particularly for urgent or high-frequency services - others acknowledged the benefits of travelling further for specialist expertise or shorter waiting times. This tension was evident across events: some saw consolidation as necessary to ensure safety and sustainability; others perceived it as inequitable and potentially harmful for rural communities. The need to balance local provision with high-quality specialist care was a prominent and nuanced theme.
1.251 Staff across all sites emphasised that service uncertainty is affecting morale, retention, and confidence in future planning. Some expressed concern about the fairness of asking staff to commute longer distances or work across multiple sites, particularly in rural parts of the region. Others emphasised that staff perspectives have not always been adequately reflected in early decision-making, that successful implementation requires genuine clinical involvement and realistic timelines, and that the process is ‘taking too long’.