Hywel Dda health board has warned that a number of its services are "fragile" and dependent on significant numbers of temporary staff.
A radical shake-up of health services is being looked at, to keep them sustainable in the future. This could involve options to close hospitals and a new hospital.
This outlines some of the difficulties the health board is facing:
Hywel Dda is projected to have a budget deficit of £64.5m by April. Its accumulated deficit by then is estimated to be £139.7m. The gloomy financial picture is being coloured by problems recruiting staff - and simply filling the rotas day to day.
RECRUITMENT PROBLEMS - AND TEMPORARY STAFF COSTS
The Auditor General, in a report published last summer, found "significant workforce challenges" despite efforts by the health board.
There were high levels of nursing and medical vacancies, long standing recruitment difficulties and increased service demand.
There were 250 nursing vacancies alone in 2015-16, with £23.45m spent on agency staff - set against the health board's deficit for the year of £31.2m.
The 6.7% of total pay being spent on temporary/agency staff was the highest of any NHS body in Wales.
Expenditure on what is called variable pay was increasing "at an unprecedented rate" - from £1.2m a month in 2013-14 to £3.7m a month by the end of 2015. The average in 2017-18 so far is just over £4m a month.
Hywel Dda also has had the second highest turnover of staff in NHS, although this has improved to 6.8%.
The health board managed to recruit 246 nurses from Europe and the Philippines and hire more newly-qualified nurses but there is still an issue.
Finding specialists in A&E, paediatrics and radiology is a particular problem, especially in coastal areas.
Also gaps left trying to fill 18 out of the 20 junior medical trainee roles for Carmarthenshire led to additional costs of £700,000.
WAITING TIMES AND AMBULANCE DELAYS
December 2017 was "challenging" at A&E and minor injuries units with waiting times targets not met - especially at the two main general hospitals.
The ambulance service only just met its target (65%) for responding to "red" calls within eight minutes and is at risk of falling below.
Meanwhile, the number of patients waiting more than nine months for treatment was 3,309 at the end of December 2017 - 667 waiting more than a year - while 83.2% of patients waited less than 26 weeks.
- The number of patients waiting 14 weeks or more for therapies continues to be high - the longest waits 40 weeks for occupational therapy and dietetics
- Targets have not been met for the three reported hospital-acquired infections: E.coli, C.difficile and S.aureus
- The 12 month reduction target for delayed outpatient follow up appointments was not met
WHAT HYWEL DDA IS DOING WELL
- It is ranked as the best performing in Wales for three out of four stroke targets - including 74.6% of patients being admitted to a stroke unit within four hours; every patient is seen by a consultant within 24 hours
- The region is also well above target for supporting people to give up smoking
- Its two sepsis targets have been consistently met so far this financial year
- It has met targets to reduce delayed transfer of care for mental health patients
- There have been no breaches of targets for patients waiting more than eight weeks for diagnostics for four months
WHAT ABOUT A NEW HOSPITAL?
BBC Wales understands that the option for building a new hospital on one of three sites around Whitland is firmly on the table.
It could be modelled on the new hospital being built at Llanfrechfa Grange near Cwmbran, which will concentrate on emergency and urgent care. The idea is that could allow other hospitals in the area to concentrate on planned treatments.
None of the options will threaten Bronglais Hospital in Aberystwyth, due to its unique position serving much of mid Wales and the coast.