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Maternity Eye On 2003-04 Index

Eye On Index

Maternity Issue

Paper To Be Put Before NHS Highland Board Meeting on 6 April 2004

Report by Roger Gibbins, Chief Executive

The Board is asked to discuss the document entitled “Maternity Services in Caithness and Sutherland” and to decide on the proposals contained therein:1. That the Board agree with the conclusions of the report that options A, B and E are not viable option to consult on.2. That the Board asks the Deputy Chief Executive (Modernisation) to lead work to:(i) assess the viability of option C as a possible subject for consultation.(ii) assess how the ‘stringent conditions’ relating to Option D may be met with a view to consultation(iii) consider other issues raised at the Board meeting on 16 march 2004(iv) continue to engage proactively with people and organisations with an interest in the proposals(v) bring a report on these aspects and a proposal and plan for formal consultation to the June Board meeting.3. Highland Council be asked to note the stages and timetable for this work in relation to their commission of the social and economic impact study.

The Board received the report, from Professor Calder, ‘Maternity Services in Caithness and Sutherland, An Independent Review Conducted on behalf of Highland Acute Hospitals Trust’ on 16 March 2004.

At that meeting the Board agreed that the Review Group had met the terms of reference that had been set for it. Namely to consider

a. The balance of risk between the current consultant led service and of not having this service in the future.
b. The professional sustainability of the present arrangements.
c. What model of maternity service offers the best balance in terms of safety, sustainability and accessibility for the women of Caithness and Sutherland?
d. What support mechanisms need to be in place to sustain this model?

The report concluded:
· The Review Group take the view however that even with unlimited financial resources and goodwill on the part of health care staff and management it will not be possible to sustain the current arrangements for specialist obstetric services at Caithness General Hospital far less an enhanced specialist service there.

· The Review Group reached the inescapable conclusion that the current provision of specialist service is unsustainable. We have, however, also reached the conclusion that it would be quite inappropriate simply to withdraw the Consultant Obstetricians without exploring all the possible alternatives in order to arrive at the most appropriate and acceptable service provision.

· We also believe, however, that with sufficient imagination and determination the future service provision, far from being inferior to the current one, may well represent a more sustainable and robust service.

The purpose of this paper is to summarise the main points raised and recommendations of the Review Group, to set those in the context of the Board meeting on the 16 March 2004 and the parliamentary debate on the 11 March 2004, and to make proposals to the Board with a view to beginning an official consultation period of 3 months.

The Calder Report
The report highlights 5 possible options for the future of Maternity Services in Caithness. Three of them:
· Option A (enhancement of existing specialist services)
· Option B (maintenance of the status quo) and
· Option E (Discontinuation of inpatient deliveries in Caithness)

are dismissed by the group as being either unrealistic, unsustainable or unnecessary.

The two remaining options from the report are Options C and Option D.

Option C. Alternative models of provision of specialist obstetricians

This option has several different possible approaches:
C.i. That all consultant obstetricians in the Highland Region be based at Raigmore Hospital but that they take it in turns to stay in Wick for periods of a predetermined length during which they would be available to provide instant obstetric support.
The challenges to this approach would be:
· It would presumably require a further significant increase in the number of consultants employed in Raigmore so that this type of scheme would comply with the new consultant contract and employment legislation.
· It seems highly improbable that the consultant obstetricians currently employed at Raigmore Hospital would be prepared to alter their contracts to accommodate such a scheme (albeit there might be contractual obligations to do so or at least to work more flexibly).
· If such a scheme were mandatory for new appointments in Inverness this requirement could have a deleterious effect on the ability to recruit and retain any consultants at all for the Highland Region.

C.ii. The idea has been mooted that consultants who take early retirement from busy urban hospital posts (often five or ten years before their natural retirement age) might be prepared to act in the style of the old single handed consultant in Wick for periods of several months or even years. It may be that special arrangements could be made to offer financial inducements to individuals to work in this way although again employment legislation may preclude it.

The challenges to this approach would be
· Although such an arrangement might seem superficially attractive individuals undertaking this style of working would become rapidly disillusioned.
· There are also serious issues concerning clinical governance, maintenance of clinical skills etc., which are probably even more pressing than apply to the current arrangements.

C.iii. A sequence of short-term “locum” arrangements. In previous years when difficulties such as the present ones confronted the small units in the Highland Region and the Western Isles a short term “fix” was provided by recruiting a steady stream of individuals currently employed in other parts of the country who would undertake locum cover for a week or perhaps two at a time during their annual leave. This often applied to old style senior registrars or young consultants who saw this as an opportunity to supplement their income at that stage in their careers.

The challenges to this approach would be:
· The problems of unfamiliarity, lack of long term commitment, and variable and unpredictable quality of the individuals that might be recruited.

In overall terms, the review group have suggested that “Option C” would not satisfy the immediate concerns of the service. “There are cogent arguments for seeking the assistance of the Scottish Executive and the Remote and Rural initiatives in the longer term objective of staffing the service with pluripotential practitioners capable of offering obstetric assistance in specific circumstances. Such an option could, however, only be implemented in the longer term.

Option D. The Community Maternity Unit Model
This would entail withdrawal of specialist obstetric staff from Caithness General Hospital and the establishment of a midwifery led unit, which would aim to confine those women who were deemed suitable for such an arrangement. This would also require such women as were not considered to be in that category or who chose not to avail themselves of that local facility to travel to Raigmore for their confinements. It is also inescapable that under such a model a small number of women (perhaps fewer than 10 per year) as in Skye and Lochaber would require to be transferred in labour to Inverness on account of intrapartum complications. It is a matter of speculation what proportions of the future childbearing population would fall into these three categories but the Group estimate that probably rather more than half of the current expectant mothers would be recommended or would choose delivery in Inverness and slightly fewer than half would be confined in Wick.

The Group would emphasise that if such a model were to be adopted it would clearly require more than withdrawal of the consultant obstetric specialists and simply requiring the midwives to provide such a service. In the final analysis the Review Group have reached the view that the best configuration for high quality maternity care in Caithness and Sutherland would be for Option D to be enthusiastically embraced and seen as the basis for the development of a high quality obstetric service that would represent the best arrangement for the maternity care of the women of Caithness and Sutherland.

Option D requires major initiatives and endeavours on the part of a wide range of medical, midwifery and health service management in order to maximise the skills of the staff concerned, to support them to the highest level and to continue to explore new and better ways of meeting the high expectations of the future generations of offspring in Caithness and Sutherland, their parents and their families.

Challenges/conditions to option D
Whilst the Review Group believe that the preferred configuration should be the Community Maternity Unit model they also stipulate that it should be developed under the following stringent conditions:

a. There should be substantial and genuine investment in enhancing the training and confidence of midwives to enable them to undertake the necessary extended role.
b. The midwives should be supported by the regular daytime presence of specialists who would be there to assist with risk assessment and care planning while contributing to antenatal and postnatal care and conducting consultations in obstetrics, gynaecology and family planning and performing appropriate gynaecological surgery.
c. All clinical practices should be guided by custom developed protocols, guidelines and care pathways with the most effective employment possible of communication links and support such as telemedicine.
d. Good quality accommodation should be provided for women and their families when they have to travel to Inverness for maternity care.
e. The best possible system for the transport of pregnant women from Wick to Inverness, particularly those in labour, must be identified and provided.
f. The current schedule of training of midwives in newborn resuscitation and stabilisation should be developed into a more definite programme.
g. The National Newborn Transport Service should take particular cognisance of, and address, the issues in Wick.

Within the report the report professional concerns of midwives were highlighted as:
i. Reservations regarding safety if no obstetrician is available.
ii. Specialist help more than 100 miles away.
iii. Potential for no resident obstetric cover.
iv. Issues of transfer, retrieval and transport.

Some of these concerns are left unanswered by the Calder Report. They are concerns – particularly in relation to transfer, retrieval and transport, which may be shared by members of the NHS Board

The Review Group also recognise one further issue that the Board will have to consider. ‘The new Board will have to recognise the wider consequences of decisions they may take in respect of the maternity services and it is incumbent on them to guard against compromise to other services.’

NHS Board Meeting - 16 March 2004
The NHS Board met on the 16 March in Wick. Representatives of the public were invited to participate in the debate about Professor Calder’s report. A full minute of the meeting is attached and Board members will note the specific issues raised by the public representatives.

The actions following on from that meeting were:
· Further consideration be given of the necessary linkages between the issue of Maternity services in Caithness to be seen in relation to forthcoming Out of Hours consultations.
· That the subject of affordability of the recommendations of the report be considered.
· That a meeting be organised between Highland Council and NHS Highland to discuss the scope and timing of the Council/HIE sponsored 360 degree study.
· That the accommodation needs of mothers who might travel to Inverness be considered further.
· That the NAG and community representatives would be invited to be involved in the consultation process.

Parliamentary Debate
A debate on the subject of Caithness maternity services was held in the Scottish Parliament on the 11 March 2004.
The debate centred around a number of issues relating to travel, wider economic factors, pan-highland working by Consultants, as well as the need to explore all alternative models with maximum input by the community.

The Process for Consultation
Any consultation process will follow that outlined in the new draft Guidance “Informing, Engaging and Consulting the Public in developing Health and Community Care Policies and Services”, that was issued on 1 March 2004 in combination with the “Draft Interim Guidance for Consultation” from 3 May 2002.

The 2004 guidance states that there are 4 stages of a realistic and proportionate involvement process.
Stage I is about Informing people and organisations affected
Stage II is about Engaging with those people and organisations proactively to develop potential options
Stage III asks Boards to ‘Consult potentially affected people and organisations on feasible options for policy or service development including service change, noting factors to be taken into account in assessing the merits of options. When you (i.e. Boards) have a preferred option for the proposal, this should be clearly stated alongside the reasoning behind its choice.’
Stage IV is about offering Feedback on the outcomes of the above/

A further stage is highlighted which is about seeking Ministerial approval for major service change. At that stage reports should include accounts of the involvement process.

Presently the Board is moving from Stage II to Stage III of the above process.

The Board will need reassurance that the following factors (as outlined in the 2004 draft guidance) are taken into account:
1. Why people are being involved in the process
2. What will happen to the information gathered
3. What methodologies will be used to gather those views.

Board Proposals
1. That the Board agree with the conclusions of the report that options A, B and E are not viable option to consult on.

2. That the Board asks the Deputy Chief Executive (Modernisation) to lead work to:
(i) assess the viability of option C as a possible subject for consultation.
(ii) assess how the ‘stringent conditions’ relating to Option D may be met with a view to consultation
(iii) consider other issues raised at the Board meeting on 16 march 2004
(iv) continue to engage proactively with people and organisations with an interest in the proposals
(v) bring a report on these aspects and a proposal and plan for formal consultation to the June Board meeting.

3. Highland Council be asked to note the stages and timetable for this work in relation to their commission of the social and economic impact study.

Dr Roger Gibbins
Chief Executive
26 March 2004