Report published following independent review of maternity services

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Report published following independent review of maternity services

Posted on Wednesday 25th March 2015

An independent review of maternity services across Cumbria and North Lancashire has called on the local NHS to set up a small project team to consider the viability of having four consultant-led maternity units in Cumbria and North Lancashire.  Click here for report.|

The review was commissioned from the Royal College of Obstetricians and Gynaecologists (RCOG) during autumn 2014 by NHS Cumbria Clinical Commissioning Group (CCG) and NHS Lancashire North CCG. The purpose was to provide independent and expert advice on the best way to arrange high quality, safe and sustainable maternity services in the future.

As part of the review, the team spent three days visiting maternity units in Barrow, Whitehaven, Carlisle, Kendal and Lancaster in November 2014.

The report received by the CCGs on 23 March 2015 outlines six options:

 Option 1 - Four consultant-led maternity units at Carlisle, Whitehaven, Barrow and Lancaster with the immediate development of ‘alongside’ (on the same site or next to) midwifery-led units at Carlisle and Lancaster and in the longer term to evaluate the development of the same at Barrow and Whitehaven.

The report says ‘it was very clear to the assessors that women, the clinical commissioning groups and the majority of health care staff’ wish to maintain consultant-led maternity units on the four sites.

However, it says that this can only be supported on ‘safety and sustainability grounds’ if steps are taken to reform the approach to staffing, improve antenatal, labour and delivery and postnatal care, address anaesthetic issues and agree sufficient paediatric cover for a special care neonatal unit.

Medical staffing appointments to both North Cumbria University Hospitals NHS Trust and the University of Morecambe Bay NHS Foundation Trust should be made across the whole Trust, with the consultant-led units at both Trusts operating on a hub and spoke model. Clear processes and the right levels of staffing must be in place for the transfer of very high risk patients (such as multiple pregnancy or women with low lying placenta) from Furness General Hospital to Royal Lancaster Infirmary, and from West Cumberland Hospital to Cumberland Infirmary.

It says this option will require increased investment and active medical recruitment.

Liaison with larger specialist units at Newcastle and either Preston or Manchester  should also be explored for the maintenance of skills.

The report says that the project team should now be established, including an external senior manager, external obstetrician, head of midwifery and patient representatives. This would be accountable to the lead clinical commissioning group and would develop a detailed feasibility report on the cost, viability and risks of proceeding with this option. Local views and social deprivation would be important considerations.

This would take place within a year and if it showed that Option 1 was not possible then Option 2 should be considered, as follows:

 Option 2a – Two consultant-led units at Carlisle and Lancaster and developing two on the same site or next to midwifery-led units at Carlisle and Lancaster. This is the assessors’ second favoured option should it not be possible to achieve Option 1. It would mean the closure of consultant-led units at Whitehaven and Barrow.

The report says that while this option is more likely to provide safe levels of medical cover for women and their babies it must be balanced against increased travel times, cost and anxiety for those living in the west of the county. Antenatal care would be provided locally, including high risk consultant clinics, to minimise travelling except for the birth. The cost and benefits of this option must be balanced against the additional cost and operational pressure on the ambulance service and the need to expand the physical capacity of the consultant-led units.

 Option 2b - Two consultant-led units at Carlisle and Lancaster, developing two on the same site or next to midwifery-led units at Carlisle and Lancaster and converting the consultant-led units at Whitehaven and Barrow to become ‘free-standing’ midwifery-led units, which means they have no consultant obstetric services on site.

The report says that while this option increases the availability of skilled local midwifery care, when compared to Option 2a, there appeared to be little appetite for a ‘free-standing’ midwifery-led unit among women or staff. This option would need significant investment in midwifery training and leadership.

Three other options were included (see Notes to News Editors), none of which are recommended by the assessors.

The report recognises that for both Trusts staff recruitment and retention has been a huge problem. The most serious difficulties have been in recruiting to anaesthetics at West Cumberland Hospital and Cumberland Infirmary which has had a ‘serious impact on patient safety’. Difficulties in recruiting anaesthetists have also meant that at both Trusts some woman have not been able to have an epidural service.

It says that the range of choices for women in Cumbria could be improved by the development of Option 1. It also recognises that the geography, pockets of deprivation and poor transport infrastructure make decisions about service changes very difficult. It stresses the importance of engaging the community in the development of future arrangements.

Dr David Rogers, medical director of NHS Cumbria CCG said: “We are very grateful to Dr Falconer and his team for carrying out this review for us. We know how important maternity services are for the local population and the preferred option, Option 1, is consistent with the CCG’s commissioning intentions. However, these services need to be high quality, safe and sustainable and there is much work that needs to be done with both Trusts to overcome the significant challenges that they face.

“Clearly we will need to think about how we take into account the recommendations and any learning from the Kirkup report following the Morecambe Bay Investigation. We will also be sharing copies of the review report with Dr Bill Kirkup and with the team who will be carrying out the national review as announced recently by NHS England. We will also continue to talk to all local partners and the public.”

Dr Alex Gaw, chair of NHS Lancashire North CCG said: “This is a very comprehensive report which we hope will help us to resolve some of the difficult problems we have had in making sure that women and their babies receive the best possible maternity services with as much choice as possible. We now look forward to further discussions with our NHS colleagues, with local partners and the public.”

Dr Jeremy Rushmer, medical director at North Cumbria University Hospitals NHS Trust, said: “We welcome the publication of this report which clearly shows the review completed by the Royal College of Obstetricians and Gynaecologists on behalf of NHS Cumbria CCG has been wide ranging and comprehensive.

“As a Trust we have been very clear about our concerns relating to the sustainability of maternity services and these concerns are clearly reflected within this report.  This, alongside concerns raised by the Chief Inspector of Hospitals last year, instigated this independent review process. 

“We will now discuss the findings and recommendations with our Board and staff to understand their views and will work very closely with NHS Cumbria CCG as work progresses over the coming months on the recommendations.”

Dr David Walker, medical director, University Hospitals of Morecambe Bay NHS Foundation Trust said: “The Trust welcomes the publication of the Royal College of Obstetricians and Gynaecologists report into maternity services across Cumbria and North Lancashire.

“We are committed to providing a safe and effective maternity service in our hospitals, and we will now discuss the report with colleagues from our two local CCGs and from North Cumbria University Hospitals NHS Trust over the coming weeks to fully review and assess the report as a whole and understand its implications.

“The Trust has fully accepted the recently published Morecambe Bay Investigation report, and is committed to addressing all 18 recommendations in full. 

“Better Care Together has already announced its intention to offer consultant-led maternity services at Furness General Hospital and the Royal Lancaster Infirmary, with midwife-led services at Westmorland General Hospital – in line with the preferred option.”

Ends

For further information please contact: Rachel Chapman on 07803 790334 or Mark McAdam on 01768 245490 or 07775 113409.

Notes to News Editors:

1 The report from the Royal College of Obstetricians and Gynaecologists will be available on www.cumbriaccg.nhs.uk| from 10.30am on Wednesday 25 March 2015

2 NHS Cumbria CCG and NHS Lancashire North CCG

CCGs have responsibility for buying and planning the majority of hospital and community health services for their local populations. Such services include maternity care.

3 The independent review team

The team was led by Dr Anthony Falconer, former president of the Royal College of Obstetricians and Gynaecologists, who before his retirement was a consultant obstetrician at Plymouth Hospitals NHS Trust. The team included obstetricians, midwives, a paediatrician, an anaesthetist and a lay representative.

During their time in Cumbria and North Lancashire they met and spoke to almost 100 people involved with or with an interest in the provision of local maternity services. The majority were clinical staff working in maternity and related services such as paediatrics, surgery, anaesthetics and intensive care. They also met a number of GPs, representatives from the ambulance service, key people from the CCGs and North Cumbria University Hospitals NHS Trust and the University of Morecambe Bay NHS Foundation Trust, as well as members of patient groups, Cumbria County Council Health Scrutiny Committee and Healthwatch Cumbria. They also provided an opportunity for conversations with local MPs.

Six options were outlined by the RCOG. The first three (Option 1, Option 2a and Option 2b) are in the main body of the press release. The remaining three are as follows 

 Option 3 - Three consultant-led units at Carlisle, Lancaster and Whitehaven and developing on the same site or next to midwifery-led units at Carlisle and Lancaster. This would mean the closure of the consultant-led unit at Barrow and the relocation of services to Lancaster.

The report says that much has been invested in maintaining a consultant-led unit at Barrow and, despite the potential ramifications of the Kirkup report, there is a strong commitment to resolve the challenges. In addition, Barrow is a large conurbation with significant disadvantage. The assessors felt that closing this consultant-led unit would not be appropriate.

 Option 4 - Three consultant-led units at Carlisle, Lancaster and Barrow and developing on the same site or next to midwifery-led units at Carlisle and Lancaster. This would mean the closure of the consultant-led unit at Whitehaven and the relocation of services to Carlisle.

While the workforce challenges at Whitehaven are significant the report says that closure would create significant disruption for patients. Also, closing one consultant-led unit and not the other (ie Whitehaven as in Option 4 or Barrow as in Option 3) would not address all of the workforces issues and be seen as a skewing of service provision.

Option 5 - Centralising all services in one unit. While prior to their visit the assessors felt this was likely to be a preferred option, because of the benefits that such a larger unit with 5,000 deliveries would have for women and their babies, given the geography involved they did not think that this option could realistically be developed further.

5 Current maternity services across Cumbria and North Lancashire are provided by two trusts as follows:

North Cumbria University Hospitals NHS Trust

Consultant-led unit at Cumberland Infirmary, Carlisle (delivers around 1,640 babies a year)

Consultant-led unit at West Cumberland Hospital, Whitehaven (delivers around 1,290 babies a year)

Penrith Birthing Unit, which is midwifery-led and opens when a woman needs to give birth (delivers 22-30 babies a year)

University Hospitals of Morecambe Bay NHS Foundation Trust

Consultant-led unit at Royal Lancaster Infirmary (delivers around 1,994 babies a year)

Consultant-led unit at Furness General Hospital, Barrow (delivers around 1,000 babies a year)

Free-standing midwifery-led unit at Westmorland General Hospital, Kendal (delivers 165 to 204 babies a year).

6 Morecambe Bay Investigation

At the University Hospitals of Morecambe Bay NHS Foundation Trust there has been an investigation led by Dr Bill Kirkup to examine the standards of care received by mothers and babies in the maternity and neonatal service at University Hospitals of Morecambe Bay NHS Foundation Trust between 1 January 2004 and 30 June 2013.

The investigation report published early in March detailed 20 instances of significant failures of care in the Furness General Hospital maternity unit which may contributed to the deaths of three mothers and 16 babies. Different clinical care in these cases would have been expected to prevent the death of one mother and 11 babies.

The report said that the maternity unit was dysfunctional with serious problems in five main areas and made 44 recommendations for the Trust and the wider NHS aimed at ensuring the failings are properly recognised and acted upon.

The recommendations in the Kirkup report will be taken into consideration by NHS organisations in Cumbria and North Lancashire during their ongoing discussions about the independent report by the Royal College of Obstetricians and Gynaecologists.

7 National review of maternity services

Late in 2014 the NHS Five Year Forward View committed to a review of maternity services to ensure they develop in a safe, responsive and efficient manner.

Following the publication of the Kirkup report in March 2015, NHS England immediately announced the terms of reference for this national review which is expected to publish proposals by the end of the year. The review will seek to achieve three complementary objectives:

 First, review the UK and international evidence and make recommendations on safe and efficient models of maternity services, including midwife-led units

 Second, ensure that the NHS supports and enables women to make safe and appropriate choices of maternity care for them and their babies

 Third, support NHS staff including midwives to provide responsive care.

The terms of reference also said that in developing proposals, the review will pay particular attention to the challenges of achieving the above objectives in more geographically isolated areas, as highlighted in the Morecambe Bay Investigation report.

8 Better Care Together

Better Care Together is the review of health services which aims to improve care for communities across Morecambe Bay both now and in the future, in and out of hospital.

 

Posted on Wednesday 25th March 2015

 

 
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