East Sussex Maternity Services Liaison Committee

Presentation to HOSC7th June 2007

Small, Safe & Successful Obstetric Units

Richard HallettRos Vinall

Outline• Births – the correct numbers!

– maternity “not small and shrinking.”

• Clinical Skills Mix on Labour Wards– Consultants

– Specialist Registrars

– Senior House Officers (SHOs)

– Midwives

• Alternative Models Group

• Format for a meaningful consultation.

“Over the past eight years the number of babies delivered by East Sussex Hospitals NHS Trust has varied but there is no long-term growth.”

The Primary Care Trust say:

Only seven years statistics given, and many of those are wrong.

Birth numbers for 2006 omitted, even though available two months before start of consultation.

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500

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3500

4000

4500

Bir

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Eastbourne DGH Hastings Conquest Crowborough BC

Crowborough BC 253 265 284 326 330 294 319 316

Hastings Conquest 1727 1549 1520 1540 1579 1618 1624 1779

Eastbourne DGH 1658 1637 1619 1684 1853 1851 1843 1934

1999 2000 2001 2002 2003 2004 2005 2006

3638 3451 3423 35503762 3763 3786

4029

"Over the last six years (2001 to 2006) the number of babies delivered by East Sussex Hospitals NHS Trust has increased by

17.7%, reaching over 4000 for the first time ever in 2006"

The actual East Sussex birth numbers show that:

Total Births Surrey & Sussex, Kent & Medway By Trust 2003/2004 2004/2005 2005/2006Ashford & St Peters NHS Trust 3457 3626 3872Surrey & Sussex Healthcare NHS Trust 4131 3982 4074Brighton & Sussex University Hospitals NHS Trust 5671 5589 5627Royal Surrey County Hospital NHS Trust 3415 3166 3159Frimley Park Hospital NHS Foundation Trust 3985 4118 4016Worthing & Southlands Hospitals NHS Trust 2455 2606 2604Royal West Sussex NHS Trust 2017 2145 2396East Sussex Hospitals NHS trust 3796 3716 3908Dartford & Gravesham NHS Trust 2640 2659 2944East Kent Hospitals NHS Trust 6462 6477 6671Maidstone & Tunbridge Wells NHS Trust 4975 4784 4962The Medway NHS Trust 4280 4554 4275

Total 47284 47422 48508

Strategic Health Authority ViewConference on

MAPPING MATERNITY SERVICES 11th July 2006

There has been a steady increase in birth numbers across the strategic health authority from 2003 to 2006.

Strategic Health Authority - Mapping Maternity 11th July 2006

Total Births Kent, Surrey & Sussex

43780

47284 4742248508

40000

42000

44000

46000

48000

50000

Total Deliveries

2002 - 2003

2003 – 2004

2004 - 2005

2005 - 2006

Over capacity is not the problem.

Ensuring sufficient capacity is the crucial requirement.”

Maternity Services for East Sussex: Epidemological Needs Assessment (Page 6)

“The PCT’s own estimate is a 6% decline in the number of women of childbearing age. However their graph (below) also shows that

fertility (births per woman) has increased since 2001, which will partly offset this decline. The 8% decline in new babies quoted in

the consultation document (page 9) is wrong and misleading.”

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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- 6%

“Using the PCT’s own documented estimate of a maxium 6% decline in births, even ten years ahead there will be more births in East Sussex Hospitals than for every year shown in their consultation document.”

Midwife to Birth Ratio Surrey & Sussex by Trust 2003 - 2004 2004 - 2005 2005 - 2006Ashford & St Peters NHS Trust 01:50 01:41 01:35Surrey & Sussex Healthcare NHS Trust 01:35 01:44 01:40Brighton & Sussex University Hospitals NHS Trust 01:42 01:36 01:33Royal Surrey County Hospital NHS Trust 01:49 01:42 01:39Frimley Park Hospital NHS Foundation Trust 01:38 01:38 01:33Worthing & Southlands Hospitals NHS Trust 01:35 01:37 01:33The Royal West Sussex NHS Trust 01:28 01:31 01:31East Sussex Hospitals NHS Trust 01:32 01:29 01:37Midwife to Birth Ratio Kent & Medway by Trust 2003 - 2004 2004 - 2005 2005 - 2006Dartford & Gravesham NHS Trust 01:40 01:38 01:46East Kent Hospitals NHS Trust 01:35 01:35 01:35Maidstone & Tunbridge Wells NHS Trust 01:39 01:32

The Medway NHS Trust 01:39 01:43 01:33

Strategic Health Authority – Mapping Maternity Conference

“There has been a decline in Midwife to Birth ratio to 1:37 in East Sussex Hospitals from

2003 to 2006 to become 4th worst in SHA region”

Skills Mix on Labour WardsMedical Grades

• Consultants– fully qualified specialists– usually want to sub-specialise – teaching responsibilities– on-call typically 1:5 (actual call in may be 1:10)– will often have some private practice – labour ward presence (40 - 60 hours per week?)

• Specialist Registrars (SpR)– chosen speciality – generally registered obstetricians– provide 24 / 7 labour ward cover on rota

• Senior House Officers (SHO)– generally trainee doctors (may only be passing interest)– short term posts changing every few months– EWTD & Modernising Medical Careers (MMC)

ConsultantsExample:Indications for Consultant Attendance in Labour Ward, Queen Mother’s Hospital, Glasgow

General Points

• There are fixed Dedicated Consultant sessions weekdays from 08.30 hrs until 17.00hrs.

• A Consultant ward round of the labour ward area and South Wing should be performed on a daily basis including weekends and public holidays.

• A "business ward round" should be conducted first in order to ensure that the labour ward throughput is as efficient as possible. Thereafter the consultant may focus on certain cases or elements of care for teaching purposes.

• The Consultants role is NOT to be a second registrar. The middle grade Obstetrician should not be "bypassed" in anything other than major emergencies.

Specialist RegistrarsObstetrician continuous presence on labour ward

North Devon Hospitals Trust at Barnstaple • 1600 births per year (similar to Hastings)• 4 ‘RCOG recognised’ Specialist Registrars• provide 24/7 cover (168 hours per week)• there are 8736 hours per year• between 4 equates to 2184 hours each per year• over 45 weeks per year (holidays & training)• equates to 48.5 hours duty per week

North Devon Hospitals at Barnstaple- manage with 5 consultants- holiday cover efficient (one at a

time!)

Senior House Officers (SHO)– Ante-natal Clerking– Cannulation– Ventouse– Initial Resuscitation of Newborn– CTG interpretation (if near SpR level)– Discharge of High Risk Women– Fetal blood samples– First assistant at Caesarean

Labour Wards can reduce dependence on SHOs:

Under MMC SHOs will become Foundation Trainees

Need to reduce hours to EWTD

Can be replaced with Advanced Midwifery Practitioners

(AMP)

AMPs brings other benefits to skills mix on labour wards

SHO Role:

Advanced Midwifery Practitioners

Diana, Princess of Wales Hospital, Grimsby– are part of SHO rota– can do everything an SHO does– work closely with Specialist Registrar– provide continuity of stable, experienced staffing on first tier ‘medical’ rota– looking at managing without SHOs at night– CNST (risk management) requirements met– career opportunity for experienced midwives– lower cost than SHOs

Princess of Wales Hospital has caesarean section rate at 17%

Not being developed in East Sussex Hospitals Trust!

(MSLC) Recommendations for Consultation on East Sussex Maternity Services

Guiding Principles

1) ‘primae face’ removal of obstetric services from either Eastbourne or Hastings is a major and undesirable reduction in local choice for women.

2) before a single site option is proposed it is essential that every other option to retain two-town obstetrics services is properly explored

3) if a single site for obstetrics is the only viable option, then that option should be thoroughly prepared, fully funded, and implemented in a manageable time-frame.

March 2007

This consultation is limited to only one option: variations on a single site. But other safe options do exist.

• Single Site – East Sussex Hospitals preferred option

• Option 5 – campaign group option

• North Devon x 2 (Combined MW & Consultant Care)

• North Lincolnshire (AMP replace SHO)

“PCTs should provide details of all options for change, with well-balanced pros and cons for each option, in their consultation process.”

NHS Chief Exec, NHS Director of CommissioningService Improvement Letter. 28th February 2007

“All the options above have different advantages and disadvantages. Public consultation should obtain public feedback on the balance of these advantages and disadvantages.” East Sussex MSLC

PCT Alternative Models Group

• PCT ignored MSLC recommendations of March 2007• Significant pressure from Health Professionals & MSLC• Visit by MSLC Chair to North Devon & North Lincolnshire• “Other Options Evaluation” not carried out by PCT• Setting up an ‘Alternative Models Group’ - May 2007 • Effectively PCT admission of “black hole” in consultation • List of “initial questions to ask other trusts” - May 2007• Learning visits to other hospital trusts - June/July 2007?• End of consultation was 6th July 2007!!• Impossibly rushed timescale for evaluating other models• No mechanism for public consultation on other models

Obstetric Options in East Sussex(A Proposed Meaningful Format for Consultation )

Single Site Option 5 North Devon x 2

North Lincolnshire

Consultant hours on Labour Ward

40 hours?60 hours?

120 hours 40 hours 40 hours

Local Accessibility Low High High High

Operational Cost Existing + Higher Median Lower / Median

Enhancement of Midwifery Skills on Labour Wards

More difficult

More difficult

Good Very Strong

Opportunity for Consultant Sub-Specialisation

Better Good Lower Good

Dependence on Trainee Doctors (SHOs)

Median Low Median Low

Opportunity for Midwife Led Units co-located

Not proposed

Yes Combined MLU / CLU

Yes

Robustness of Income (Payment by Results)

At risk Strong Strong Strong

Retention of Hospital Core Services including A&E

Less Likely Essential Essential Essential

Recommendations to provide a genuine Public Consultation

• Stop the clock• Provide time for additional models group• Publish additional consultation on options• Restart the clock• Hold series of “debates in public” that deal

with complex issues.• Allow doctors and midwives ‘free speech’• Synchronise with adjacent area reviews• Review results of additional consultation• PCT Board decision

Richard Hallett• Co-chair of East Sussex Maternity Liaison Committee (MSLC)

• Chair of Eastbourne MSLC

• Co-chair of East Sussex Clinical Services Review of Maternity 2004

• Chair of Wiltshire Maternity Services Review 2005

• A Director of the Birth Centre Network UK

• Chair of Crowborough Maternity Unit Monitoring Group 1997-1999

• Member of User Involvement Sub-group for the National Service Framework on Maternity 2003

• Crowborough resident & father of 3

Ros Vinall• Co-chair of East Sussex Maternity Services Liaison Committee (MSLC)

• Chair of Hastings MSLC

• Qualified as Registered General Nurse

• NCT Breast-feeding Counsellor & Tutor

• Member of East Sussex Clinical Services Review of Maternity 2004

• Hastings area resident & mother of 3