East Sussex Maternity Services Liaison Committee Presentation to HOSC

1. Small, Safe & Successful Obstetric Units East Sussex Maternity Services Liaison Committee Presentation to HOSC 7th June 2007 Richard Hallett Ros Vinall

2. 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.

3. The Primary Care Trust say: “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.” 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.

4. The actual East Sussex birth numbers show that: "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"

5. Strategic Health Authority View Conference 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.

6. Strategic Health Authority - Mapping Maternity 11th July 2006 Over capacity is not the problem. Ensuring sufficient capacity is the crucial requirement.”

7. “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.” Maternity Services for East Sussex: Epidemological Needs Assessment (Page 6)

8. “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.”

9. 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”

10. 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)

11. Example: 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. Consultants

12. Specialist Registrars Obstetrician 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!)

13. Senior House Officers (SHO) SHO Role: • 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

14. 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!

15. (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 • 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

16. 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) “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 “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 Commissioning Service Improvement Letter. 28th February 2007

17. 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

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

19. 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

20. Ros Vinall Richard Hallett • 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 • 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