– 8th October 2013

Panel Members: Dr Charles Parker - GP Governing Body Member of the CCG Dr Ruth Roberts - Consultant Paediatrician, South Tees Hospitals NHS Foundation Trust Jill Moulton - Director of Services Strategy and Infrastructure, South Tees Hospital Foundation Trust Fran Toller - Divisional Manager for Women and Children’s Services

Facilitator: Good evening everyone, hopefully you can hear me alright. Welcome to the Leyburn Consultation event on Children and Maternity Services at The Friarage Hospital. I am Judith Bromfield and I’m Chief Officer of Richmondshire Council for Voluntary Services, a local charity and I’m pleased to be an independent Chair for the public meetings. Just before I say a little bit more about the conduct for the evening, can I just alert you to come housekeeping issues (TC: 00:00:36 – 00:00:51).

In terms of the format of the evening, hopefully you will all be able to have sight of an agenda with a pack on your seat. We will start off with a short video presentation which will tell you something about why the options are being proposed and clarifying what the options are. Following on from that there will be a question and answer session where you will be able to ask the panel questions and there are other people in the audience who should be able to respond if the panel aren’t able to.

Your panel this evening are Dr Charles Parker, he is a GP Governing Body Member of the CCG. Dr Ruth Roberts, Consultant Paediatrician, South Tees Hospitals NHS Foundation Trust and Jill Moulton, Director of Services, Strategy and Infrastructure at South Tees Hospitals NHS Foundation Trust. Quite long titles so bear with me. We will start by going straight into the video presentation.

(TC: 00:02:00 – 00:11:09 DVD presentation)

Can the panel come up and join me please? When you want to ask a question just indicate and hopefully you will catch my eye or I’ll note you. We are using microphones because we all want to hear the questions, but also because it’s been recorded so please wait until the microphone comes to you and if you say your name, if you are representing and organisation that would be helpful if you can tell us that as well.

This is the interesting part of the evening – the first question of the evening? I’ll ask the panel to introduce themselves.

Panel: I’m Jill Moulton, a Director at South Tees Hospitals. Hello I’m Ruth Roberts and I’m one of the Consultant Paediatricians at Friarage Hospital. I’m Charles Parker, I’m a GP and member of the Clinical Commissioning Group. Fran Toller, Divisional Manager for Women and Children’s Services at both The Friarage and James Cook and I’m also a Midwife.

F: Thank you. Yes at the back there if you can just wait for the microphone.

Audience: Hello, David Bowlam. I would just like to ask Fran. The whole maternity issue hinges on ‘high risk births’. What percentage of high risk births are there and what percentage of risk do you think that are low risk, will end up as high risk and thus needing transport to James Cook urgently? When we discussed all this five years ago, Yorkshire Ambulance – or was it TENYAS in those days? – they would ask for a quarter of a million to provide a specialist ambulance to cover this eventuality. And now they are saying that they want half a million. So, can you answer the high risk question?

P: Yes, I certainly can. We currently deliver about 1250 ladies at The Friarage Hospital and what we did as part of the exercise in preparation for what the options were, we looked at how many ladies had actually had a normal uneventful antenatal period, also had an uneventful labour episode as well of care, and also hadn’t requested something such as an epidural. Out of the 1250 ladies, there were approximately 500 women who are eligible to choose the Midwifery-led Unit at The Friarage should that be the option that was part of the engagement at the time. Of those 500 ladies, obviously people have a personal choice to make and not all 500 women irrelevant of being eligible to deliver in a Midwifery-led Unit will choose that. Ideally from our perspective we would want to see approximately 300 or more women delivering in that unit and that is because we want to maintain the skills and the competencies of the Midwives that work that and make that a truly viable option for the community really.

In relation to criteria, there is strict criteria that is chosen in order for women to be eligible for the Midwifery-led Unit. We monitor that they have no complications throughout their antenatal period and at the point of entry in labour and obviously, that means that we have got the safest starting point for the women in the unit anyway. But, I can’t deny that occasionally women need to transfer in labour from the Midwifery-led Unit to a high risk unit. In this case it would be to James Cook and we have been reassured that with support of the CCG and investment into the Ambulance Service, that I understand is around the bigger ambulance picture for the whole of the patch, that we will be guaranteed the inter-hospital transfer response time of eight minutes, which is the expected response time.

Does that answer your question?

A: Thanks, yes.

A: Just following on from what that gentleman said. There has been some transfer from James Cook to Friarage for deliveries because there has been no room at James Cook recently. You wouldn’t consider transferring low risk Middlesbrough ladies to The Friarage to keep your numbers up would you? Or would you?

P: In actual fact it is a choice that we can give all Middlesbrough ladies to actually deliver in the Midwifery-led Unit and at the moment because we have two sites in operation, we see ourselves as one service really. We happen to have two units that deliver at James Cook and at The Friarage and therefore obviously, if there is pressure on one site, then we do use both sites to transfer in both directions. I think you are right in that it is an option that we can give women in Middlesbrough as well to have a Midwifery-led Unit in a non co-located Midwifery-led Unit but there is also a Midwifery-led Unit at James Cook. So yes, it’s definitely an option that we would keep open and yes, it wouldn’t be just around keeping numbers up but it’s about giving patients a true opportunity and an option and choice really.

A: Just following up again from the gentleman’s question. He asked about the cost of moving the ladies over to James Cook. Have you had more cemented costs as I’m not sure I heard the answer to that?

P: I haven’t got a figure to give you at the moment but I know that we have made a commitment to support the Ambulance Service to provide extra cover around The Friarage Hospital for urgent transfers and we will monitor the use of that and how often it’s used and decide how much needs to be invested in the future.

A: And the lady just mentioned there about having ladies transferred over from James Cook to . Is that because there is a short fall in beds or something at James Cook and is there any plans to increase that at James Cook?

P: By nature, maternity services – if you look at the average number of ladies that we deliver or care for in any given month, it usually works out around the same each month but the true reality is that babies come in peaks and troughs so one day you can have 20 births and the next you might have two. That’s how it happens and that happens at both The Friarage site and at James Cook and indeed in every maternity unit in the country. When you get a peak of activity, if you’ve got a peak of activity in one unit that you manage and not in the other, your common sense says to give everybody an equal experience, you try to use both of those facilities to the best advantage. There are times where both units might end up with a surge of deliveries and need for care that does mean that you outstrip the bed capacity that you have in one of the sites and that is why we also do transfers.

You are absolutely right, that then begs the question ‘where would we transfer ladies if at the point that we had one of those sites that wasn’t operating in that way?’ Well the answer to that is that we have to build extra capacity at the James Cook site and put more bed facilities in and put more labour facilities in. In actual fact, we also need to put another Theatre in for Caesarean Sections as well but we need to do that anyway without any transfer of The Friarage site. So, that is the only area that we are doing a build if you TC:00:20:00 like to provide that Theatre but we have to do that as an organisation whether anymore deliveries come to James Cook or not because the birth rate has grown in the Middlesbrough catchment. So that increase in beds and facilities will make sure that it allows for the peaks and troughs of the workload in the totality of what would come from The Friarage and also what already happens at James Cook.

A: Just out of curiosity, do you know how much that is going to cost to put in place?

P: I think it’s difficult to put a precise figure on it because to some extent it’s still a work in progress. The biggest element of the cost, as Fran said, is the Theatre and that means that we are converting and existing space next to our existing Theatres and the approximate cost of that is about £1million. Now the other things are really cutting and changing bits of accommodation which is lower cost. I can’t give you the total of that but £1million is the biggest element for the Theatre.

F: Thank you. The lady over here?

A: When they are considering about the ambulance transfer times and things, if somebody is high risk and isn’t able to book for The Friarage Hospital and they are going to have to go further afield, will the ambulance be taking into account that there may be more women using the services just to get there safely really. A lot of the time it won’t be very safe for the husbands to drive from up at Hawes or around this area if they are having to travel further. If some of them are high risk but have still had rapid births so it can be quite a dangerous journey trying to get there really.

P: Unfortunately we haven’t got anyone from the Ambulance Service here but most people actually do transfer in labour in their own domestic vehicles, it’s not an Ambulance Service job for the majority of time. Yes, there are occasional times when it is needed….

A: I think it will increase though if this happens because sometimes – I’m actually a Community Midwife and sometimes I feel that I will be needing to recommend to the woman that she should – because I hear some stories of them trying to rush in and the husband is trying to drive like a lunatic and if they have got to go even further to get there, they are not just going to The Friarage, then sometimes we are going to have to recommend that they go by ambulance so it’s just something else to consider when the ambulance are considering the pressure that they are going to be under.

P: It’s certainly something that we need to consider and as I said, unfortunately the Ambulance Service isn’t here but yes, we have considered that and for the most part, that would be a small number of ladies but we will keep an eye on that and plan for that.

A: Geoffrey Lenahan, Hampton Parish Council. One of your factsheets shows the potential impact on other Womens Service Gynaecology, if you have the Midwife-led services it says in here that some of the Gynaecological Services will be dropped from The Friarage. Is that correct or can you enlarge on that?

P: Most of the Gynaecology Services that are delivered in The Friarage, the vast majority of it is actually delivered in outpatients and that is both in visits and in procedures. So, Gynaecology is very much an out-patient type of facility now and all of that facility will be retained at The Friarage. We also then have a very high level of day case and 23 hour surgery and all of that will stay at The Friarage as well. There will be a small proportion of women who currently stay overnight at The Friarage with complex conditions and that is the group that may need to transfer to James Cook. But that isn’t even one lady a day; it’s a very small number. Everything else will be supported within The Friarage site. We already send very high risk complex cancers and things like that for example, they already go to James Cook and historically that has happened because of the development of cancer networks and the changes in the way that we manage patients with cancer. So, really it’s a very small number of women with complex or morbidities that may need to go to James Cook and have an overnight stay. All of the rest of Gynaecology will be retained at The Friarage.

P: You mentioned earlier that the numbers that you were hoping for would be 300+ a year at The Friarage. It strikes me as quite a small number. Is that actually kind of sustainable or is that the kind of numbers that a few years down the line might be the fuel for an argument that says that actually it isn’t a big enough service to keep and eventually we will lose all of it?

F: The first thing I would say is that I can answer that question based on the national guidance and the national evidence and the current requirements that we have to abide by in the delivery of maternity services. It’s probably important to say that that does change over time and the way you are monitored and assessed and expected to deliver and the skills you are expected to have in a unit has changed in the past 10 years quite considerably. I can’t guarantee that that won’t change again over the next 10 years. The reason why I say 300 is that what you will find is most Maternity Units or Midwifery-led Units that deliver about 300-350 women consistently every year seem to be fairly sustainable on the grounds of, you are getting a delivery every day, you’ve got a regular client group, it helps you to maintain the skill set of your staff. It keeps a vibrant unit. If it drops way below that, then no I couldn’t guarantee that the long term sustainability of the unit, but we would have to come back out and talk to the public again if that happened. But, with the option of being able to choose already, 500 women who are eligible then the important thing is about how, as a group of service providers, we provide information to make that a true choice for women to make sure that people feel comfortable with that choice and that we don’t lose that opportunity to the public by people saying that ‘it’s not safe’ or ‘what happens if?’ because all of the research evidence will tell you that as long as you very carefully select the lady, you very carefully monitor her through the antenatal period, you have highly skilled staff who monitor carefully during labour, you’re outcomes in a Midwifery-led Unit are exactly the same and just as safe as an Obstetric Unit.

That’s a really important message to get out to the public and really that’s the onus is on us to make sure that when a lady books for her care, we sell that service really and make sure that we maintain as much of a vibrant unit as we can. But we need people to use it and make that true choice.

A: Can I ask has any calculation been put into the calculations that you’ve worked out for who will use the unit for the increase in people at places like Catterick Camp. All the soldiers that will be coming from there. A lot of young families maybe having more families. There is a lot of housing being earmarked for this area for Leyburn, for Richmond, for Catterick. This is going to increase the demand I would expect on your unit. Has any calculation been done for that?

P: We were asked that quite a lot during the engagement phase and I know the CCG has done quite a lot of work and actually talked to the Garrison. The development of the Garrison, as I understand it, and Charles may know more, is very gradual so over the next 15 years, there will be a growth. But actually 15 years in Health Service terms is a very long time so in the immediate future the growth will be fairly small and translating that into a number of births and a number of children actually, it’s not a huge difference in the planning period that we are looking at. But the CCG did respond to those engagement questions and did do quite a lot of investigation I think.

P: Our understanding is that the growth at Catterick will be substantially training units at first and they will be single men at the training units. The vast majority won’t have partners and won’t have children and that’s going to be growth area to begin with.

A: In the video it mentions about the steady degradation of the quality of the services if it’s been left as is. Do you have any – where is The Friarage at the moment in terms of its rating or whatever and are we seeing that now?

P: I can start to answer that if that’s ok? At the moment I think we are fine but what we do TC:00:30:00 know is that we don’t meet national standards. So, a couple of years ago the Royal College of Paediatrics and Child Health set a standard of what they expected for all Children’s Units. And there is similar guidance for Obstetrics as well and what we know is that we come nowhere near meeting that. Now, for example it recommends that there will be 10 Consultants and there must be middle-grade staff so we just have a very Junior Doctor and a Consultant. The Consultants on-call so that mean that they are not permanently in the hospital. So, we know that we don’t meet those standards and we are actually the only Paediatric Unit in England that doesn’t have a resident second tier. So, we haven’t had any problems but we just feel that we are not prepared to sit back and wait until we do. We don’t want to have people sitting and working in something and having a situation like what happened at Mid-Staffs, we want to make sure that we modernise our services and make sure that they are safe and modern and what people expect.

P: Perhaps just to add to that and say, of course we have already had a problem with the unit back in 2009 which came about because – well it wasn’t just limited to The Friarage but it was about the whole Paediatric staffing but the result of that was that we couldn’t reliably staff that unit and last summer in the Obstetric Unit we had gaps right across the Obstetric rota which meant that we had Obstetricians who were having to do their day job and then come in and night and essentially be their own Registrars. So they were sleeping in the hospital and as a Board of the Trust, we have got to stand back from that and say, ‘is that safe and acceptable?’ and we came pretty near last year to feeling that that wasn’t acceptable and this whole exercise is about making the change before we get into a situation where a service is unsafe because we can’t offer that as a Trust and the CCG can’t commission that as a service so it’s about looking forward and making a rational planned change and that’s also based on us saying, ‘could we sustain the service as it is safely?’ The whole basis of having this conversation was that we concluded and the CCG supported that unfortunately we couldn’t, hence the options that we have put forward.

A: And how does the situation at James Cook compare to that in terms of standards?

P: It’s a bigger unit so in terms of staffing, it’s not to say that we don’t have problems because we do have problems on occasion in terms of trainees and vacancies, but when you have got that bigger team, it’s easier to box and make sure that you can actually achieve that degree of sustainability. The difficulty is, is that we have got to do exactly the same for The Friarage really as we do for James Cook and that’s becoming increasingly difficult and as Ruth says, as the standards move on, really what we need to guarantee is that any child and any mother that does into that unit has access to a Consultant 24 hours a day. With the way that the staffing is currently put together, that’s very difficult to achieve on a consistent basis.

F: Thank you. The lady at the back.

A: I appreciate that this meeting is really to do with the Midwifery Unit etc. but you did mention that services have to be good almost as a general. So, what else at The Friarage is not up to standard and what will you be considering closing next?

P: We look very carefully at The Friarage as a whole. If we thought that a service was in the same position as the two services that we are talking about, we would be saying to the CCG that we need to go through the same exercise. At the moment we’ve got very specific situation with these two services which has led us over the last two years to be having those conversations. We are not having the same conversation about other services with the CCG at the moment but we are having, and we are continuously do have a conversation with the CCG, about how we need to change small elements of service in order to keep them safe. I think it’s fair to say that if you think of some of the problems that we have outlined for Paediatrics and Obstetrics, other services at James Cook, at The Friarage, frankly at Darlington Memorial, at , at Harrogate are facing the same issue. What it’s incumbent on us to do with the CCGs in all of those areas is to keep on talking and find ways in which we can maintain as much possible local access to services as we possibly can.

So, if you are saying, ‘is this the thin end of the wedge and will we be back next month saying that something else is changing?’ that isn’t under discussion at all and you can have confidence that the services that you rely on at The Friarage will continue to be there. If you were to say to me, ‘over the next five years, will The Friarage be exactly the same as it is now?’ I think the answer will probably be ‘no’ because the national guidance will move on and some of the problems that we experience in terms of staffing will affect other services and we will have to think about how we respond but that will always be done through this same sort of process and engagement with particularly local GPs.

A: I think the problem in that is that it is all very well having meetings and having ‘supposed’ consultation and I do put that word in inverted commas because certainly I get the impression that on this Paediatrician business, that really you have made your mind up before you ever came and the last meeting here I remember as being quite a heated meeting and people who live high up the Dale were seriously worried about what would happen to them if they had a problem. Now, it may not mean much to you because you’ve got a lot of other things on your plate, but it means a hell of a lot to a young women, stuck up in Hawes or Gayle and I would say also that if you are going to have these consultation things, only come and get the public interested if you really want our views and our opinions because as I believe, a lot of people protested about this. I appreciate what you are saying there that things had to change, but I’m just wondering how much you really took on board the serious fears of people?

P: Genuinely we do come out and we’ve done an awful lot of engagement, we spent an awful lot of last summer talking to people. I think the CCG, to give them a pat on the back, have done an excellent job trying to get information out, trying to find different ways of talking to people and especially young people and the people who are most affected by the service. I think a lot of the things that we have heard are about transport, particularly it’s about certain groups of patients, the DVD talked about the open access patients and the planning that the CCG are doing for the future very much will take on board those sorts of concerns. But I think it comes down to the core issue. Is this a consultation? Yes absolutely it’s a consultation because at the end of this, the CCG have to make a decision. They’ve got to make a decision based on everything that they have heard through this process. But I think the difficulty that we have getting across is that there has to be a change, we believed as a group of Managers and Clinicians when we engage in the conversation that there had to be change, we didn’t have a closed mind particularly about what that change was but the CCG brought in national people who spent a lot of time talking to other hospitals and they concurred with us that there has to be a change. So, a consultation then becomes about the nature of the change doesn’t it? Rather than whether a change takes place at all. Obviously what we have heard from other people is that they don’t like change and they don’t want change and that’s fully understandable, but unfortunately, that’s not the position that we find ourselves in where we can honestly stand up and say that no change is an option for the future.

P: I think Jill has said a lot of what I wanted to say but I just wanted to emphasise that although we’ve got two big organisations involved in these changes, for me, I’m a local Paediatrician and I work at Friarage that’s my job, that’s what I do and I don’t under estimate the impact and the fear that it may create for families out here and up in Hawes. I really don’t. They are families that I work with all the time. However, I feel that I owe it to our families to make sure that we are providing a safe and up to date service and I have no doubt that a change is the right thing to do. Scary though it is. It’s very scary for me because my whole job will change but I’ve no doubt it’s the right thing.

P: Can I just say that it sounds like we are taking everything away from The Friarage all the time and actually that isn’t our intention, we want to bolster the services there, the ones that we can keep and expand. There is specialist surgery that happens at The Friarage that doesn’t happen at James Cook and patients from Middlesbrough have to come down so we are looking at expanding the Paediatrics Out-patient services so that more children get TC:00:40:00 seen locally and don’t have to travel as far to be seen. We are looking at expanding the specialist Paediatric Nurses so more children will be treated at home rather than having to go into hospital. So, these services we are looking to expand and not just retract all the time.

A: I came to the consultation, ‘so called’, when The Friarage was going to be joined with James Cook and we were assured at that time how wonderful this was going to be. The Friarage would get all this expertise from the James Cook; it was going to be an absolutely superb centre. Not true. It hasn’t happened.

P: Can I take issue with that? Actually it has happened. I was part of that consultation. I sat here in 2001 or 2002 so I was one of the people saying that and actually if you look at what happens in The Friarage compared to what happened in 2002, there is no comparison actually in the range of services that are offered and frankly in the quality of some of the services and the hard truth is that if that merger hadn’t happened in 2002, The Friarage wouldn’t be operating as a hospital because frankly it needed to join with a bigger centre, with a bigger pool of Doctors with more expertise so that there could be what we call ‘peer reviews’ instead of one or two Doctors. Some of the specialties, Cardiology was one Doctor. Actually in isolation really from any of his colleagues. Now there are specialist Cardiologists, three of four who come down the Friarage and offer services and as a result you are tied into a much higher level of service than you ever have had before. And I don’t know how we get this across to people. I think there is this perception that somehow, since it merged with James Cook – you know, before it was the land of milk and honey and since then it’s gone downhill and it really hasn’t. People will have individual experiences of the hospital, but it’s a much busier hospital and it offers a much broader range of services than it ever would as a standalone hospital in its own right.

A: Well, it is our hospital and we are the tax payers and we do pay for it and my feeling is that we should get what we want and not what you want to give us and what particularly with the Maternity Units, what the young mothers and fathers want. That should be your role doing that, not putting forward something else or two other options which are what you want to put forward.

P: Can I just answer that? I think that I absolutely understand where you are coming from in relation to the fact that the hospital is part of the community and very much seen as part of the community and from a hospital perspective, we really appreciate that. It’s actually the community that makes the hospital. Without the community we wouldn’t need a hospital would we in the first place? However, from a ladies perspective, when you have your baby the absolute pinnacle of what you want is that you want to walk out a fit and well woman with a lovely healthy baby in your arms who, if there was a problem, has had the right people with the right skills to care for you and to care for your baby. The onus is on us to ensure that we can provide that and if we can’t then we shouldn’t provide that service no matter how much people want to have that service locally and how much they want to have it at The Friarage Hospital. The safety of that mum and baby has to come first and sadly we are at a cross roads where going into the future, we cannot guarantee the safety of that mum and baby and unfortunately, if you go back 20 or 30 years, the expected outcomes for mothers and babies was grossly different to the expected outcomes that we expect today, which is all for the better for the community because within your community you want healthy mums, healthy baby and healthy children. So, the onus is then on us to make sure that we provide that.

Units that don’t do that hit the headlines. Lots of you will have read headlines about what has gone on at Mid-Staffordshire Hospital. Not in Maternity, I have to say, but there are units where there have been maternity issues. Anybody who wants to read up on it on the internet, one big Maternity Unit was a place call Northwick Park and another unit that is currently under review is Barrow-in-Furness. I don’t want to ever sit here saying that we have put the lives of mothers and babies at risk because we didn’t want to close the unit because patients wanted it to be local. Because, that’s the wrong end of that equation really and that’s the difficulty we have got and that’s the difficulty we have got in providing an option that people might want. But in actual fact, it’s unsafe and nobody wants to be unsafe. That’s the dilemma we have got and why we are presenting the two options because we know going forward that we can maintain the skills, maintain the safety, maintain healthy outcomes for mothers, babies and children and make those sustainable and robust for what we can see is the future for particularly, medical staffing requirements because that is a big component of the whole problem that we have got which is nationally driven. It’s not unique to us, lots of units are having the same discussion.

F: Thank you. Anything to come back on?

A: So, what we are saying is that expectations are much higher now, child mortality rates are much lower, we need the expertise so the world has moved on and we need to move on with it unless you want to stay in the old emergency ward days, which is very nice and quaint but the world has moved on and I think people expect a better service now. They expect to live longer and they expect their medical services to be first class.

P: Absolutely, that’s exactly what I’m saying.

A: Is there anything specific that prevents the Consultants being shared across the hospitals in a kind of ‘on-call’ basis so effectively moving the Consultants between the hospitals instead of the pregnant ladies?

P: I can talk about that in Paediatrics but that does exist already in Obstetrics so people work across both sites and we also do that in Paediatrics. We have a base core of mainly Friarage Consultants which I am one in Paediatrics but we do work on both sites because one of our problems is that low throughput of patients means that you maybe don’t see many sick patients with certain conditions. So, we do a certain amount of weeks up at James Cook but the Obstetrics Team are very integrated and do quite a bit of time on both sites to support both units but to also ensure staff maintain skills really. But yes, I think that is definitely a vitally important way to maintain skills for Friarage.

P: Can I just add to that if what you are suggesting is ‘why can’t we rotate the existing group of staff to keep the existing services open at The Friarage?’ It’s a question that we have been asked a lot and it’s something that we looked at at the very beginning of this exercise. The difficulty is that we have got just enough staff at James Cook to run the hospital as it is. It’s a busy unit we’ve got about the right number of hours there. The difficulty at The Friarage is if we are going to run it in accordance with modern standards and keep it safe, we need an awful lot more medical time to do that because as the moment, as Ruth has outlined, after normal working hours which are extendable, but after the end of the normal working day the only people in the hospital are Junior Doctors, only medics in the hospital at Junior Doctors with a Consultant available at home. That is unique. There is no other hospital in the country that works like that so we need another tier of Doctors overnight and overnight is actually two thirds of the day. Working hours are 9-5 so you need a massive expansion in the amount of medical time that is required in order to be able to run the services effectively. Which is why, when we looked at this option during the engagement, we came up with an apparently ludicrous sum of money, you know £2.3million but that’s because you need to move and appoint something like 12 extra Consultants to cover the Obstetric and the Paediatric Units. So actually, just moving the existing resource around and asking people to cover doesn’t work. You need the Doctors at James Cook and you need more Doctors at The Friarage to meet the standards that are needed for safe delivery.

A: Thanks, yes I think it was quotes at £2.7million but is that an independent body that has come up with that figure or where has that come from and has that been verified in any TC:00:50:00 form?

P: It’s our calculation but in coming to that number but in the instigation of Councillor Blackey who at the time was instrumental in the Scrutiny Committee, he wanted us to go to Banbury Hospital where they have done more or less what I am talking about in Paediatrics they have moved to a fully Consultant delivered service and they were also in the process of changing their Obstetric Service and actually, they had spent closer to £4million on a recurring basis as they had also had to shore up their Anaesthetics Service as well. I also talked to the Royal Free Hospital who have got a similar arrangement in place who were spending similar sums of money. And actually, it’s a fairly basic calculation. You work out how many hours you need, you translate that into bodies and you multiply it by the current pay rate so it’s a very transparent calculation and yes, we have checked that with other units who actually do run the services in that way. I’m afraid it’s not outlandish.

A: Were they in a different circumstance then, how come they got the money and we haven’t got the money?

P: I think they were in a different circumstance in that they all wanted to do what we are doing. The Royal Free is slightly different because it’s a London based hospital but certainly Banbury wanted to move to an Assessment Unit and a Midwifery-led Unit and frankly, they didn’t do it very well and they had knowledge that they didn’t do it very well and they didn’t talk to their GP’s the PCT at the time and they just got themselves into a bit of a difficult situation really. Their local MP is David Cameron and they ended up in a situation where essentially they were told that they needed to appoint these Doctors. If you get the Clinical Team to one side and talk about it they are very unhappy because actually they have got Doctors who spend a lot of their working hours at night in a very quiet environment and they are really worried with how they keep up their skills. And as to where the money came from, frankly the PCT had to divert resources from other things into propping up what is frankly a really strange way of running a service. They have started another review now, another public engagement exercise to think about how they actually unpick that and move to something like they wanted in the first place.

A: You’ve got very compartmentalised various people into high risk and low risk, this sort of thing. Obviously as we have said already there can be various instances where somebody is low risk and complications occur and have to be transferred and for all the eight minutes that have been quotes plus transfer time, it’s going to be at least an hour before somebody is transferred from The Friarage to James Cook. Has there been any work done on the increased risk to the patients that this will cause?

P: There is actually no evidence or very little evidence in relation to literature or research in relation to distances increase or decrease somebodies risk of a complication or problems. Most of the work that has been done about distances travelled is actually to do with Trauma patients, it’s not to do with maternity related patients and most of that research says that, whilst there is an increased distance, in actual fact to get into the right place first time with the right set of skills gives you better outcomes. That was actually the whole basis of the national review of who retained Trauma status and why they removed Trauma status from some of what was then District General Hospitals and concentrated it in a few main hospitals. So, that is the research that is out there. Other than that, there is actually very little research. There is hardly any research at all around Midwifery in relation to transfers. The research that there is, is really around numbers of patients and the sense of patients that you can expect to transfer from a Midwifery-led Unit to a main unit and that is different depending on whether you are having your first baby or second or subsequent babies. So, yes there is research out there, but its application to Midwifery is quite limited really. But there are greater distances than we are proposing.

Can I just come back and answer a question that this gentleman raised? Just because you identify how did we check some of these, there is a college document – a Royal College of Paediatrics document – called ‘Facing the Future’ and within that document it clearly does set out the minimum number of requirements that you are expected to deliver in relation to what Ruth talked about earlier about junior grades, middle grade people who should be in the building and Consultants. That is very readable and it’s very clear on what the numbers are, so all of the numbers that we have come up with fit very clearly with that Royal College guidance. But also in the Royal College guidance it explains because of the national workforce changes, the expectation of what units should deliver in relation to who should have in-patient Paediatric Units, who should have Assessment Units and who should only deliver Children’s’ Out-Patient Services and the way that they calculate that is based on the number of episodes of care that currently go in within units and your population size. But also, whether you are in close proximity to a main unit or you are distal from a main unit. Now, The Friarage at the minute in relation to Children’s Services sits on a cusp really and if we went with the true letter of word of the recommendation, the choice that we would make is to have a Paediatric Out-Patient model only. To not have In-Patients or an Assessment Unit. But, part of the listening exercise when we talked to the public about concerns around children, particularly children who have what we call ‘open access’, which are children who have long term conditions who need to come back on a repetitive basis and also because we were at the cusp of whether the distance from the main unit, we chose and the preferred option therefore chosen was an Assessment unit. So, whilst people think that we haven’t listened the true reality is that we have listened and we are prepared to not just follow the letter of the Royal College guidance but to accept that we are on a cusp and the public want us to offer as much as we can locally. That is why some of those options have come up. The delivery of a full in-patient service to cover Obstetrics is very clearly laid out within that document. If you wanted to look at ‘Facing the Future’ it’s on the Royal College website if you just pop it in its easily accessible.

A: Just in relation to the gentleman’s point about the increased risk from travel and you were mentioning that there wasn’t much research out there in terms of Midwifery and all that, do we not think that it’s important to do that research and to find out the sums on the increased risk from the distance travelled. Surely that is the whole point to decrease risk of problems in birth in taking it to James Cook, so isn’t it absolutely imperative to get the research to find out what is the other end of the balance in terms of the increased distance?

P: Ideally from a clinical perspective I would absolutely agree with you but I think it’s important to note that we can’t do that research, it needs to be a nationally led piece of research that looks at transfer of women in labour from Midwifery-led Units all over the country which would have to correlate between reason for transfer and distance to travel. What I would say is that there is a lot of research out there on Midwifery-led Units and the safety of Midwifery-led Units and built into that safety is obviously the understanding that there are per cents of women who transfer in labour and going back to my first point about ensuring that you have a good access criteria, that you clearly communicate that with the lady, that you monitor throughout the antenatal period and at the point of entry in labour, that you have highly skilled Midwives who are constantly monitoring in labour for any signs of deviations from what we would consider to be normal and choose early transfer. Then your outcome in a Midwifery-led Unit is just as safe as anywhere else that you could deliver. The same would apply to home birth in TC:01:00:00 actual fact, that’s why we still offer home-birth as an option and yet, when we have a discussion about home birth, people don’t sit and suddenly say ‘well what about the transport?’ The important thing is early detection and then the reliance upon the support service to quickly attend the unit so in this case the ambulance, attending the unit in eight minutes and early transfer to the unit. They are the things and they are all very well researched and they are very clearly researched right across the country for decades, which has happened. Obviously in that mix is all outcomes of women who entered a Midwifery-led Unit whether they transferred or not.

What they don’t look at is distance in isolation and I don’t know why that hasn’t been done. I can’t answer that but we can’t do that research because it wouldn’t tell us anything. The only thing I can say to you is, when we temporarily shut last time and what will happen this time, is that every transfer will be subject to a full review. So, you will look at everything that happened to that lady from the minute she booked to have her baby right up until she went and delivered at whatever unit she delivered at if a transfer was involved. Every Midwifery-led Unit does that and looks at its outcomes.

P: Could I just come in with a little bit about Paediatrics and transfer times because I think that might be something that is worrying people? It’s interesting when we talked briefly about mortality figures and outcomes earlier in the evening and in fact, when we look at mortality figures in the UK, we score poorly against the rest of the world and Europe and we are way down the league tables, even in Europe. Some countries we might guess will do better but other countries you wouldn’t guess actually do better than we do and the reason for that is centralisation of care. Having fewer hospitals but Specialist Children’s Hospitals definitely improve the outcome. So, although our gut feeling is travelling further for your care is a bad thing, that is not born of out with evidence for children and actually the evidence is that if you centralise into more specialist units, the outcome of ‘will you live or will you die’ is better.

F: The lady at the back.

A: I think a lot of people in this area have great faith in the Paramedics, the ones that come out of the Leyburn surgery in particular. Would there be any merit in increasing the number of Paramedics so that if there was a problem higher up the Dale, a Paramedic could get there rather than bounce somebody all the way to James Cook?

P: We have been looking at the use of Paramedics and in fact there are extra Paramedics going to Health Centre very similar to the system that works out of Leyburn. We have also looked at the Paramedics when they attend the patient, being able to refer that patient to their own GP for care, should they not need a transfer and saving an unnecessary transfer down to Accident and Emergency. Those two systems are working well at present.

A: I don’t think you quite answered my question. Are there any plans to increase the number of Paramedics?

P: I said that we had increased the number just recently within the last two months there has been an extra Paramedic gone into Catterick Garrison Health Centre. That is under review and if we think that we need more, we will put more in.

F: Thank you. Lady at the front.

P: Two comments really. First of all I think that nobody has actually thanked you for this opportunity tonight and coming and giving us a chance to take part in the consultation. Perhaps not everyone in the room shares the view about the worthiness of the consultation and how it has been conducted but a lot of people do, so thank you for that. Would you like to say about a little bit more on page 16 of the document, you say ‘what next’? It’s a very short section and it only refers to a decision needing to be taken in January. Having made a decision ‘what happens next’, what sort of timescales are we looking at for changes, will there be some opportunities for review of the decisions taken, what will that review be based on and what’s the strategy for you know, modifying anything that is decided upon?

P: Remind me as I go through. We are making a note of all the comments that have come out tonight, looking at the weaknesses and we have had several pointed out to us and we are working on those and improving those. We are duty bound to reassess all ideas that are given to us and we are expecting a couple of ideas to come through for us to reassess and compare with our existing options and we will assess those in the same way that we assess the original options and we will get all the GPs together and go through that. So there will be an assessment process on that. Once we have completed that process and we come up with a report, that will be given to the Overview and Scrutiny Committee at the Local Authority and they will look at that and scrutinise it and come back with questions and take it from there.

A: But then including implementing it?

P: But then I will hand over to Jill.

P: In terms of implementation there is the consultation process to go through. I think, looking at Fran that we probably need four or five months after a firm decision has been taken actually to make the change, partly for practical reasons and also because we need to do some communication and education with people so that they understand the nature of the change. But we need enough time to do that but we don’t want it to be so extended because I think that would be difficult for staff working in a unit that they know….and also confusing for the public once or if the change is going to be made, I think that we need to get there is a fairly timely manner so I would have thought five months or so.

P: I haven’t got anything more to say around that really but obviously one of the key factors is that at any given time we have a high number of women who are on-going within their pregnancy and part of the exercise will be that we need to see every one of those ladies to offer them the choice to change their place of labour really. And that is quite an extensive process. We also need to do some work and consultation with our staff as well so that staff know what is going to happen, who is going to be in the Midwifery-led Unit, who might need to change where they work and be in the Obstetric Unit at James Cook. Do we need to develop some skill sets, how are things going to function and be very clear about that. So, that just takes a bit of time really and I think it’s important that we do that right because what we don’t want is to change the service and then end up with a high risk Obstetric patient coming to the wrong unit and ending up being at risk because we haven’t communicated clearly. So, it’s a massive communication exercise, but Jill is absolutely right, we equally don’t want a massive longevity on that because what we will end up having in it is that we will be expecting ladies to come and deliver who have suddenly done their own thing and gone and changed her place of labour anyway or gone to the wrong unit or didn’t realise what choices she had or equally, it’s important that we sustain and make sure that our staff know what is happening and what you don’t want is staff to become demoralised and not sure what is happening and not be in a position to be able to communicate that clearly with their patients.

So, I think the true reality of it is that it will be somewhere between four and six months from the definite decision that is made until the point that services actually close. We may do that gradually, we may do that whole scale and that hasn’t been truly decided but I think that one of the important things to note is that is assuming we get that decision quite quickly. What we don’t know is whether there will be a second request for any independent review really and that might delay. So, I guess we are talking next summer at the earliest.

A: Ok thank you that is helpful but none of you have quite answered all of it because I think that kind of gets you to the ‘get-go’ and you know hopefully at that stage you have got it all right and all your ducks in a row. I think people would be actually reassured to know what then happens after that. So, you get the new arrangement in place and the services are operating. I think people want reassurance that this is something that is going to be monitored and reviewed because the whole performance management of all of this is something that needs to be constantly revisited so can we have a bit more about that please?

P: I think obviously there are two different services that are changing. So, if we start with the TC:01:10:00 Midwifery Service that will change. One of the things that we will definitely be putting in place immediately in the Midwifery-led Unit right from day one will be monitoring patient experience throughout that process because what we need to make sure is that Midwifery-led Unit is delivering the service that patients expect. I’ve already talked about we will be putting a process in that will be both from a patient perspective and a full clinical review of any patient that is required to transfer in labour so that we are constantly learning lessons on that. We also will have regular contact with the Ambulance Service to make sure that that key arrangement is working and the usual way that we manage is that is that we pull all of that information together and that is produced in part of our Governance Network in quarterly reports. Those quarterly reports currently go via our Governance Network ultimately to the Board and that information is available to the public once it’s at Board level so that information would be out there. We also have to make sure that patients who are choosing James Cook are finding simple things like travel arrangements satisfactory, that they are finding their way around because we have had some concerns expressed around that, so we also need to monitor that arrangement. But also some patients will be choosing to go to Darlington, they will have arrangements similar to ours in place because in actual fact that whole Governance arrangement is a nationally required expectation at Maternity Units.

In relation to Children’s Services, then obviously we will be monitoring the satisfaction of families going through the Assessment Unit. We will also be monitoring the use of the Assessment Unit and making sure that we are maintaining skills for our team and what’s coming there and what’s going elsewhere really. Monitoring, you know the impact again at James Cook, making sure that we are amended rotas. I believe that we will adapt and amend consistently probably throughout the first twelve months to get it absolutely the best quality service that we can deliver to the public and it’s important that we do those quarterly reports and we brief people back because I think one of the things that we have taken away from both engagement and this consultation process is that we come and tell you when things are a problem and what we need to do about it, we don’t come and tell you when things are great and what’s working well and what service we are adapting and what services we are putting back into the service. I think that probably, we need to make sure that we find a way of doing that, whether we use the Press to do that, whether the CCG come up with some type of formal process to do that. We certainly…part of our scrutiny is to make sure that the CCG are happy with services on looking at outcomes, you know we look at patient satisfaction is assessed, patient dignity is also assessed, quality metrics outcomes such as lengths of stay, how long they have to wait, how many patients, how quick your out….all of that is monitored and that will continue to be monitored into the future, irrelevant of what the service configuration is like and that is really important because what we have got to make sure is that we get that service right from day one and any new service has to have extra scrutiny out in because by default its new and we’ve got to make sure that every process and pathway is spot on and you adapt. But those processed and those systems are already in place, we already have to adhere to that. All we need to do is make sure that new service is specifically part of that assessment, rather than just generically in the mix really because we have got to be able to tell you, the public, that this is absolutely delivering that we expected.

P: Can I just add to Fran’s things that we don’t tell you are going to happen? There is going to be a shuttle bus between The Friarage Hospital and James Cook University Hospital which will be operating five times a day.

A: One wonders, if this a typical attendance at your meetings, and if so, where are the young people who would be using your services?

P: There are some yes. Yes it has been noted that we may not have the right people coming to the meetings – the right age group coming to the meetings. We have made great efforts to get people to come. We have given all the leaflets and the posters to the Local Authorities, they went out to all the schools, nurseries and we send them to the supermarkets and it has been advertised through the Facebook group, so there has been a lot of advertising gone on. Unfortunately people have not attended.

A: So, one wonders if the young people who are going to use your service are not really bothered.

P: I think they are bothered, I think to some extent I think it’s confusing the engagement and the consultation. Some people may feel that they had their say last time, why are we doing it again? And the difference is so subtle that it’s got lost.

A: Hello, my name is Chris Johnson. My part may not be directing me at the panel at the moment but my visit to the hospital over a year ago found two worrying points about Northallerton Hospital. One is the cleanliness. I went round at least four different toilets and all of them had copper or residue on the taps and that gives me a worry that there might have been diseases coming through the water system. The second point I’ve got for you is that you are talking about time for patients in the hospital and bed space. I had to wait I think three hours to get a senior person to discharge me when I could have been away three hours earlier if the right person was on duty and that is obviously taking up more bed space and what’s the panels view on those points?

P: If we take the cleanliness point first, you are right. There shouldn’t be copper residue on the taps and we do have a regime for going round and actually maintaining taps. So if you saw that, that is unfortunate. I can reassure you though that we do monitor the cleanliness of the hospital very closely and there has been a recent study up and down the country called ‘The Place Study’, I don’t know if you are aware of it where the hospital is inspected, included Lay People coming round and all of those results are aggregated and actually The Friarage came out very very well. Both sites came out very well but The Friarage, I think particularly, and that’s a typical picture at The Friarage in terms of its cleanliness.

A: Are you saying that if I visit four toilets a year ago, that copper residue was only in that month?

P: I can’t answer that and I don’t know that but I mean it’s something that I can perhaps talk about with you after the meeting if you have got a specific knowledge about that. I can’t say. If you are asking me, ‘can I say if you went into the toilets now, will it still be there?’ I don’t know that.

A: I hope not.

P: I hope not too. In terms of the wait to discharge, if that was an experience I don’t know when you said that was, was that over the winter last year or longer away than that?

A: Over the Christmas period.

P: I think it’s worth saying that we were having particular issues in fact in all the hospitals in the north-east had problems.

A: I did solve it myself in the end.

P: Right, but I think that we have a recognition that actually faster discharge and particularly what you are talking about, that senior involvement, is absolutely key and we have put an awful lot of effort into our discharge processes in order to try and speed that up in preparation for this winter because we recognise that some people had poor experiences both trying to get into hospital and trying to get out because of the volume of work. I can’t say hand on heart that that experience will never happen again, but we do recognise that discharge does need to be much slicker and an awful lot of clinical effort is going in. We have got a study going on which is involving virtually every ward in the hospital, looking at how they do discharge, working through that process and coming up with the plan for how to make that better. And also, increasing in some of the areas, certainly in medical areas, the number of say acute Doctors positions that we have in place so that the service both at the front end when a patient is admitted and when they are discharged is faster.

A: Well my final comment is that the staff were very good and very caring and I would like to thank them for their service.

F: Thank you. We have time for perhaps one more question before the meeting closes.

A: We’ve all listened here to what you have got to say and I think you have explained it very well. I think that seems to be in the back of probably a lot of peoples mind, maybe particularly not here but within the Dale, and I know it’s been touched on by yourselves as the evening has gone on and I think that what a lot of people are after is really the reassurance that this is not the start of a death by a thousand cuts at The Friarage Hospital. I think that is the main, I appreciate the maternity side of it is what the issue you are discussing this evening but I think a lot of people would like it for the record that this isn’t the beginning of the end should we say?

P: From a Commissioning point of view, we want to maintain the services at The Friarage as far as can. We want them to improve and evolve. Things will not stay the same. Things will change but the idea is to increase the quality, increase efficiency at The Friarage Hospital and maintain that service for the community.

F: Thank you very much. I’m going to close the meeting now but just to mention a couple of things. The gentleman raised the issue of younger people being represented and at Catterick we did have a pregnant lady who’s question was ‘will the changes happen while I’m still pregnant and where will I have my baby?’ and the panel were able to answer that. But also just to remind you that the survey is in the back of the booklet. There are more packs so feel free to take a couple of those booklets if you know people because the providers are really keen to hear young people’s views. There is a free post envelope within the pack so just a little bit of time. There are also fact sheets at the back of the room if you want to pick them up when you leave in case they cover things that haven’t been asked this evening and have a good journey home. Thank you.