The future of children’s and maternity services at the Friarage Hospital,

Public engagement event – Thursday 10 May 2012 Masham Town Hall, Masham

The panel

Name Role Cllr Jim Clark Cllr Clark chaired tonight’s meeting. He also chairs the North Scrutiny of Health Committee. Charles Dr Parker is a GP in Topcliffe, near , and a GP Board member of the Parker Hambleton, and Clinical Commissioning Group Ruth Roberts Dr Roberts is a consultant paediatrician who works at the Friarage hospital and was tonight’s lead clinician from South Tees Hospitals NHS Foundation Trust

Many of the questions and consultant paediatrician’s comments made below were in the context of the current thinking that option 5 is the preferred option of doctors and staff working with children at the Friarage Hospital – which was discussed in detail during the presentation.

Q & A

Have short labour times been considered when factoring in journey times to James Cook? Is this not considered a risk factor for mothers and babies?

Kumar Kumarendran (a consultant obstetrician at the Friarage Hospital in the audience) – As an obstetrician, I have a duty to provide safe care. 60% of our mums’ babies will need some sort of high dependency care. There are around 1,200 to 1,300 births a year at the Friarage and about 500 of them will be classed as low risk.

With low risk births mums are suitable to give birth in midwifery-led units without the immediate availability of consultant paediatricians.

That leaves around 700 mums with high risk factors. When they are in labour it is unpredictable so if we don’t have paediatrician cover, it will be unsafe to take these mums and allow them to go into labour if there were complications.

When we had to temporarily close the unit for three months because we could not provide full services, we ran a midwifery-led unit for three months and it worked well and was audited.

There were not huge numbers of transfers and we very carefully selected who would be eligible to give birth at James Cook and who could give birth at the Friarage. It is true that despite our best intentions some mums, who may have had complications, needed to be transferred to James Cook but we do have trained midwives who know what they are looking for.

The main transfers were down to slow progress in labour and women who may need a drip or a caesarean section, so normally we have enough time to transfer but the midwives will identify when labour deviates from normal.

Even now it can happen that some babies come without much notice or fairly short notice but if there had to be a transfer, the midwife will accompany mum in an ambulance. They are also trained to resuscitate babies as well.

The temporary closure gave us the opportunity to assess a midwifery-led unit and it worked well.

For any chance of survival, a seriously ill child needs specialist treatment within half an hour. If there are no paediatric doctors on site or on-call, how will accident and emergency cope? Or will A & E be the next facility to be lost from the Friarage?

Ruth Roberts – There are no plans to take away accident and emergency. What we have already for children badly injured is a drive-by policy so they go straight to the trauma centre at James Cook. There is very good evidence that shows the best way to ensure survival is to get the injured child to the most appropriate hospital as soon as possible and stopping off in a hospital that does not have the required skills is detrimental to the child’s outcome.

Your gut feeling may say you should get the child to the nearest hospital as quickly as possible but the evidence does bear that out.

Of course having enough ambulances also needs to be factored into this process but there are no plans to do anything with A & E.

I have had babies at and Northallerton in recent years. I have grave concerns regarding the capacity of Harrogate maternity services to absorb even great numbers of births, given Harrogate’s increasing birth rate (midwives and health visitors will confirm) and the impact that this will have on the delivery of safe and quality care. When I had my baby in Harrogate the unit was at capacity. All homebirths were cancelled because the community midwives were drafted into work on the delivery suite and the wards. Has there been a scoping exercise to estimate the increasing numbers of women who are likely to need services at Harrogate for consultant care?

Jill Moulton (director of planning at South Tees Hospitals NHS Foundation Trust who was in the audience) – We have not done a detailed scoping exercise but we have looked at babies delivered and where people who do deliver live, and tried to estimate who would want to go to other centres.

We estimate there’s probably between 100 and 200 women who may choose to go to or Harrogate. As we go through this process and if one of the options is we will change the model of how we provide obstetric services at the Friarage Hospital, there would have to be detailed conversations with Harrogate, York, Darlington and other hospitals although we are already talking to them. You are right to ask what the impact would be on all surrounding hospitals and we do need to take that into account.

Our baby has complex health needs and multiple specialists. How is continuity of care maintained when a child under specialist care at James Cook and the Friarage is admitted to Harrogate as an inpatient for unscheduled care - for example Rotavirus and dehydration because it is the nearest inpatient facility? This is not feasible especially given that there is no electronic health record between hospitals.

Ruth Roberts – There is work being done on the electronic health record nationally. I think it’s a really important question and something very important for us to consider. We do already have that issue with many of our children with complex needs who are being seen in Leeds, Newcastle or James Cook.

Continuity of care would have to be looked at very carefully. It might be some families would prefer to transfer all of their paediatric care to Harrogate, for example, and if they did want to do that we would do our utmost to facilitate that.

How many children and babies in special care are resident overnight at the Friarage receiving inpatient treatment? I do not recognise the claim that there are ‘very few or no’ children needing an overnight bed. Our baby has complex but not life-threatening needs. We have had nine days in the Friarage Hospital in the past two months and the unit has been busy on both occasions we have stayed. Our specialist care is at Leeds General and the James Cook. Inpatient stays at these hospitals for specialist treatment is necessary and unavoidable, however the impact on our whole family and the distress is causes to our older child is immense due to the separation. The Friarage has provided quality care for antibiotic therapy and avoided further separations for our family.

Ruth Roberts – The last two months have been really busy and have not been average months. We have ten special care beds on the baby unit and we do have families who come to us but Middlesbrough does have the extra capacity available on the baby unit should that be necessary.

I can’t deny the difficultly for families when we don’t have inpatient beds nearby and it would be difficult.

For children who are recovering and becoming better, who may not need frequent antibiotics for example, one of the things we do now is allow children home and allow families to give antibiotics. If we were to increase our community services we may be able to offer that more broadly for families but it really depends on how well the children are.

The public and the NHS are telling me it’s okay because we have Darlington close at hand. But I believe they are suffering the same austerity measures and there is no assurance that they won’t scale down services. I appreciate that this hospital is not in your area, however every aspect has to be taken into account.

Charles Parker – We have been in contact with the chief executive of Darlington and they have guaranteed that they do not plan to scale down paediatric services into the future.

When I used to be the chair of the children’s scrutiny committee, one of the problems arising was the lack of health visitors. I think at the time it was something like 56 short in and it was a dilemma. If this is not rectified how will that impinge on the work you do, especially the outreach work?

Ruth Roberts – There has been huge changes in paediatrics in the 20 years since I’ve been doing this job. We used to keep kids in hospital for ages but as years have gone by, increasingly families have been more likely to get advice and go home with support.

There has been a big increase in community nursing and I think that’s the modern way and it would be important to enhance that service as it can enhance children’s care to a great degree.

Charles Parker – I do know there is a Department of Health programme specifically looking to increase the numbers of health visitors so the figures will be increasing.

You’ve mentioned Darlington, York and Harrogate – have you considered the traffic congestion people face? It’s 20 minutes to Northallerton but an hour to York. I think it’s of paramount importance to protect these services at the Friarage.

Charles Parker – I think Ruth has mentioned the preferred option of the doctors is to maintain the majority of paediatric services at the Friarage – more than 90% of care will still be provided there. You’re talking about overnight travelling so congestion would not be as considerable. Children’s assessments would still take place at the Friarage if the preferred option was adopted.

I’ve a question about length of stay on the children’s wards. What’s the longest length of stay for an individual child?

Ruth Roberts – We have a young man who’s going home this week who has been in for two weeks. We do have some long-stay patients – for example some orthopaedic patients – but it’s very rare to have children in for weeks and weeks like I did as a junior doctor.

For example we don’t have school teachers in our hospital anymore, because if you’re in hospital now you’re too ill for schooling.

Charles Parker – We are aware there is not sufficient accommodation for patients to stay at James Cook and we would want to develop that if needed.

The children’s unit at the Friarage is all relatively new. Why was such as large unit built? Is that because everything has been moved to James Cook?

Ruth Roberts – When it was designed the old ward had 20 beds and when I started it dropped to 18. When you look at all paediatric units there has been a huge reduction in beds so although overnight they aren’t used much, if you come into the wards at 3pm it’s teeming. So we can use the space, it’s just not as much overnight. I was classed as ‘low risk’ and had a horrific time at the end. The thought of having to be transferred to James Cook when I was in pain fills me with horror.

Ruth Roberts – I think that thought is with many women and in a lot of areas, midwifery-led units aren’t particularly well used. It’s important to mention the choice of how to deliver

What if there’s a snag and they have to be transferred to James Cook? If you think they are low risk and there’s a problem, will women go straight up there?

Kumar Kumarendran – There are always cases where women look like ‘low risk’ on paper but there are complications during labour – no-one can predict that. There are always going to be transfers.

There is a growing number of midwifery-led units adjacent to consultant-led units (for example James Cook has one) – so there is low intervention but if something goes wrong they have immediate access to consultants.

There is a study which shows mums who have had a previous straight-forward birth, the outcome for their second child is exactly the same- even home-birth is safe. But for mums who are first-time mums, there is a higher transfer rate because they are not making the progress we would like to have.

In that situation we would have a few hours to spare and midwives are trained to detect that progress. There will always be some urgent cases – that can happen now - and that’s a concern – we would have to arrange a 999 ambulance to transfer and the midwife would accompany that lady.

We can minimise risk but not entirely eliminate risk – but that is the nature of childbirth, it can be unpredictable.

Has anyone given thought to the traffic – the stress and trauma to the family and for people who come to visit? If you’re in labour, to get in a car to Northallerton is bad enough, it would be awful to have to travel further. It’s the knock-on effect – not just about the care and medical intervention but it’s the experience for patients and their families.

Kumar Kumarendran – I accept it’s not pleasant at all if you are in labour and being transferred. But this is why we’re having these discussions. As a consultant obstetrician, if there was no consultant paediatric cover at the Friarage I can’t say you could have a baby safely there if there were complications. You have to look at the best and safest options – that’s why women would have the choice of a midwifery-led unit or another hospital with a consultant-led maternity unit.

As I’ve said before, midwifery-led units can be very suitable for some women.

I think a midwifery-led unit could be wonderful but it’s not that adjacent. If you come across Harrogate in busy traffic it does take a long time. Is there going to be a lot of training into supporting a midwifery-led unit?

Kumar Kumarendran – When we temporarily closed paediatrics and maternity services a few years ago, we ran a midwifery-led unit at the Friarage. We wanted to know what people’s experiences were and sent out questionnaires to every single mum who delivered.

Their experience was very important to us and interestingly we had very positive feedback. We did have a few transfers but no disasters. At this stage we have not decided on an option for maternity and there is the possibility we might not have a midwifery-led unit at all.

It is worth mentioning we’d have around 500 mums who would be eligible to give birth in a midwifery-led unit at the Friarage but for precisely the concerns raised about transfers, women may not choose to book and come here to have their babies. We don’t know the numbers of who will book.

I think to be viable it’s about a minimum of 300 women who would have to book but unless they choose to do that we could not run the unit safely. 300 babies a year means one a day – if it’s less than that how do you maintain the skills of the midwives? We are continuing to look at what innovative options are available to us.

Is there going to be more community midwives if this happens?

Kumar Kumarendran - In maternity it’s very difficult to plan and manage the workload. We may have four babies coming into this world at once and then nothing for three days.

We have already said for it to be safe, we have to have a flexible unit and when it is busy we can draft in community midwives to come and help – we do work in a larger team.

I have had two babies – in 2007 I had a high risk pregnancy and did most of the labour at home. The second time was in 2009 when the Friarage unit was closed and I had my second baby at Harrogate. My waters broke so I was taken straight away to Harrogate. My concern is the stress this caused and the distance covered. We went in at 1.30am and were told we were going home at 11.30pm at night which wasn’t appropriate as my husband was really tired. Then there were no facilities for my husband to stay with me. These things have to be taken into account.

My question is numbers – what day clinics would you do at the Friarage and Duchess of Kent if you went with option five?

Ruth Roberts – We go out about two-and-a-half days a week on average so what we would like to do is have a presence – be it some of the team, community nursing or paediatrics there most days and have more emergency outpatient clinics.

We would like to have slots so our Dales/Catterick GPs could phone and say ‘can you see this child this afternoon’. The assessment unit talked about under option 5 would be at the Friarage.

The way we run things at the moment with the five of us (consultants) is we have a five-week rolling rota. Every fifth week you would be on-call on the ward, the other four weeks would be outpatient clinics. Already we have a bit of a model doing that but want more emergency access on both sites so we would combine the two. We also want some of our James Cook consultants to go out to Catterick and in the community.

Your vision of the Friarage – how many full-time post equivalents would this take?

Ruth Roberts - We could staff this from what we already have on the two sites. I think having a more modern service would enhance our chance of recruitment. One of the things that puts people off is having no juniors as there is a perception it’s not a safe model of care.

For example, the way we have already recruited into a consultant post is to appoint someone who is a specialist in neuro-disability in paediatrics. If we are delivering a more modern basis of care, there’s a stronger chance of recruiting into posts.

What would happen if the mum herself, who was in the situation where she had to transfer because of complications, refused to transfer? Could certain facilities be retained if the scenario arose where mum could not transfer? There will be extremes…

If we don’t have paediatricians on duty, that possibility won’t be there but that is no different from any midwifery-led unit around the country. Every midwife is trained to give resuscitation so the baby would be kept breathing and then transferred to James Cook.

If the lady is undelivered it’s a question of getting her stabilised and she would be accompanied by the paramedic/midwife to the nearest hospital.

In terms of a mum refusing to transfer – it’s very important if women book into a midwifery-led unit they should not have any unrealistic expectations of the service because it’s in a hospital.

There may be an assumption that doctors would be around if complications arose so it’s very important information is made available from the very beginning about what a midwifery-led unit can provide so there should be no confusion.

If mum did not want to be transferred she is taking a risk. It is extremely rare for a mum to decline the best care for her baby.

If a child or mum and baby had to be transferred to Middlesbrough, they are virtually cut off from the rest of the family. The cost of fuel is so expensive – the patient is going to be virtually cut off from their family.

Charles Parker – We have considered this and it is one of the difficult areas. We have no solutions to the transport issue and if things progress we will have to have long discussions about how we solve that problem.

The cost of parking at Middlesbrough should be taken into consideration. Also have you got enough ambulances? You’re talking about extra clinics but you’ve got a good children’s unit at the Friarage – they should be going there!

Ruth Roberts – I think the families at Catterick and the Dales would disagree and we’re only talking about outpatient clinics in the community and they would help these families.

The meeting closed at 9pm