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

Public engagement event – Thursday 22 May 2012 Tennants Auction House,

The panel

Name Role Cllr Jim Clark Cllr Clark chaired tonight’s meeting. He also chairs the Scrutiny of Health Committee. Vicky Pleydell Dr Pleydell is a local GP. She is also the Shadow Accountable Officer and tonight’s lead clinician from the Hambleton, Richmondshire and Whitby Clinical Commissioning Group Fiona Dr Hampton is a consultant paediatrician and clinical director of paediatrics Hampton and community child health 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

What happens if a child had a tonsillectomy or other procedure as a day case but was too unwell to go home overnight?

Fiona Hampton – The child would need to be transferred to another hospital.

What would happen if you needed an emergency caesarean section and James Cook was full? I’ve heard that Darlington, and Harrogate will only take planned caesarean sections?

Fran Toller (a midwife and divisional manager for women and children at South Tees Hospitals NHS Foundation Trust) – I can understand people’s concerns. If a caesarean section was required you want to be assured that you would get that care from whichever hospital you went to.

Wherever possible, ladies who we predict will have problems we will plan the caesarean sections and they will go on an elective (planned) list and we make sure there is a bed available.

If there was an emergency section and a lady had predisposing high risk factors, she could not deliver at the Friarage Hospital in a midwifery-led unit. If she came into labour in the midwifery-led unit a transfer to James Cook would be required. Part of our planning process is making sure we have the capacity to cope with that extra workload.

Vicky Pleydell – There is capacity in Darlington – if people are booked they would go. If they were at the Friarage, there would be a discussion about where they went but they would never turn someone away.

How can you convince me that this is not the thin end of the wedge and that more and more services won’t be closed down and as a result we would have to go to James Cook?

Vicky Pleydell – I hope I answered some of your concerns in the presentation. The clinical commissioning group (CCG) is committed to a future for the Friarage and, in my experience, the Friarage Hospital is more vibrant now than it was ten years ago – there are all sorts of services there now.

There has to be a balance about what is done locally. As a CCG we would like to get more people out of hospital – we think too many people get stuck in hospital – and we have to have the care in the right place.

The very high-technological care tends to be in centres of excellence. The Friarage does have its place and will provide care for the local population but we would like to provide more care at home also.

The Friarage Hospital needs to stay and there is definitely a future for it. My worry is if it gets downgraded because it’s not safe or the service in paediatrics is not as safe, others will not choose to go there. That’s more dangerous for the reputation of the hospital.

Can we please have district midwives again?

Fran Toller – We have got district midwives or community midwives now. They are out there in the community supporting ladies, both ante and postnatal, and ladies who want a home birth. There is no impact on that service with any of these options being discussed.

NHS County Durham wasted £18,000 of taxpayers’ money for advice on how to win awards. If all NHS quangos shed some chiefs, they could employ more indians so keeping more departments open!

Vicky Pleydell – I can speak on behalf of our CCG and as a CCG our costs are going to be lower than the primary care trust’s costs were. Of the £1,477 that we get for each patient, £25 will be spend on CCG administration which is a tiny amount. We are very lean and are very careful about how we manage our resources. I am aware in these times that we need to save money. We work hard in our team to do the right thing.

When you started speak you mentioned the stroke situation at James Cook. One of the questions I was going to ask is a neighbour had a stroke and was taken to Middlesbrough – why can’t that service be available in Northallerton?

(Footnote to above question – patients now go straight to the Middlesbrough hospital for clot-busting drugs – thrombolysis – if a stroke is suspected which has saved lives and provided quick recovery. If patients have a slower recovery, they will receive their stroke rehabilitation at the Friarage Hospital)

Vicky Pleydell – It’s really about the numbers. A service like this needs high levels of skills, expertise and equipment and serves large areas. It is happening all over that these services are only in specialist (tertiary) centres. There are schools of thought on this but patients do tend to be taken to the larger centres. Everyone has to travel to James Cook for this service, as well as us.

Jill Moulton (director of planning for South Tees Hospitals NHS Foundation Trust) – There was a big campaign about stroke that was on the back of a whole new set of standards. Essentially these standards were saying it was better to take a patient further to a centre which can provide very well co- ordinated, well delivered services very quickly.

It’s simply not possible to do that in every hospital as we need people available 24-7 to make sure patients get the right treatment. Because of this, some patients can now go home after their clot-busting injection at James Cook but if patients do need to stay in hospital, they can get very specialist stroke rehabilitation care at the Friarage.

We’ve invested money there for more specialist doctors, nurses and specialists to care for this group of patients.

If you have a stroke your chances of living are much higher if you’re in a specialist centre and the chances of recovery are high because you’re looked after by an expert team.

We’ve actually got one of the best services in the country. There has recently been an audit and James Cook came out extremely well. I think you can be confident the care received is amongst the best in the country.

(Three comments) I’m totally baffled by the shortage of money and I’ve written to William Hague to ask Andrew Lansley about this. We were told there were billions coming to frontline services.

There’s a great shortage of ambulances, you increased the problem by moving trauma out last year. You’re now proposing to make the problem even worse by moving maternity services. If you can’t get an ambulance in time people will die. I would be against this move on the grounds there aren’t enough ambulances to do it.

The European Working Time Directive. The Government has said they’re going to opt out of it now…

Vicky Pleydell – Can I address the money issue first? The formula for money we get per capita is not changing. It’s the same as what we got last year – there is no new money coming into the health service.

I think the changes are in the structure – this is about government savings. There are a lot of organisations being formed such as the NHS Commissioning Board and services which support the CCGs; public health is moving into local government so there is a lot of movement and an enormous amount of complexity.

The new Bill has produced mind-blowing complexity in the NHS but in terms of funding what I will get will not go up. We all have flat-line growth next year but we have a population getting rapidly older and older people consume more healthcare than younger people. We will have to make £4.5million possible savings just to stand still.

I’m seeing William Hague on Friday and I want to raise money with him and I’m also trying to see the MP Anne McIntosh. This is a political issue and William Hague is asking us to look at innovative solutions but to do that I need money.

In terms of your comments about the ambulance service – ambulances are a chronic problem. As an out-of-hours doctors at I am aware of this.

The day I’m seeing William Hague I am also meeting the ambulance service and I want to talk to them about how we make the service better. We need to find different ways of dealing with this. There are lots of things being done around the country which have reduced problems, similar to ours, by looking at things a bit differently.

For example 999 calls – ambulances could go out and could transport patients to out-of-hours. This is not necessarily about putting another ambulance crew in Leyburn. We are modelling what all of this could mean for patients.

The extra impact on ambulances is no greater as most people travel to hospital by car. Most of the children I’ve sent onto hospital go in their own cars unless they are critically ill and as an out-of-hours GP I’ve only done that once in the last six months.

Fiona Hampton – In answer to your question about the European Working Time Directive, individual senior doctors can sign to not do it but junior doctors are not able to work more than 48 hours.

Do you spend £1,477 per head of person in the area or person coming through the door of the hospital?

Vicky Pleydell - £1,477 is what the CCG gets to provide everything we need in healthcare per person in the area. I’m not part of the hospital – the trust provides services from the Friarage.

I’m a GP and run the clinical commissioning group. We buy healthcare on your behalf and the hospital provides that healthcare so the CCG gets charged for every patient who goes through the door of a hospital whether it’s in Darlington, Middlesbrough or Northallerton.

Also if you were on holiday in London and went into hospital there, we would pay for that bill as we would for your mental health, out-of-hours care etc.

Is there any difference in the cost of the Friarage and James Cook?

Vicky Pleydell – It’s a national menu if you like – people would get paid the same amount of money so if you went to Darlington we would get charged the same amount as James Cook.

You mentioned if someone was being transferred to James Cook you would arrange for a taxi?

Vicky Pleydell - What we are saying is if someone was transferred by ambulance to James Cook with their child and they had left their car somewhere else and couldn’t get back, we would have to find a pragmatic way of looking at that.

You mentioned transport is a significant issue. If there is a level of service you’re trying to maintain, if people are being transferred further afield, especially families, there would be an on-cost which would make them worse off.

Vicky Pleydell – Most children who go into hospital go in for a short period of time. The average stay is 0.7 of a day. We’re talking to the trust about shuttle buses but before this has never really flown as there haven’t been enough people who would use it. That would still be an awkward transfer and we do appreciate there would be an on-cost for some people.

The other thing we would do is bring outpatients out of hospital into the Duchess of Kent at Catterick Garrison so that would mean some patients would not have to travel so far and that would make a considerable difference in the area.

I would challenge you on the ambulance issue to say it would not make a big difference. It made a big difference when you introduced the new stroke pathway….

When you’re 60 miles from a hospital there are very few options to be honest. I understand air ambulance would not be sent to the expectant mum in labour?

Fran Toller – It’s true an air ambulance wouldn’t be sent because they have not got the space. If you’re an expectant mother, the only way you could go into hospital is by ambulance.

Vicky Pleydell – Darlington is only a few minutes further than Northallerton so they would not have to go to James Cook. They would have the choice to go to Northallerton but that too can be a difficult journey.

There’s another set of safety issues when you live in the Dales. If you are going to continue your allegiance to the Friarage Hospital, you would want to move to James Cook. In terms of when you come to have your baby, it’s 60 miles. We know from the NCAT report they’re talking about up-skilling paramedics. We know there’s bound to be an increase in lay-by births because 60 miles is a long way to travel in labour.

It’s not only the Dales and Hawes; we have mums in Coverdale – who will speak up for the safety of these patients?

Vicky Pleydell – l think people have to make a free choice about where to have their baby if these changes come about. No decision has been made but people would have to make a choice and there may be a change of allegiance about where to go. Each person will have to make their own choices as they can – and do – now. In Catterick a lot of people choose to go to Darlington.

In Colburn (first engagement meeting), the public said they didn’t know they could choose. Having said that, a lot of research says you’re better to travel further to a centre of excellence than you are to deliver somewhere that is not safe. If you look at safety, there’s a lot of research which says that. High risk babies should be where there is an intensive care unit.

There is no easy answer which is why we’re here – if there was, we would have sorted it.

The figures we have seen have 800 inpatient (paediatric) stays from Richmond, Catterick and the Dales and if they take your advice and go to Darlington, it would change the allegiance of a lifetime. If you start losing that footfall in the door, isn’t there concerns about other services and accident and emergency would be on the list?

Vicky Pleydell – People are different now and young people are more consumers of healthcare. People choose to go to Woodlands in Darlington for some simple procedures. Actually people can ‘spot purchase’ their healthcare and don’t necessarily have that allegiance. There are all sorts of things happening at the Friarage now that weren’t happening there before – ENT (ear, nose and throat) operations for example.

Yes it is possible if you have a baby there, you would want all your care there but that’s not really the pattern of care I’ve seen. People also look at waiting times and through ‘choose and book’ they can ring up and ask about them.

I had a patient last week who chose to go to Harrogate as the waiting list was shorter for that particular procedure.

Has this swung too far in the direction of developing centres of excellence which means at the end of the day the ordinary hospital will not cope with people suffering from some normal ailment? We won’t be able to get into hospital as it won’t be there?

I do think, as a taxpayer, this is not what I want. I want to go to the hospital nearest to me where I can expect to get a service.

Jill Moulton – It is a national debate and interesting question. A big reconfiguration recently happened in London and that was discussed. I think we would share your concerns if everything gets centralised, there’s a question about the quality of what is left.

If you think about the things that have changed in heart services, trauma and orthopaedics services, it’s been done because all the evidence says you (the patient) will get better faster and quite frankly live.

I quite agree at the Friarage Hospital, the onus is on us to say where services can be provided locally, we will work hard to keep them local as far as possible. I think we will be back to debate future standards in the service.

Vicky Pleydell – As a commissioning group we’re committed to get as much healthcare locally as we can and we will work very hard to do that. That’s our commitment to you but we can’t deliver things that aren’t safe to deliver here.

I’m not sure your finance comes into it – is this empire building? If a person went into the Friarage with a stroke and was transferred to Darlington, you’d get a bill for it. If he was then immediately transferred to Durham are you getting two bills?

With regards to middle grade doctors, there are none at the Friarage. Who plans for training these doctors – is it the government? When I was a young man, I went through my training and was posted to the station the chief fire office thought I ought to go to. We as taxpayers, pay for the training of doctors – are we allowed to choose where they go?

Vicky Pleydell – Darlington and Durham have some arrangement as Durham is their stroke centre. On this patch it’s James Cook. As far as the bill goes, it should be the same bill regardless where our patients go.

Fiona Hampton – As far as junior doctors go, they are paid for nationally and there will be a cut in middle grades over the next five to ten years. We couldn’t have any at the Friarage as they would not see enough patients for their training – the Friarage is not a training facility, it’s too quiet.

I live in Wensleydale. If I have a stroke and I’m taken to James Cook, will I be taken by ambulance and not by car?

Vicky Pleydell – Absolutely. If we saw that emergency we’d call 999 and we have to make sure the ambulance has the capacity to do that.

In the report ‘Facing the Future’ it says to meet the standards you’d need twice the number of consultants – 10 whole time equivalents on the rota. Also in the context of when you talk about doctors, you’d need doctors with specialist skills.

The Royal College is responsible for training consultants – surely they have to envisage if you don’t have generic skills you’re reducing the numbers of available doctors?

As paediatricians and doctors, has anyone gone back to the Royal College of Paediatricians and said their standards are unrealistic and unachievable? Instead of us debating this, the Royal College should be looking at flexing and readjusting standards so doctors have a set of core skills in other areas?

Fiona Hampton – I can understand where you’re coming from and I am old enough to have been trained to do the majority of things but there is no way I have got the brain power to cope with all the areas as they are now.

Each area has become so much more specialised and we can’t have the skills to do everything. I am a paediatrician, I look after children – if you’re 50 and having a heart attack you would not want me anywhere near you!

All doctors do have a certain amount of generic skills but are they enough to make the service safe, probably not. There can’t be that system – there aren’t enough of us.

We do try to ring colleagues if we have a specific query about a child – that’s the reason for centralisation. In Newcastle or Leeds for example, you don’t go into paediatrics, you go into respiratory paediatrics if a child has breathing problems, but if I was a respiratory paediatrician, you couldn’t expect me to be available every night to take phone calls.

Fran Toller – Just for clarity, ‘Facing the Future’ came out in May. It was not the first of its kind – it’s a repetitive two to three yearly document and for a long time the Royal College has been building on these standards.

At the Friarage Hospital, you’re not only expected to be a paediatrician, you’re expected to be a neonatologist as well. There is an acute difference between a baby who is born and not breathing to a child and it is a different set of skills.

I can understand you saying generic but the reality is that’s not how it is now. One; junior doctors now work 48 hours a week not 100-plus hours a week which is a safety issue and two; what you can get today is nothing like ten or 20 years ago, the people are different.

The important thing is if it’s your baby and your baby is born, you want someone trained in that skill with extensive practice and experience. You don’t want someone to say to you ‘hang on a minute – let me think this through, I haven’t done this for six months’

We have no middle-grade cover and one consultant group covering paediatrics and neonatal. Added to that when the Royal College looks at training they’re making plans for ten years’ time and there will not be enough posts for all these doctors. We don’t want to see thousands of doctors on the dole.

My baby was in the special care baby unit for six and a half weeks and I had a caesarean and it was a nightmare travelling to Northallerton. If we were at James Cook, how would you propose I travel to visit my baby every single day?

Fran Toller – I think you’re right and that’s one of the key discussions we’re looking at – transport arrangements and parental accommodation at the James Cook – they’re very important factors. We need to look at alternative solutions to transport.

With the proposed new model of a paediatric day care unit, you say there would be no overnight inpatient services. What are the proposed opening hours?

Vicky Pleydell – We’re currently looking at the numbers. Certainly what NCAT suggested is 12 hours – something like 10am to 10pm – and that was done looking at the biggest numbers coming in.

A lot of admissions are when GPs have seen people and send them in and often it is in the morning and then again in the afternoon after school. We want to make sure the unit could work on these peaks. Sometimes as a GP, you just want a consultant to have a look at the child if you’re slightly anxious. To be honest if a child was really ill now they would be sent to The James Cook University Hospital.

Fran Toller – The numbers also indicate it would be very little hours at the weekend.

The meeting closed at 9pm.