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

Public engagement event – Thursday 3 May

Richmond School, Richmond

The panel

Name Role

Cllr Jim Clark Cllr Clark chaired tonight’s meeting. He also chairs the North 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, and Whitby 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

Why is there no mention of accessibility and transport for patients from more distant areas?

Vicky Pleydell - Transport is and always has been an issue. If problems were simple we would have sorted it before. One of the pieces of work is looking at the three- month period when hospital paediatric services were closed and what the impact was on the ambulance service. If people have ideas about how to make transport system better I would like to hear. Transport needs investment but it is not a health issue. We would have to work with the county council.

If you are going ahead with one of the suggestions you are taking it out of council’s hands as you are creating the need for extra transport. You will need to look not just at cost of putting in doctors but also how much you will have to pay to put appropriate transport into place.

Vicky Pleydell - The problem is always the numbers. I am part of a practice which delivers minor injuries services at Catterick. We have had a budget for this to fund taxi transport to the Friarage if they need to go and in all the years we have done this we have only used five taxis. It is only small numbers of people, but we will happily have a conversation on how to work this out.

But what we are talking about is emergencies at night. We are not talking about changing the day time service. We are talking about bringing services closer to people.

There are pros and cons and not everyone will travel further. If we had five-day outpatient services at the Duchess of Kent Hospital in (one of the proposals in the hospital’s preferred option 5) many people would travel less far. We need to understand what options mean and will look at in detail.

Will and Middlesbrough be able to cope with extra cases?

Ruth Roberts – Some work has been done on that but it would take some future planning.

Fran Toller (Divisional manager, women and children’s services and practising midwife who was in the audience) - There is no doubt we need to improve capacity at James Cook and this would be part of plans. When we closed for three months three years ago we did temporarily increase capacity, but we would need to ensure we had more accommodation, with the emphasis for women with children in the special care baby unit where lengths of stay are slightly longer. People in Middlesbrough may go home earlier and we would plan for that.

Darlington –We have had discussions with Darlington and they are aware of the issues and would welcome increase in births as it would make their unit more sustainable in future.

Why is it not possible for patients to travel to Northallerton from Middlesbrough to increase workload?

Ruth Roberts - We have started to do this. We have kept the special care baby unit going by bringing special care babies to Northallerton from Middlesbrough. We also get some outpatients with choose and book and this is effective. It may be possible to bring day case surgery patients down from Middlesbrough.

Why is it not possible for consultants to share cover with James Cook?

Ruth Roberts – We do share some of the cover already and rotate to maintain skills. The difficulty is we have 10 consultant colleagues at Middlesbrough and 5 whole time equivalent consultants at Northallerton.

We would have to provide a rota for both sites on-call and the college guidelines stipulate you need ten to run a safe rota so even across both sites we don’t have enough.

We would be able to increase rotation by implementing option 5. We would enhance the outpatient service bringing specialists across from James Cook to Northallerton and also to Catterick Garrison.

I wanted to talk about maternity services, because with option 5 you don’t know what would happen – if safety is primary factor I cannot see you would continue to allow births at the Friarage. Without paediatric back-up you would have a serious problem. At Kidderminster there were 6 unexpected neonatal deaths when they had a midwifery-led service. If you do decide to close it you would need to say this now.

Ruth – All of our midwives have neonatal first responder training.

At Kidderminster they had this and still had the deaths.

Fran Toller– Historically having midwife-led units is a controversial area of provision. It is fair to say when the National Clinical Advisory Team came and we looked at options for paediatrics we did not have options ready.

We are working through this and maternity staff have been to a number of midwifery units across the country. They have some key criteria and you must correctly select women who are eligible to have a low risk delivery - that is fundamental. If you don’t pick true low dependency women and observe for signs of complications you have got the wrong lady in the wrong place from the start.

When you have successfully done this and regularly check this process, the next step is to have highly skilled, trained midwives. I have done investigations as a senior midwife as to why things have gone wrong and for the vast majority of times it is because you don’t have the right skills.

You need to have the neonatal resuscitation skills which are regularly practised in a true unit. You need systems to retain those skills. Ideally you would rotate midwives at James Cook and the Friarage to ensure skills are maintained.

The other key is how many babies are delivered - if you only had 100/150 deliveries the midwives aren’t getting the skill and practice and they don’t respond appropriately. Will women want to deliver there? We are getting mixed messages from the focus groups and from what we glean from our ladies.

We are going to do a straw poll with women being delivered and asking whether they would wish to go to midwife-led unit. High skill helps recognise where you need to transfer early. We are not misleading anybody – we are auditing the outcome of whole engagement event, visiting units and talking to focus groups.

This will determine whether we propose a midwifery-led unit or we don’t. Even professional colleagues have different views as every piece of research changes the tide of thought.

The current tide of thought is that the best units are co-located with the main obstetric unit. If you truly do it correctly there is evidence you can be safer if you are a true low dependency lady.

The NCT did some research from enforced closure. I don’t think mothers would not wish to go to a midwife led unit.

Fran Toller – This would have to be something we need to talk to people about. We need people to use it.

What would happen in situation where the patient was well chosen and the midwife was well trained but unexpected problems occurred.

Fran Toller – There would be a conversation with main unit and the lady would need to be transferred via 999 with escort of midwife.

Cllr John Blackie - I notice you have changed the presentation and you have softened it, but you have introduced two new issues, one about capacity issues at James Cook and the second is from Ruth Roberts that what we are doing now will only be good for another five years.

What really concerns me is that if the Friarage goes in terms of maternity I believe there is as much chance of getting a midwife-led unit as I can fly to the moon so you are telling people who have connections of a lifetime with a particular hospital to go elsewhere – i.e. Darlington.

The chief executive of Darlington is talking about 500 births a year. If you say this is only for 5 years, when will we have proposal for downgrading A&E like Bishop Auckland?

Ruth Roberts – my five year suggestion is that for me this is about planning ahead so we don’t run into a problem. What was so difficult about the sudden and urgent closure was that it was hard to plan safely.

This has come from looking ahead to the future from retirements and raised standards so we can plan. You are right to ask questions about capacity. We need time to do this properly. All these issues are important and we have to talk together so we don’t get rapid changes as we know these are difficult.

Vicky Pleydell – We are learning. After each of these sessions I reflect so that the next time we do better. One of the things you brought up two days ago at Colburn was that people had been promised things that weren’t realistic when the Duchess of Kent Hospital closed.

We are trying to be honest. We can’t predict the future. We can do our best to say how things will go but I am not going to promise we can do things in ten, 20 years.

We don’t know what will happen. We have real financial challenges over the coming years that we haven’t seen before. No-one knows the impact. I am not going to promise anything so you come back and say we did. We cannot promise things we have no control over.

Jill Moulton (Director of planning at South Tees Hospitals NHS Foundation Trust who was in the audience) - A midwifery unit is a genuine option and up for debate with whole population. We genuinely have an open mind. We are going to Perth to look at what they are doing.

In terms of Darlington it is Sue Jacques at Darlington who said they are committed to remaining a consultant unit, they will welcome it. Mothers-to-be could equally chose to come to James Cook and we provide a quality service. It is choice.

In terms of A&E if we change maternity it has no direct effect on A&E. There have been changes at Bishop Auckland but it is more wide ranging. It is not comparable with the Friarage.

John Blackie - There is loyalty from the community to a particular hospital. Lots of people could go to Darlington Memorial which is excellent but over generations people have gone to the Friarage.

You will lose a customer base and eventually you will come back and say that it isn’t viable. Another question for Vicky – you are a very caring doctor and care particularly about patient safety. If you are going to make people do journeys they have never done before what consideration has there been about patient safety of the mother-to-be and baby and when you closed for three months there were a number of layby births.

Vicky Pleydell - Layby births happen, they happen everywhere. With a small increase there would be a small number. We must make sure services respond to this. Ambulance staff are well trained and can deliver babies.

It is an issue and I understand that and I am always struck by how far it is to Hawes. I therefore completely understand the issue and I am not minimising it, but we have to look at a safe solution.

How can we make sure the ambulance can tell us staff are well trained, clear about what standards they deliver and the response times? We are having conversations.

There may be hard choices for people in Hawes and I can’t predict them. When I have had discussions with people in the Dales they think it is much further to Darlington, but it isn’t.

I understand they are not used to this. For me it is how we ensure people have a choice - to go to the Friarage or Darlington – choice versus taking money from somewhere else.

Remember clinicians say even if I give all the money the service will not be safe or sustainable into the future. I wish I could find a solution that did it all. We have looked and looked and there doesn’t seem to be anything which does not mean a change. The point I would like to make first of all is that I can see the trust has two hospitals sometimes and one when it suits them. Training should be addressed by proper rotation between hospitals but I am not totally convinced it happens as much as it should do.

Ruth Roberts – Before we had our closure there was some resistance about rotating, but the one good thing which came out of the closure was that we have had more planned rotation since the closure. We certainly are sharing skills between the sites a lot more. It could be more and we need to work on this and keep developing. For staff it is hard to travel just like patients. Most can work on both sites.

Many of the arguments John Blackie put forward could be put forward for other services at the Friarage – what worries me is that this is the thin end of the wedge. What concerns me is that paediatrics and children are the hospital’s heart and soul - you are taking out a key part and the atmosphere – no children. What worries me, it is a culture you are changing and you are changing this for a whole family. All that community feeling towards the hospital will be seriously eroded. It is not tangible but it is key to the way hospital is viewed by the whole community.

Jill Moulton –If the changes to paediatrics go ahead it would affect two or three children on ward – for the vast majority things will be the same. Maternity is integral. This debate is going to happen in virtually all hospitals in the land. Every community will have to begin to understand, it is going to get much harder to have a maternity unit in every hospital. There have been about 18 different consultations over the last few years. Some have had to change. I agree that if we change it will shake people’s confidence, but if we do nothing we damage children or damage babies and this will not give you any confidence. This would be the worst possible outcome.

Barry Heap – I was born in 1942 and have seen quite a few changes to the NHS and it worries me now that it is more an urban health service rather than national health services.

It was admirably covered once by cottage hospitals and people who could see to the needs of residents. Now it’s a postcode lottery. We are being penalised for living in the country and this is not what the NHS should be.

We all pay according to means and contribute to the national health service. I am going over ground which Cllr Harris has done and that is to suggest that as far as the Friarage is concerned once these services disappear what is going to be next? It appears what we are looking for is super centres of health and I watched these buildings built under PFI and it is worrying that only large hospitals are going to provide future health safety and care for people of this country.

Vicky Pleydell– I would echo those worries. There is no doubt drivers are coming from the centre and driving us towards big centres. The only thing I would say as a clinician is that there are things we can do much better now than we couldn’t do before, e.g. stroke. Until recently if you had a stroke in Richmond you would have gone to the Friarage with weakness for ever and the best you could get was physio and rehab. Now new developments enable you to have an investigation and if you have had the right kind of stroke, an injection makes it go away. This requires special equipment and staff and our nearest one is at James Cook and the residents of Hambleton and Richmondshire got this service years before other places got it so we have done very well.

I have a patient who had a stroke in Tescos and walked into my surgery the following week as she went to James Cook. I understand the feeling all is moving centrally and it is very difficult. I live here and don’t want this to happen. I want my children and grandchildren to have the best services, but these specialist services are moving and they can offer extra things we have never had before.

Jill Moulton – At the other end of the scale some care is moving out of hospitals and closer to home, and this is what is happening with children. In actual fact there is a lot more going on at the Friarage these days. We used to have a very small service for cancer ten years ago - now we have specialist cancer doctors, including operations for prostate cancer by laser treatment at the Friarage and not at James Cook. It is not one-way traffic, but there’s a lot of work being done which you can’t imagine. I can assure you there are many more consultants based at James Cook working at the Friarage now than in the past and the range of services and access has increased. There are also lots of ENT (ear nose and throat) services now – people can have operations done at the Friarage and not Darlington.

Vicky Pleydell – We need to tell this story better. We need to publicise what we are doing locally. My GP colleagues want me to say we want to improve care in community hospitals back out of the Friarage and James Cook and to get people out into the community and we are working hard to stop them going into hospital in the first place.

Lots of my friends had babies recently. If you are talking about more changes in two to five years’ time what concerns me are people who haven’t even thought about planning a family. They aren’t even involved in this process of consultation. What about young mothers – how are you going to engage them in this process?

Vicky Pleydell – If you are talking about very young people they would not be interested. Our focus groups are picking up people as young as we can. We will try to put a focus group on. How do we find people? If you have any suggestions I would value your help.

Linda Curran – I go back to the beginning when South Tees and the Friarage had a partnership. It seemed to be unequal but we expected it to work because people wanted it to. Now I get the feeling that the partnership has become extremely unequal. I would say if I was looking at South Tees being the senior partner seeing impact of a low number of children staying overnight at the Friarage would it be reasonable for more children from the Middlesbrough area to be admitted to the Friarage? Would it be easier to travel from Middlesbrough to Northallerton than from the Dales to Middlesbrough. This partnership does not engage in supporting each other in a way that recognises we are rural, they are urban and there has to be a little bit of compromise.

Ruth Roberts – This is an important point. It is staffing which makes for viability particularly medical staffing and middle grade to make the service safe and sustainable.

The mixture is about feasibility and viability – recruiting the consultants - which is really key to all of this. The low number of patients is critical. It works where patients stay in a while, and we do do this but for acute services it is more difficult.

Following on from what the lady said before, the hospital itself is one of the biggest employers in Northallerton. If people are moving to the area, will it have knock-on effect on the local economy?

Question for Fran – In response to what the lady said about the emergency situation if someone had to be transferred in labour. Is there is standard limitation on distance you would transfer?

Fran Toller – There isn’t a standard for a midwife-led unit to be within a specfic distance. The rule is that you have to have an agreement with the ambulance trust to operate as a Category A (999) call.

The meeting closed at 9pm