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

Public engagement event – Tuesday 1 May 2012 Colburn Leisure Centre,

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 Jon James Dr James 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

My main concern is transport between Northallerton and The James Cook University Hospital and the cost for us mothers who do not drive or have money. What happens when a doctors says we have to go to James Cook?

Jon James – It’s a good question. The transport system and services between the James Cook and the Friarage does need to be looked at. In terms of the ambulance service, they would need to up-skill and that’s the conversations we need to have with them.

I wish I could say there are grants/benefits to pay for travel but unfortunately there aren’t unless families are in receipt of family support.

Since the closure of the Duchess of Kent Military Hospital, it has never made sense for paediatrics and community services to be at the Friarage. Darlington is closer and quicker so surely the service should be moving to Darlington and County Durham?

Vicky Pleydell – We’ve had lots of conversations with Darlington and have been assured they are very happy to see patients in this area. Patients already go to Darlington for quite a lot of specialities and have a choice to go there.

As a commissioning group we do have a contract with Darlington and it is a personal choice for patients. GPs should offer you the choice of which hospital you prefer to go to.

I had a baby eight months ago and there was no option to choose Darlington – it was Northallerton or James Cook.

Vicky Pleydell - The midwives should be offering you the choice.

I was looking at the statistics for 1,250 child births a year at the Friarage. I went from having a healthy labour to my child being on death’s door. If you had a midwifery-led unit and that happened, you couldn’t put me in an ambulance and say see you at James Cook.

Vicky Pleydell – One of the issues is you would be able to go to Darlington which has all the services needed there.

The problem is you can go from a having a perfectly normal birth to a critical situation…

Fran Toller (divisional manager for women and children) – I think the question you’re asking is if mum’s are going to go to a midwifery-led unit, what plans are in place is something goes wrong?

With any mum we have clear criteria – it’s very explicit. If you have any pregnancy deviating from what would be deemed as ‘normal’ we would not advise you to deliver in a midwifery-led unit.

Obviously, we know for some people unexpected complications can arise and there is no doubt at all if that happened, the woman would have to be escorted to the nearest consultant-led unit as it would not be safe to keep them in a midwifery-led unit.

There is lots of research both for and against midwifery-led units – that’s because there are no absolutes with them – so the other question we have to ask is would women use it?

These units are run by trained midwives who are highly skilled and if there was a deviation, the key is quick and early transfer in an ambulance with a midwife escort.

But that’s in an ideal world. The Friarage Hospital has a fantastic maternity unit now…

Fran Toller – It is really difficult and I understand the point you’re making about your own delivery and the care you received at the Friarage, but all I can say to you is most deliveries occur with no consultant or staff intervention.

As a midwife myself, I would say with very clear criteria and highly skilled midwives, there is a place for midwifery-led units, but as a midwife I would have to be assured we get early response from the ambulance service if we were in a position where we had to quickly transfer someone to James Cook.

And the reasoning behind why I say James Cook, rather than another hospital, is the trust already has two units (James Cook and the Friarage) which work together well now. They use – and work to - the same policies and guidelines and that understanding of transfer is already there.

If Darlington has a similar low birth rate why isn’t it in the same situation?

Vicky Pleydell – If mum transfers – or chooses to go - to Darlington that makes the maternity unit there more sustainable. From the early results of our focus groups, most people would not choose a midwifery-led unit because of that risk if there was a complication.

In Catterick, there are a large number of married families, military personnel and a lot of young families. I’ve come to the conclusion the basic problem is staffing levels. I would like to know how many professional people would be required to continue the service at the Friarage and has anybody done any costings around what it would cost to bring the service up the statutory minimum requirement?

Jill Moulton (director of planning at South Tees Hospitals NHS Foundation Trust) – The honest answer is we don’t have detailed costs because we want to listen to your views and the views of other units who have made the move to a consultant-led service.

Ultimately we want a service that is safe so it is interesting when you talk about staffing numbers. We do know the staffing numbers that would have to be in place but these staff would need to be able to keep their skills up to speed.

Our issue is in order to meet current standards, those staff would still be seeing the same numbers of children and babies so we would have more staff but it is arguable whether the service would be safer as a result.

We need to do the costing at the end of this exercise when we have established all the options and we will put this into the public domain. As a rough idea we have 5.5 paediatricians – the current standard is around 10 but to run a 24-7 rota effectively we would need more than 10 consultants.

Banbury has 12 and a doctor on average costs around £120,000. You’re looking at extra doctors in paediatrics, obstetrics and neonatal care and anaesthetic cover to support maternity services. It is effectively a big bill.

Vicky Pleydell – The information we have from Banbury is they spent around £2.5million. At the Friarage, the issue is there are not enough children going through the front door and people are not having enough babies so the income currently generated through the system is not enough.

Cllr John Blackie then asked a number of questions

Scarborough has 1,000 live births a year but has received £20million extra funding from the NHS. What is their trust and the CCG doing differently to get their money to what you’re doing here?

Vicky Pleydell – The Scarborough money is specialist funding to do with quality and it is an issue which has been going on for a number of years at the trust. It’s also short term - £20million over five years – and that funding will then be withdrawn. A lot of it will be spent on redeveloping the actual site. Funding is a political issue.

You are using another hospital’s experience when you talk about costs. When you do the costs can we have reassurance that you’re also including the extra cost of ambulances? The new stroke pathways costs to James Cook cost an additional £250,000 for ambulances. Can you cost having residences at James Cook for people travelling distances and the additional costs to go to remote areas in the Dales with the appropriate level of skilled cover including having paramedics on ambulances skilled in paediatric airways? What about all those costs?

When I first cut my teeth in health, it was about the closure of the Duchess of Kent Hospital and people fighting for A & E. When it closed the people were reassured ‘don’t worry there will always be the Friarage’ Now we’re being assured when you close the Friarage there will always be Darlington. Even the NCAT report raises questions about Darlington. What trust can we give when promises that were made crumble in front of us?

Vicky Pleydell – We can only promise what can be done in the short-term. All I can say is I was there when we had the Duchess of Kent closure and the decisions were taken in good faith by the people concerned and based on the situation at the time. None of us know what will happen in life and it would be wrong to say that people who made promises did so in a disingenuous way. I’ve had reassurance from Darlington that they will continue with full maternity and paediatric services for the medium term.

The Duchess of Kent was 15 years ago – maybe even longer – and the health service and technology has changed. Safety has changed. It is not that people were lying.

People have long memories – that promise has not come to fruition…

Jon James – We live in constant change. Medicine changes all the time – we don’t stand still so it is inevitable services have to be reconfigured over time. If a baby was born 12-weeks early 40 years ago, they would have died. Twenty years ago if a three-month premature baby was born, they would have been stabilised and transferred to Leeds. Yes it would involve travelling some distance but travelling for the best possible care available at the time.

You talk about 1,250 ‘live births’ and are now positively pushing people towards Darlington Memorial as the hospital of choice. That’s going to be their closest hospital if the Friarage doesn’t accept live births. Associated with births and children are attendances to A & E. If you divert what has been a pattern of community networks to a new hospital (Darlington) and they take everything you send them, how long is it before you come back telling us you want to close accident and emergency at the Friarage?

Jill Moulton - There is no connection between births and accident and emergency. I agree people should exercise their choice but as a trust we don’t want people to move. We want the Friarage to remain viable in the future and to continue to provide exceptionally high quality services. Plus we want people to use the hospital. We’re looking at developing a model for its future and want to keep the hospital strong. To do that, we need people to have confidence in the hospital and continue to use it for their operations and treatment. However the services there do need to be safe - unfortunately with paediatrics and maternity the only way to ensure safety is look at possibly changing the service we have now.

Vicky Pleydell – The CCG is committed to the future of the Friarage but services do to be safe and sustainable. If people ask me why they should go to the Friarage, I’d say there services there are as good as anywhere else.

Questions returned to the floor…

Is this the thin end of the wedge? My concern about A & E is if paediatrics becomes a five-day service, there won’t be paediatric cover for A & E. What would happen to accident and emergency? We need reassurances. It’s a local loved hospital and people want safe care close to home. James Cook is not near and a long way from home for local people. The government is encouraging care closer to home.

Vicky Pleydell – We are trying to move care closer to home but that means care that’s safe to deliver at home. There is a lot of care that happens too high up the chain – for example who know there are people in hospital and in community hospitals that should be at home.

The issue we’re talking about here is paediatric patient care and the few children who need an overnight stay in hospital. The average length of stay at the Friarage for paediatrics is 0.7 days so most children come in and go out the same day – that used to be three or four days.

As a CCG we need to move care closer to home although we know some patients will still need very technical specialist care in a place where people are trained to provide that.

I broke my leg and had an orthopaedic operation at the James Cook involving two consultants. I was in hospital for two days and when I came home I had my physiotherapy locally and my reviews at the Friarage. You’re now in hospital for a very short period of time.

Jon James – Almost 7,000 children currently use accident and emergency and the majority have bumps and knocks. The vast majority won’t need hospital admissions.

It sounds like you’ve already decided what you are going to do.

The only absolute is we can’t do nothing. But this is genuine engagement – we would not be here if it wasn’t.

Catterick Garrison has a high number of young mums and children – many who are deprived – and has many characteristics of an inner city population. It does seem strange that funding for the care of these people does not take this into account. Is there not a deprivation index for the military?

Vicky Pleydell – It is a great point. It does not take this into account and there is no extra funding. The welfare of army families is close to my heart and most are temporary here – 18 months to two years.

What about the high population of non-English speaking soldiers? Will there be doctors/nurses who can help and assist them?

Jon James - We did some additional training around looking after them and made sure we had family officers who could translate so if there were any problems we knew about them. We will try to do our best for them.

Pregnancy and childbirth is the most primitive thing women do. Any woman in here who has had a child knows there is nothing on God’s earth in which you can second guess –but generally speaking they want to know they are close to home in safe conditions. They don’t want to go to James Cook because it’s too far away?

Once your child is born, the greatest fear is keeping them fit and healthy. If you remove paediatrics, what about accident and emergency? Those who are seriously ill need a paediatrician and parents want to be reassured at all times. Mums want services on their doorstep as much as possible.

Jon James – The crux to this is providing services as local as possible and as safe as possible. As a rule of thumb, the more technological the problem, the further away the service will be. If you look at large national studies mums who are having their second babies (and had no complications during their first labour) are low risk – statistics show it is unlikely anything bad will happen although obviously there are exceptions.

The issue is around mums maybe having their first baby (who want to be in a consultant-led unit) or mums who have had complications in the past would have to travel to another hospital. The issue is if we decided to run a midwifery- led unit would women use it?

The meeting closed at 8.45am.