Meeting at Thirsk Racecourse

Panel Members: Jill Moulton – Director of Services Strategy and Infrastructure Fiona Bryce – Consultant Obstetrician and Gynaecologist

Facilitator Is there anyone for the first question?

Audience Good evening, someone has got to start. My name is David Tucker. I live in Thirsk and I have grandchildren and I write for the Thirsk Weekly News. My question is this: Does the CCG accept that the over-whelming majority of people in the catchment area of the Friarage Maternity and Paediatric Services, who have expressed their views, want full Maternity and Paediatric Services to be maintained at the Friarage? And does the CCG accept that this constitutes a reasonable requirement by people on their GP lists for the purposes of Section 13 of the Health and Social Care Act 2012? And if not, why not?

Panel I think it’s the duty of the CCG to make sure that all Services that we commission are safe and that is the clinical duty for us. I am on the GMC Register, as are the other GPs, and it is the fundamental principle that we can’t commission an unsafe service. I think that in these days where there has been so much discussion about safety and quality, we have to be absolutely certain that the service that we are commissioning is safe.

When we did the pre-engagement we listened to the public about transport, we listened to them about their concerns, particularly with the families who use the services a lot and we listened to the experts around safety – I am not an expert around Paediatrics and Maternity but I trust the people who are. We have listened to the experts locally, in the hospital, we have listened to experts nationally and internationally and I have had phone conversations with the President of the Royal College of Paediatricians and what I know is that we have looked at every option and we feel that we have no choice but to do what we think is the right thing clinically for patients.

Have you any other questions?

A Hang on, you haven’t answered mine. My question was do you accept, from the views that you have heard, constitute a reasonable requirement on their GP lists for the purposes of Section 13 of the Health and Social Care Act 2012? Or are you ignoring their views?

P We are not ignoring their views, but there are …. What I am trying… what I think I said is that there are some ‘bottom lines’ around safety, we cannot commission an unsafe service and I think the other thing is; what we had was 600 questionnaires, we didn’t have a 121,000 responses which is our list.

A That’s across the whole of the area; I’m talking about the catchment for the Friarage.

P That’s 121,000 people that live in Hambleton and Richmondshire.

A No, no, no, no … you are including Whitby.

P No there is 144,000 people if we include Whitby.

A How many have approached you that are not doctors, who are in favour of the plans you have?

P Many, many people …..

A Number?

P I don’t have a number, all we have is 600 people and even within that 600 we have had some people in favour of this and I think there are …. A lot of people had conversations and there are people who are unhappy with the service at the Friarage who have come to talk to be personally, they don’t come to a meeting like this, so I think it isn’t true that the majority people on our list have contacted us to say they are not in favour of this.

A But you haven’t told them about the Midwife shortage, have you? You say it’s unsafe to have a clinical lead service and you want a Midwife-led service but there are 4,500 vacancies for midwives across the country, and that’s a figure from the Royal College of Midwives, so is it any safer to have a Midwife-led service when there is a dire shortage of midwives, and the Royal College says that will last until 2024?

P Perhaps I can comment on that from my point…. you are talking about a national situation of course ……

A Yes.

P But that varies up and down the country; we have got a midwife sitting in front of me that will tell you that actually locally we don’t have a problem with recruiting.

A You can very glibly say ….. with respect.

P That’s not glib.

A Oh it is because it only needs a change in salaries and they all drain away to other places, don’t they?

P Can I tell you that that is not our experience actually and we have a very stable midwife population locally and I don’t know what change in salaries you are referring to but, you know, we do not experience recruitment problems with midwives at the James Cook or the Friarage Hospital?

A Despite the national shortage?

P Despite the national shortage.

A Of 4,500?

P We can talk at length about problems with other staff but midwives are an area where we are secure.

A So you are telling, at this meeting, that you have no anxieties that you could run out of midwives?

P I mean Fran, would you like to respond?

I’m a midwife (TC: 00:06:00 inaudible) at James Cook and at the Friarage. There is a national shortage of midwives and that national shortage has been (TC: 00:06:06 inaudible)

A 1 to 28.

P (TC:00:06:14 – 00:07:03 inaudible)

We have not had this problem in relation to staff, what I would say about salaries is that it is a nationally recognised set standard for salaries of midwives that is supported by the Royal College of Midwives and is supported under the gender for change and therefore there isn’t a salary issue, every midwife in this county doing a midwifery job is paid exactly the same, so we do not have the same problem in midwifery the same way that it could happen in nursing as it is a set standard.

Thank you for that Fran, I think that was one question and several others, so we will just move on but you can come back. Did I see another hand towards the back of the room – the gentleman at the back there?

A Hello, my name is Andrew Eaton, I’m the father of Amelia who suffered brain damage at birth from oxygen starvation. I want to ask, are all options linked with the Midwife-led Unit or is there a no birthing option? I say this because there are a number of mothers and fathers who feel that a Midwife-led unit without paediatricians is just too dangerous for low risk mothers and to add onto that I would like to see figures and the numbers of births that entered the Friarage over the last 5 years that are considered as low risk that have had paediatric or some kind of intervention that would not be there under a Midwife-led unit. That’s one question….

P Can I answer that first?

A Yes, sure.

P We aren’t consulting a Midwife-led Unit that’s true and I think that was a decision made by the PCT and I think that is based on the national evidence, which actually shows, there has been a big study that 1,000’s of births across the country and it showed that if you get the selection right and the right people delivering the Midwife-led Unit, it is as safe as delivering in a consultant lead unit.

There are risks in both, I completely agree, there is no such thing as a completely safe delivery anywhere, not even in a consultant made unit, things go wrong but actually evidence is that it is as safe in a Midwifery-led Unit as long as you select the right patients and I think it needs to be an individual decision for each person making that choice. There will be no compulsion to go to a Midwifery-led Unit, every patient will be able to make their own choices and there are many women who would rather go to a Midwifery-led Unit because they feel that there is less medical intervention, it’s a nicer experience and actually there is some evidence that there is a lower intervention rate and they have nicer births. So there is a counter argument, but absolutely agree with you that I think there are some concerns with delivering within a Midwifery-led Unit.

A I think more in a Midwifery-led Unit, the statistics you have got are when there are obstetric and paediatric support not 20 miles away.

P No.

A That’s where my last part of that will be, can we just show … I’m just going back as my wife entered their as a low risk and we have … I would like to see …. And she has actually asked me to ask that question – how many low risk births enter the Friarage that then needed intervention during …. That is something we would like to see and that would give you a figure of how many need to travel up the A19.

P Actually the study was about standalone Midwifery-led Units, it looked at them, it looked at the ones that are alongside a consultant lead unit and it looked at those that delivered in a consultant unit, so it is all three and it did actually say it was safe. But, absolutely, if TC:00:10:00 you deliver in a Midwifery-led Unit and something goes wrong very, very quickly, you would have risks involved in that, that’s true and that would be decision that each women would have to make.

A That’s a question come from mothers aren’t here tonight ….

P Vicky is absolutely right in what she said about birth rate, what I would say is I can’t actually discuss your particular wives position but strict criteria to enter a Midwifery-led Unit is about low risk and it is very specific low risk factors equally the other element of it is having well trained staff, with clear guidance and at the point that it becomes a deviation then you have to have back-up support and direct transfer to a main unit, that you may not do if you are in an obstetric unit, that keeps patients safe.

You can never remove every single risk, you can’t, patients need to know that but the reality is, we can only go by the evidence and the evidence says that if you have strict criteria, you measure patients very carefully against that, you monitor that criteria throughout their anti natal period, on admission you do an assessment, you continue with that close assessment, you identify your problem and you transfer or you retain in the unit if you don’t identity any issues then you have exactly the same safe outcomes and possibilities as you have walking into an obstetric unit.

You can never remove a whole risk, but it is important to remember that the vast majority of patients and women who come through our unit have safe, normal, uneventful outcomes. You asked about numbers, there are 1,250 on average, per year, that deliver at the Friarage, of those that entered antenatal, without any identified complication went through labour without any identified complication and did chose an epidural, because you can’t have an epidural for pain relief in a Midwifery-led Unit, there are 500 women who have the option of delivering in that Midwifery-led Unit but then patient choice will come into that and it’s not a Midwifery-led Unit as soon as you put paediatrics in. It is an important distinction in it.

A I’m fine with it, but I think there are people who do not understand the risks and I think, as long as you can highlight them then … that’s what these ladies have asked me and it’s not just one it’s a significant number who have asked that question. So jumping on ….

P Have your second question and then we will move on – yep.

A Friarage – of women who went in as low risk that turned to high risk. You must have those statistics, how many women in the last few years have gone in as low risk deliveries at the Friarage that have turned to high risk unexpectedly because they will be the women that will be ... or may need transferring in future.

P I’m not sure I can give you that percentage, but we do know …

A How can you not have that percentage? It is completely relevant to your decision making process, is it not?

P We can get the percentage, but we know from studies that around about 40%-45% of women having their first baby will, and that comes from studies from home confinement, will need to transfer into hospital, it is slightly less for women who deliver (this is a study that was done a couple of years ago) … it is slightly less for women who are in an MMU and then transfer to a high dependency care …..

A And that’s on a national level?

P That’s on a national level. I would very much like to see …… specifics …. In my experience that is probably the same for women in the Friary too, but as Fran mentioned there may not be very high risk but may transfer to high dependency care because they are having an epidural, for example, for pain relief, now that doesn’t mean ….

A So any women wanting on a birth plan that she would want an epidural will not be encouraged to go to James Cook?

P We wouldn’t have that service.

A No-one who was intending in any circumstances to have an epidural?

P It just wouldn’t be there.

A So most first time mothers want it as a back-up plan …

P Absolutely.

A So most first time mothers will elect to deliver elsewhere.

P If they want an epidural, they will not be able to have that.

A So the numbers are probably going be unsustainable for a Midwife-led unit?

P Yes. You have to think we only have about 9% of our women have epidurals so our uptake of epidurals and women wanting epidurals is very low, we pride ourselves.

A But I would think that the percentage that would like it on their birth plan as a back-up is probably quite high.

P We have never said and have never hidden that fact that epidurals will not be available at the Friarage, just as consultant paediatricians will not be available to resuscitate your babies. Midwifes are trained in resuscitation skills and they can resuscitate the baby to a degree but they cannot resuscitate the beyond that.

A Well, I find it hard to believe that that is going to be safer than what we currently have but I am sure you will convince us of that. I’m sorry to interrupt.

P Epidurals do not make labour safe, an epidural is to provide a women with pain relief it’s not about having….

A No your conversation of having paediatricians at hand, I can’t see how that will not be safer than having a midwife unit.

P Because we select the patients so that they are low risk.

A Yes, it is clear but there are circumstances when the unexpected happens which there won’t be any back up for in future.

P Well, there will be midwives that will be trained to resuscitate babies.

Ok, we will go back to the second question.

A At the previous meeting in Thirsk, you said about there would be a review about the ambulance support, has this been carried out and are there any outcomes. I believe in your initial support there was a lack of paediatric ambulance technicians or was that in your very original report - I don’t know whether that has now changed?

P I think that was a concern that was raised and what my response was, the ambulance service are now trained to resuscitate children from road traffic accidents and that kind of thing, they have always had that kind of training. We have a member of the ambulance service, if that is helpful, I’m sure Vince is happy to take questions.

We have planned to put in an investment into the ambulance service for the first six months of any change, and that ambulance service will be based around Northallerton to support the MLU particularly, so that we get fast transfer between the two hospitals. We are also going to put in a shuttle bus between the Northallerton site and the James Cook site, which will run five journeys a day and that’s in response to people struggling to get to James Cook, particularly those who have children in the special care baby unit etc., who have children there for a long period of time and that will benefit not just those families but everybody who would like to go up to James Cook and doesn’t want to drive that far.

A Can anybody use the service?

P That will be for everybody and it will be free and it will run from the Friarage site to the James Cook site five times a day.

A Is it just for six months?

P It’s for six months initially, because obviously if people don’t use it, we won’t continue to commission it but if people use it we will continue to fund it.

A That shuttle bus, is it ….. sorry, the shuttle bus itself, is that for parents to use who have sick children who need to get to James Cook if they can’t get to the Friarage?

P No.

A OK, so what do you do in that situation?

P If your child is unwell, what you need to do is get hold of your GP or GP Out Of Hours and they will then be assessed by your GP and the next stage of that is, if they need hospital care will be a decision you will make with your GP as to the fact as to where they will go and how they will get there. Most children now who are unwell and are seen by their GP goes to hospital in their parents car.

A What if you don’t drive or don’t have a car? How are you going to get from the Friarage to James Cook and back again if you don’t have the transport?

P You would go … if was considered the right thing to do, you go in an ambulance and the other thing that came up at a meeting in Northallerton was that somebody mentioned to me that they had gone up with a child with abdominal pain and they had gone in the ambulance with their child and they hadn’t taken their car as well and they got stuck at James Cook and couldn’t get home, so what we are going to do is organise for a taxi service to be available to take those people home, which we will pay for.

A So the Trust are going to be paying for taxis but they cannot afford to put any more money towards the services that we actually want to stay there?

P The amount that ………… the number of people that this will actually affect is very small and what we need to ensure is that those people will get home safely but the numbers are tiny.

Just before …. Have you finished your …. Have you got something to add and if you do want to talk as a supplementary question to the topic, please indicate rather than jump in and I know I have two people waiting, the gentleman and the lady just to the left here.

A I have one more, this is more sort of a logistical thing, will any suggestions to changes to TC:00:20:00 your options you have presented in meetings being incorporated into any future options or end solutions or will you enquire somebody to formally present those and I’m talking about … we’ve had a lot of talk about nurse practitioners etc. which don’t appear in yours but if someone has made that suggestion, how would you incorporate that or would you expect them to provide a bit more of a solution?

P What we like to do if you could put those ideas in writing, if they can and send them to me, then what we will do it work them up and then they will be put through the same assessment criteria that we have put through all the other options, the seven options, and then we will feed back to the people that are concerned and that will be part of our report. We will take them very seriously and I have already spoken to the Trust and we will work together to really work them up as a business case and understand what the issues are and feed that back.

If people do not feel they can write it down, then they just need to contact me and we will have a conversation about it.

Thank you. The gentleman that had his hand up much earlier on, am I right in thinking that? Did you have your hand up? It’s the lady in white then at the front there and then I’ll come to you madam at last.

A Hello my Rachel Hawkyard I am a parent of two children and I also work as a paediatric dietician in the Thirsk area. My question comes because my youngest son has had quite a lot of medical input since his birth and would just like to highlight the problems of getting from Thirsk to James Cook where he has had two overnight stays, there is no signs off the A19, so to get from here to James Cook there no road signs at all. There are no road signs until you get to almost the hospital really and for people going to the hospital from here, which is an area that you have probably never been before, it’s very difficult. On both of my experiences up there, already stressed, not knowing whether my son is going to be in hospital overnight and no road signs at all.

The second problem is, when you get to James Cook there is not parking, end up parking on verges, double yellow lines, in front of other cars, blocking cars in, it’s a really big problem and it’s very stressful when you are a parent with a sick child in your car. Third problem, when you finally battle into the hospital, the letters they send out have different names for the departments that are on the signs in the hospital, so you are struggling around trying to find paediatric outpatients and on the letter you have, something along the lines of, paediatric day assessment, this took up lots of time because of the misprint on the letter versus of what all the signs said. We got to the appointment quite late for all of the reasons stated and then for the overnight stays it is quite difficult to find the children’s ward, I have to say when you actually get there the quality of care was outstanding and the staff looked after my son very well and looked after us as parents very well and looked after his sister, as a sibling, very well. I can’t fault the care, once you get there but getting there is very stressful.

P We will absolutely address the road signs, it’s a really good point and thank you, I am sure there is a lot we can do around that.

Can I just comment on that the road signs are actually the responsibility of the Council, so we cannot go and put road signs up but we do work with the Council with that and we do go back on a regular basis and talk about it, so if you found that difficult we can share that experience. On the car parking area, yes we recognise it can be very stressful, I think sometimes there are car parking spaces there but people don’t find them because the site is so busy, we have got planning applications at the moment, again with Middlesbrough Council, for more car parking spaces and also to take an awful lot to the staff car parking off the site, because part of the problem is that visitors coming onto the site are battling with staff coming off at some times of the day, so we are talking about a different road access which means that over 1,000 staff can leave the site by another exit.

A Sorry, but you are closing a car park, aren’t you that is 900 spaces?

P We are relocating it, we are moving it.

A So you are not actually locating any additional spaces.

P We are, we are creating 400 additional spaces, as we are closing a car park of 900, building a car park of 1,100 and then building a car park of at least 200 and actually if we can push it with the planners we would like to put that up to 400, so there will be a minimum of 400 extra spaces and some of those will be patients spaces. Also, they will be better located, because I agree with you the layout if far from ideal and we have got to make it better, but believe me … it is very important to me that we bring this particular scheme to a conclusion because it can make a big difference to people and I don’t minimise the stress that people experience, I do know that it is very difficult, I am responsible for car parking so I do deal with people in your situation very often and genuinely we recognise it needs improving.

A And will you also look into checking that the letters that are sent out say the names that are in the hospital?

P Yes certainly, and again signage we need to keep refreshing all the time to ensure that it is as good as it can be, so thank you for your points, I think they are well known.

The lady at the back and then I will come to the gentleman the other side.

A I have been here several times and nothing to do with maternity or paediatrics, what you keep saying is safe – what do you mean by safe? I mean James Cook is not 5 miles away, it is from 23, from here, you have to go 23 to 30 miles to get to a hospital, and so what is safe? I mean it’s not just like a short journey to the next town, it’s a long, long way and that is if when you phone a doctor, you can get the proper response and when you don’t get the response and you have to phone again and the doctor can’t come but the same phone an ambulance and you phone an ambulance and they won’t take your call because the doctor hasn’t ordered it. So you go on and on until you don’t know which way to turn and you are talking as if it is safe but when you take the facilities away, it’s not safe – it means death. I mean it … how many side wards to you have at the Friarage to put people in because they will not survive the journey to James Cook and let them die. I know. I know a person who it has happened to as well. You are talking, all we can do … it’s clinically safe, what a load of …. It’s not safe at all.

It’s a long, long way … especially children and women when they are in a desperate situation, it’s a long way. I hold you all accountable and I think this decision was made long before, long before you’ve made it. How much has it all cost? You could have built nearly a new hospital all this consultation and everything, it’s costing a fortune and you’ve already made the decision ages ago.

P A question from the gentleman in front of you John.

A I would like an answer to that question please – an answer to the question of safety. Are we going to hear it or not hear it?

P Thank you John, there was a question about clinical safety, do you want to take that?

What we mean by clinical safety, I think … I went round the Friarage Hospital and went to the maternity unit and it was lovely and I met mums who had had their babies and it was lovely but what we know … and there is a lot of research behind it now, there is a lot of very good research you can find online, but what it shows us actually from a maternity and paediatrics you need to have people who regularly see serious things happen and what the Friarage don’t have is enough through put so that the staff their do not find it as easy to recognise a deteriorating child and somebody getting into trouble and when TC:00:30:00 things go wrong you need to have all the facilities there for resuscitate your child. If I had a child now, who was unwell, I would take them to James Cook and if I think that is right from my child then I think that should be right for everybody’s children. That is what I would do and I think that safety, there is no such thing as 100% safety ever, but what we know though is that the services at the Friarage are not going to be as safe as those at other big hospitals.

A They have been in the past, they have been in the past but you want to make dinosaurs in big hospitals. We don’t matter.

P But services move on and standards improve and we do more things and it’s a bit like, if we talk about heart attacks, in the old days, when I was a young doctor if you had a heart attack and you were over 70 the hospital wouldn’t even take you.

A Well you’ve got that here at the Friarage.

P But now what happens is that if you have a heart attack the ambulance is call, the ambulance does an ECG, they take you straight to James Cook to the Cath Lab where they put plastic tubes in your heart, open your heart up and the muscle that was going to die doesn’t die and you don’t die and that has made such a difference to the life expectancy of people who have had heart attacks in that that …. As a GP, as a young GP, loads of my patient s just died of heart attacks and there was nothing I could do. That service has been completely revolutionised now and I think that is what we mean by safety, those things were not available 25 years ago, they are available now. That is also true of different procedures within maternity and different things in paediatrics, the whole of health care has changed and moved so much and we need to keep the services here up to date for people.

Thank you. Gentleman to the right and then I’ll come to you.

A If the facilities are the Friarage are, in your opinion, very good the only thing you are short of is people, why not just move the consultant with the blue light on top instead of moving a sick child and a parent? Isn’t that more obvious or maybe I missed something I came in late – I’m sorry.

P The problem is the consultant is busy looking after lots of sick children at James Cook, the problem if you want a consultant in two places you get back to the original problem of an extra £2.7m to provide a service for 1 or 2 people which, as Vicky says, deprives other people with other different problems, not paediatrics, of money and that’s not acceptable for everybody else. We have to consider the fact that providing a service at a small unit has been shown to be unsafe even if you invest in it, there are situations, down in the south of the country, where similarly consultations have happened and two units were kept open instead of merging as had been planned and there were multiple serious untoward incidences some of which ended in death, both in the maternity unit and the paediatric unit.

We have to accept that safety is very important and if that means having all the doctors, all the facilities and all the nurses in fewer larger inpatient units. There is a recent consultation that you can access on the internet, a paper from the Royal College of Paediatrics and Child Health saying that we are going to have to shut even more units because of maintaining safety, everybody has to be in a bigger unit.

A But it’s 30 mile away.

P There will be often more further away than that in the future, there will be fewer larger units further away.

The gentleman next to John and then John. The hand at the back.

A Sorry, I’m going to talk a little bit more about risk again and I think it goes back to what Lisa said about wanting local statistics, because I looked into quite a lot of information about midwifery units and I was actually quite surprised to realise the different distances between the different units. So … some of the midwife unites are on the same sites as the obstetric units, some are 5 mile away, some 10, some 15, some 20, some 35 and some more than 40 miles away from the obstetric unit, the problem with looking at national statistics and as Andrew mentioned about the fatalities and people that don’t make it, they don’t distinguish between … if you have a statistic that is national about emergencies well logic would tell me that if you have got something that happens in a unit that is next door to an obstetric unit that can actually bias the statistics because what we don’t know at the moment, we don’t know whether there was worse outcomes for children, babies, if the units were further away and that’s what is missing from your national statistics.

P Actually the statistics you are talking about is there is one unit that is co-located and then a distal unit, the evidence that usually presented is all distal Midwifery-led Units, because it’s all about transport and all about transfer, you don’t have a transfer issue if you are on a co-located Midwifery-led Unit, you literally, wheel a lady round the corner, so in actual fat you will find that most of the statistics relate to non-co-located units.

A Well, that’s what I am saying, some of those co-located units are 5 miles away from the obstetric unit and some are 40 to 45 miles away, I’m not saying there is any difference between these journey times but as a nurse and personal logic, I would think that the longer the delay is in treatment the worse the outcome. If we go back a little about what was said about the heart attacks, you know, if you don’t get someone to hospital in time it doesn’t matter what you are going to do, if you have to get to a hospital within 18/20 mins from a major cardiac arrest in a rural location like this, it’s OK that you can say you can give this treatment but the person has to be in hospital to receive the treatment. The other thing is, in these distal units, there is also the response time for the ambulance as well as the journey time and that, it could take up to 40 mins for an ambulance to arrive, we don’t know because the information isn’t there at the present moment in time.

P What I would say is actually you are right, there is no national evidence in relation to transfer time, so the total transfer time that it takes to get from a Midwifery-led Unit to a main unit, that is … there is no evidence out there to provide you with nationally, however, what they do recommend is the response time to an emergency but the ambulance service and all Midwifery-led Units run on response time of looking at 8 minutes. So obviously, running the midwifery unit is vital to that which is why the CCG have looked at an investment for an extra ambulance to ensure that and that’s not a response time from home it’s an inter-response time from hospital to hospital, which is different but is absolutely vital.

It is equally important that when the ambulance arrives the Midwifery-led Unit is very clearly geared up and ready to transfer the lady, there is no point in the ambulance arriving and then the Midwifery-led Unit takes 20 minutes to get the women onto the trolley and into the ambulance, so the whole system has to be absolutely protocol driven and par to that protocol is that if you ring ahead, you ring the unit you are transferring to, you align the protocols of the Midwifery-led Unit to the main unit so that everybody is clear what the actions are and you are absolutely right there are distances of 60 miles and more in places in North England and Scotland, particularly, and actually you will find that there is actually little difference in outcomes that are relevant of the distance. I will go back to clear admission criteria, early detection of abnormality and quick transfer and they are the 3 keys things that will keep you safe.

Vince, do you want to say something from the ambulance service?

Yes, as far as we are concerned from the ambulance service perspective, we are quite happy, we have put forward a proposal for extra resources and from our prospective so long as we negotiate the pathways with the clinicians concern, and that means the doctors that work for the ambulance service as well, along with our colleagues from South Tees, as long as we get those pathways right and as far as I am concerned we will be able to still provide a safe level of care in this area and the important part for me is the fact that if we provide that extra ambulance cover what it does do is preserve the emergency cover to the existing emergencies that we deal with on a day-to-day basis.

Thank you.

John.

A Hello, can you hear me? I am John Blackey, I am leader of the Richmond District Council and I am also the County Councillor for the Upper Dales and I hold various positions for the County Council, I just have three questions are this point in time and I would like to say something later in way of an announcement in respect to an option but at this point in time three questions.

My first question is about the long term sustainability of Midwife-led units, the one at Guisborough at Jill Moulton knows has closed down, right I’ve just seen her mouth ….

P Yes, you’re right John, I’m agreeing.

A After a great fanfare when we sadly saw the Midwife-led Unit at Whitby, Bridlington and TC:00:40:00 Malton close to open a super, duper Midwife-led Unit in Scarborough, co-located fair enough, with a consultant unit the Midwife-led Unit there is closing for 20 weeks and I have spoken with Mike Propter, Jill Moulton will agree with me, is the Chief Executive of the Scarborough Hospital, there is no guarantees it will reopen again, they need to save £1.8million. Bishop Auckland used to have a lovely Consultant-led Unit, people came along to a meeting like this and were told it was no longer sustainable; we put a Midwife- led Unit in and the Midwife-led Unit doing about 250 births a year has now closed temporarily, of course, why? Because the ambulance service could not find two ambulances a week to rush people from Bishop Auckland to Darlington.

Bearing in mind our ambulance service, Vince didn’t say anything about the statistics, but of course we only get 56% opposed to 75% the national standard of emergency response times. I see your hand up Vince, but I’m talking at the minute. The fact is what we are being consulted on here is a Midwife-led Unit that is doomed to failure, doomed to closer and simply this is just the first phase of a total consultation where there will be no live births anymore at the Friarage, it will be just a matter of time. I would like a response to that. I would like to know because I represent people 60 miles away from the James Cook, a wonderful hospital but 60 miles is a long way to go, I’m sure mothers to be and mothers in this audience will realise that. I would like to know then … can I take back to them tonight that if they are considered high risk and they live in Hawes then your advice would be that they should book in at the Darlington Memorial Hospital because it is the nearest. I want you to say that so I can tell them.

The third point is, somehow or other I seem to be the target occasionally of mothers-to- be when they want to come and have a chat with me and recently expectant mothers have been telling me that when they have booked in, as they do when they say they are going to have a baby, the offers have been anything from January onwards, yes you can book in the Friarage or you can book in at the James Cook University Hospital because the Friarage might be closed, so all of this is a pantomime, is it not? Could someone answer this please, because at the end of the day you have already made your minds up, it was a done deal, the lady behind me is right, you had made your mind up years ago and we are just going through a pantomime and exercise of fait au complet? I look forward to your replies.

P We will take the long term sustainability first.

I think we are very clear about the MLU, we hope it works, it isn’t for us to choose, we can commission it, i.e. we can talk to societies about providing it at the Friarage whether it is sustainable will be dependent upon the choices that individual mums make. We know we need about 300 births a year to make it sustainable and absolutely John, if people don’t choose it then it won’t stay open because it won’t be safe and I’m not pretending about that, I’m very clear about that … we have always said we can only have a unit there if it is sustainable and actually that is up to individual people and the say it true, actually, for the short stay assessment unit for paediatrics, if people choose to go to Darlington instead or to Harrogate or straight to James Cook that unit will not be sustainable and I think that is a real discussion with the public, this isn’t up to me to decide what you want , the service will be there how you choose it will be up to you and that is my same response when we talk about the mums in Hawes, I think for mums in Hawes it will be an individual decision, certainly Darlington is 4 mins longer than the Friarage, so it really is a real option for people having to travel all the way to James Cook but there may be women who want to go to James Cook for some reason.

A If they are high risk I said.

P Yes, absolutely.

A At high risk, your advice as a GP would be that they should book into the Darlington Memorial.

P No it wouldn’t be actually, I would explain the different options to them as a GP, that’s my job, I don’t make choices for people I …. I think GP’s used to make choices for people, quite a lot actually, but I think General Practice has changed a lot now and what we do is give people the options, we explain the pros and cons of the options and in the end it is up to the discussion between the GP, midwife and the patient decides the right place to go and there may be many reasons why they may wish to go straight to James Cook, you have to look at each individual case. So I don’t think I am saying that everyone in Hawes has to go to Darlington….

A Is it the safest choice if you are high risk?

P No, I would think … my view of it is that going to James Cook, going to Darlington or York or Harrogate is the same, it depends on where you want to go.

A Do the Friarage take high risks now?

P Yes.

There are some very high risk births at which time it would be safer to have a delivery at James Cook because they may need either the baby may need intensive care or there may be a high risk that the mother needs some intensive care but that has always been the way, that is not different now than it has been all the time I have been there.

In terms of the pantomime, I would not want to not answer that question, it is absolutely not a pantomime, we have tried and gone all over the country to try and find a different solution, I have talked to many, many people because we know that everybody here wants a different solution, the difficulty is that we had some real ‘bottom lines’ and we have listened to the public about transport, we’ve listened to the public about how to make services better for the children that use the Friarage all the time, we listened to the public and I am completely will sort out signage on the road to make sure that we work with the car parking and all those bits and those are bits that we absolutely want to do, but we can’t compromise on is safety, because what I do then is listen to the experts about that and I think that’s the right thing to do. So, I think I have always been very clear when I have done these meetings that we listen as much as we can but there are limits to that, there are those things that as a clinician I know I cannot promise you.

A And expected mothers being offered from January onwards one or the other.

P No John they are not, we are not telling midwives to do that that is not what the hospital is doing.

A And the fact that I have been told they have been you would be surprised would you?

P I would be surprised yes, very surprised.

A (TC: 00:47:35 inaudible no microphone)

P If they book now for delivery will they be able to deliver in the Friarage and our midwives are asking us what is the advice and our clear advice is this unit is business as usual, there is no decision that has been made, we need to wait until the consultation and at point of consultation, if that changes, it will become our responsibility to contact every woman that is current booked with our services and make sure that there options and choices are clearly discussed. But women already have the option to go to the surrounding units and some of them indeed do and historically have equally patients in Harrogate sometimes choose the Friarage or James Cook and patients currently chose Darlington so there’s …. We do try and give patients choice but patients are actually asking us and we have been very clear that it is business as usual and we must reassure the public as much as we can.

Thank you very much Fran. That is a response to all of your questions I think John. There is a lady at the back then .. this is this something to do with a particular question? Yes, it was yes, we will take that person and then come to you.

(Vince) Thank you very much for sitting here and been patient, I just wish to put the records straight, I know John quoted the figures for the ambulance response times and was specific to the red one calls which are the most life threatening emergencies that we categorise as an absolute priority, I think just to put the records straight and to readdress, and reassure the public basically, because this is a public meeting, in August the latest figures were we actually exceeded the national response times for red one, life threatening emergencies in the Hambridge and Whitby area, I think that is due to a lot of hard work by my management team and we have a good liaison with the CCG in terms of working differently and we are actually working with Commissioners now that actually understand the ambulance commissioning agenda, that’s the difference, yes alright the challenge for me is to sustain those kinds of figures and that’s what we intend to do and (0050:00) by working alongside commissioners and doing things differently I just felt it was really, really important that we just readdressed the balance in terms of what we are providing as an emergency cover and the fact that our figures are now, or certainly for August, have exceeded the national response times.

A (TC:00:49:57 in audible – no microphone)

P I will take that as a well done John, because we have worked very, very hard to provide the locality of Hambridge and Whitby with a better response time and we’ve actually done that in August and as far as I am concerned that is down to the hard work of the paramedical staff we have out there in vehicles and the management team they are supported by and, as well, some of the liaison and the work that we are doing with the Hambridge/Whitby CCG. Thank you.

And John, I think we actually talked to the Health Committee last month about the initiative that will be happening with the ambulance service, we have three or four initiatives going on which are designed to stop the ambulances going out of Richmond and Hambleton with people who could be seen by their GP so the ambulances can now take people directly to their General Practice rather than take them to hospital if that is more appropriate. We have also worked at having the ambulances stood outside some of the surgeries and we have had paramedics working in the practices and we believe that those things that we have done with the ambulances are improving the response times.

Thank you. Definitely going to the back this time.

A A really, really easy question sorry, I hope you can answer. How many beds are there in Scarborough or James Cook?

P Well in special care or intensive care.

A Well special care is more precedent on what I can answer to or ask questions regarding but you can give me both that would be nice.

P There are 10 intensive care baby unit cots and there are 12 special care beds and the cost would be a flexibility to actually extend that.

A And there are 10 in the Friarage, so how many are you adding to James Cook?

P 10.

A Is that it? Interesting, because the night I had my child the closest bed, if I hadn’t got the last one at the Friarage was Manchester.

P That would have been for intensive care.

A No that was Scarborough and by the time I had my child, two nights after the closest bed was Glasgow, so I’m pleased I didn’t have to go to Glasgow. Going on from that, because I think you probably need a few more beds than 22, possibly because for the Summer of 2010 but that’s not for me to decide, I’m only a teacher.

The next thing I wanted to point out was on page 8 of this book, I don’t know whether anyone has read it, but it says here …. If you are at low risk you can choose and it is then the home birth or the Midwife-led, I just wanted to point out bullet point number 5, 24 hour advice line for breast feeding support and if you are on high risk you can go to, wherever you want to go to probably James Cook, it doesn’t say you can have any advice re. breast feeding, now I presume you can and I know there are helplines that you can, because I am a committee member of the NCT, I just think it needs to be there, because my baby was in SCBU and let me tell you I needed support with breast feeding., a 33 week premature baby was something I needed help with, that needs to be in there if you are putting that as an option, people need to know it’s there. Going on from that, the shuttle bus that will be presumably running at night so people can go and breast feed in the night?

P No.

A No and the next thing is the increase in high risk birth, it’s what you said in the video, so would that, like I said I’m not a paediatrician or anything but I’m thinking that means that you will need more medical care needs to be available. So if there is an increase in high risk birth and you are saying that there is a higher risk, James Cook perhaps is not enough on its own anyway.

P But the doctors who are working currently at the Friarage will be working at James Cook. Is your point that we won’t be enough ……

A I keep worrying that there won’t be enough care. You say it’s better care fine, I’m happy with you saying its better care, fine but will there be enough care, if you are taking beds away and what not …..

P We aren’t taking beds away we are adding beds at James Cook.

A Yeah, keeping the amount the same.

P The clinical times, the high risk deliveries that are currently at the Friarage will be redeployed at James Cook so there will be more consultants and clinical input. It is our responsibility to make sure that when these services transfer that the care is safe and the resources are in place to do that.

A I do get that, I do get that you are not going to leave people to die on purpose, but I just don’t, I just don’t get it. I just don’t get how moving the consultants from A) at the Friarage up to James Cook solves everything and I know you are saying that they can share skills and all the rest of it, but like somebody said over hear about bringing the consultants down to the Friarage, and I think you said in one of the meetings a while ago now that you couldn’t recruit to the Friarage because people would not want to move to the area and I just don’t get that either. I also don’t get when you said that a consultant needs to live within 20 minutes, they have to get to the Friarage or the hospital within 20 minutes and then you are saying they do not want to live within 20 minutes of Northallerton and the Friarage, and then you are saying that James Cook is only 20 minutes away.

P Can I just say, we are not saying that people do not want to live near the Friarage, we are not saying that people do not necessarily want to work at the Friarage, but …..

A Well, I’m sorry I misunderstood your point before ….

P But we have had difficulty recruiting into the Friarage, we have succeeded recently for one recruitment it took us 2 years to get somebody with the appropriate skills, part of the problem is that when we do successfully recruit, whereas our current consultants do live round the Friarage, people we have recruited more recently; for instance we have two consultants who are job sharing, live in Newcastle. So yes they are available to work in the hospital during the day for their normal hours and when they are on call they will stay in the hospital but they cannot offer the service that our current consultants offer who are willing to come in outside of their on call duties whenever, simply because they will locally and our problem about safety is we cannot continue to plan to provide a service on the way it has been provided historically because people are not going to work in that way into the future, so we have got to plan for the circumstances we have now and the circumstances we will have not on what has traditionally worked. In terms of doctors working between sites, as Fiona says, we have 4 obstetricians at the Friarage for 1,200, we have 9 at James Cook for 4,500 and we do some good. But James Cook is a very busy hospital, we have just about the right number of doctors to provide the right level of care but we can’t have people trying to cover 2 hospitals at the same time, we need people at the Friarage and people at James Cook and we simply can’t guarantee that we will have the right people at the Friarage in the future to keep people safe, that’s it.

A You say it’s a big and busy hospital James Cook, I wouldn’t like to be there, it would freak me out, my choice would be the Friarage but that isn’t going to be a choice is it?

P It is going to be your choice, in a certain number …… If you don’t like very big hospitals……

A No, it’s not my choice but if you remember I delivered prem, so I am automatically at high risk next time.

P OK, well James Cook isn’t your only choice there are other hospitals in the area.

A Well, put it this way, if I deliver like I did like last time I will be having no choice because it will be just there, I would have had it, it will just be there….. but that beside the point, that was under other consultations, that’s been and gone. My point is there isn’t really any choice for the women and out of a group of friends of mine there are 4 of us who have delivered prem babies and we have no choice and I know I will be high risk.

Hopefully you can tell me that I won’t be high risk and you can’t and I have a really good idea that I will be as soon as I go to see ….

P We can’t tell you that you will have the choice, you are absolutely right for you, yes we have got to accept that the Friarage is no longer an option, where we can offer people choice at the Friarage, but not in your circumstances, we very much want to do so. As Vicky said there is a choice of hospitals if people need to choose what suits them, other than the Friarage, the high risk ladies need to choose what suits their personal circumstance and that choice remains there. Yes, you are absolutely right for high risk deliveries the Friarage won’t be an option in future and that is because we do not think TC:01:00:00) that in the future it will be safe for us to continue to offer that service. If afraid that is the dilemma, isn’t it? It’s about having a service that you value and is local against us being able to say you will be safe.

OK, thank you. I am going to move on because we have 15 minutes left to get a few more in. Are you waiting and you at the end are you any further .....?

A I will be very quick. Jill, when you said about the consultants on call, at the moment as far as I am aware you have got consultant on call, registrars there, there will be house officers there, this is at James Cook, are you envisaging that with the increase in numbers that there will be more consultants on call at night? Is that what you are saying or are you saying you will have the same numbers on call at night at James Cook in the new model?

P In the new model, certainly from the paediatrics point of view, there are likely to be more on hours, as it were, from senior staff, so at the moment the consultant stays in the hospital until 9 o’clock or 10 o’clock at night depending on when it quietens down, that is more likely to extend to about midnight, but there is more likely to be more consultants present. In the afternoon, at James Cook, there tends to be only 1 consultant, there is 2 in the morning at weekends and week days, it is highly likely there will be 2 all day.

A I was just meaning overnight, after say 10 o’clock to 8 o’clock in the morning will there just be the 1 consultant paediatrician?

P Yes and the juniors, yes.

A OK, that’s fine.

P Lady at the end of the same row.

A Hi, my question is about patient choice and sustainability. On your little diagrams as well, it is clear on those as well, if I was to take my child or go into labour at the Friarage as low risk and then things changed or I needed an overnight stay for a child because they are not improving, is patient choice still available there or is it an automatic transfer to James Cook?

P For maternity, it would be an automatic transfer to James Cook for precisely the reasons that Fran said before, the safety we have to have those protocols in place that immediately we can pick up the phone to alter James Cook that a patient is coming and then we know that a patient is being safely transferred.

A Well that is going to affect the numbers because anybody that doesn’t want to go to James Cook will not step into the Friarage in case things are going to change; they are just going to choose another hospital over the top of that.

P Yes.

Thank you Janet, I think you were next.

A Janet Kirk. This is not going to be very popular but I actually support what you are actually doing and I understand completely why you are doing it. I am not going to take the time up tonight to explain why that is, but with that thought in mind, just in case this actually occurs…. You have obviously got, or will have possibly, areas that won’ t be in use in the Friarage, have you thought about what you are actually going to do with them because the one thing I have noticed that unfortunately James Cook do not seem to do since taking over the Friarage is they will talk about what they are actually going to move from the Friarage but hey never advertise what has actually been moved into the Friarage from James Cook and I think it is one of the faults that you have got and therefore consideration as to what you will do with the space and advertising that and the possibility of what you could do with the space and advertising that would possibly stop people thinking you will be closing completely the Friarage down, which I believe quite strongly you are not, but the public actually think you are.

P I think it is a good point well made. What I would say is that any space, in any of our hospitals, is an absolute premium. You know, we need to make the very best use of it and we will talk about how we are going to use that space once the consultation has finished and we will make the best possible use of it. I think your point is absolutely right. While we might not have actually moved wholesale down from James Cook to the Friarage we do offer a lot more complex specialist work at the Friarage rather than we ever did, I gynaecology and urology and we are trying to promote that and if you have been to the Friarage in the last few months you would have seen posters and banners up saying that.

You are right we do need to tell the story better that actually the range of services delivered there has changed enormously over the period since I have been involved in the hospital in 2002 and we do need to reassure people that our commitment is to making it the best possible local hospital we can with the services that can be safely delivered there.

A I have been going there since I was 9 years old.

P The lady in front, if you don’t mind pressing the mike.

A A couple of things to say I, like the lady over there I would be high risk and therefore would not have the choice of the Friarage, I would like to know, you mentioned before that you were in very interested in the views of the people and people who were of a child bearing age like myself, I haven’t seen this published anywhere actually, apart people on social media who have asked people to come because they are opposed to it. I have not seen anything from any of you, I haven’t seen posters in town or in Tesco, which to me seems like a good place to advertise it, so I think that is a point I would like to make that I don’t think it has been publicised.

P Can I just answer that first, we sent posters and the documents out to all the practices?

A But I don’t go to the doctor though.

P Sorry, I haven’t finished, I sent them to the local authorities and to the schools so that there should be fliers.

A Has anyone seen any?

P Can I just … can I just …

Can you let Vicky answer and we will see where the gaps are?

OK I’m just trying to answer the questions, the fliers went out through our local authority partners and they told us that they would send them out to every school, to every children centre and to nurseries and to child centres, so if that hasn’t happened …. We asked the local authority to help us with that and I would be very disappointed if that hasn’t happened.

A I certainly wouldn’t have seen any of those though, from what you said, I don’t go to the doctors; I don’t go to a health centre.

P The difficult thing about Tesco’s is that ….

They have actually been sent to every supermarket in every village store in Richmond and we sent a letter so thing is that they aren’t in front of you, there is a need to check

It’s very difficult if we have asked them to do it and they don’t, if we have asked Tesco to put them up and they haven’t there isn’t a lot we can do about that, what we know is that doing through the newspapers doesn’t work because that gets an older audience, we have tried to do it online and we have done it through Facebook and we’ve been on television and on the radio, I have done as many of those things as I can possibly do to try and …. It is really difficult how to get hold of people. If you have some ideas?

A Employing young people who could go and leaflet the local area, I only live probably a stone through from here ….. even if I had it …. there is a massive poster outside here, as you drive past, about a wedding fair, maybe you could have had a huge poster about this out there, it would have made much more sense to me.

P The problem is that we also get criticized on spend money on consultation; you do feel sometimes that you just can’t win.

A I know.

P We are trying.

A And then I just wanted to also say and I don’t think , I don’t know if anyone agrees with me, even though I would automatically be classed as high risk anyway, I don’t really think that the Midwife-led Unit is a choice for low risk people because personally and I am sure that … well my friends that I have talked to about as well, I would not want to have a baby, despite even if I was classed as low risk, in a place where I thought that that baby wasn’t going to get good care if something was wrong with it, that is just a point to think about I think.

P And I think I completely agree with you about that, but I have also talked to women who are very keen to deliver in a non-medical Midwife-led Unit and there are very different views about that out there but I have to say I am with you on that, but I absolutely think people have a choice.

A But also when I was a child I was in hospital for every weekend for 4 years in the Friarage, and I got great care there, but what I wanted to ask was, when a child goes in for something routine at a weekend, which I was on a Saturday and a Sunday, and there was a choice to be made that actually it was better for the child to stay overnight, which sometimes it was for me and I was on a drip and it sometimes overran, that to me is not an emergency for me to be red lighted to James Cook, what would happen in that situation now?

P We are working very closely with the paediatric community team because a lot of those things that were delivered in hospital can now be delivered at home. So actually this is one of the pieces of work we have done with the Open Access Families, the families that have got specific problems. Actually, a lot of those traditional services that were delivered in hospitals can be delivered in your own home and a nurse can go in and do that during the weekend, so those people should not need to go to James Cook or any other hospital and actually that is an improvement in services and it brings it home.

A And when, obviously there is going to be a lot more people going to James Cook, is there going to be a big overhaul of James Cook to take all these extra patients and kind of cope with the extra demand?

P We will put on extra capacity yes, because of the leading time and because of other TC:01:10:00 pressures we are doing some of the alterations now, because we have got to plan. For instance, we are putting on an additional theatre because of the number of births we have and have to have and people will say that we have already made the decision but it is very difficult for us because it takes a long time to build a theatre so when do we start, so we are putting that plan into effect now. As I said to the lady earlier, we have to be sure that we can offer a safe service and a best experience that we can, we are taking that very seriously.

And we have also been in conversation with Darlington and they know all about this and they know they will probably have an increase in births because of these changes, so they are also planning that dependent on the outcome of the consultation.

So we are at the end of the evening, we are a couple of minutes off 8:30pm, there will be other opportunities, I will come back to you in a minute John, there will be other opportunities to ask questions, I think there are nine meetings overall and there are other ways to respond to the questionnaire survey.

Thank you very much for coming and I will end the evening with John, who has an announcement to make.

A Well thank you very much indeed; I wasn’t expecting to get a star turn.

P I wanted to build it up.

A I just wanted to say, and present here tonight is County Councillor Jim Clarke, who is Chairman of the North Yorkshire County Council Security of Health Committee, the consultation Jeremy Hunt MP, Secretary of State for Health, the Independent Reconfiguration Panel, all invites an alternative option to come forward which will be properly considered and you have given your word Vicky that it will be, the Richmond District Council, the Scrutiny Committee, the County Council Scrutiny Committee are working together with other organisations and with clinicians, obviously not from the local NHS because they tend to be a bit bias but from beyond, clinicians who are quite happily running small units, Consultant-led maternity and paediatric units and we intend to put together, for the end of the consultation, a fully worked out option, a unique option that will retain Consultant-led maternity and paediatric services at the Friarage Hospital.

No Vicky, I’m not going to tell you what it is until such time as it is available for you to actually review, because you would want to see it properly worked up.

P I look forward to it John.

A I haven’t finished yet, I wanted to reissue the audience that the invitation you have made to us, that in fact the Secretary of State demanded that you did make to us is to be taken up. Thank you very much.

P Thank you John and thank you for coming along. Have a safe journey home.