Report on Review
of Reconfiguration of Woman's and Children's Services at Worcestershire
Acute Hospitals NHST
Introduction:
The project team for the Woman's and Children's Service Reconfiguration
had considered four main options at its meeting on the 13th
March 2006. Further work was proceeding on the costing of
these options and on ensuring that each was compatible with
national policy. A further recommendation was that the options
should be validated by the Royal Colleges of Obstetrics and
Gynaecology, Paediatrics and Child Health, and Midwives. This
report is presented by a Fellow of the Royal College of Obstetrics
and Gynaecology who was recommended by the College for this
purpose.
Methodology:
A documentary review was carried out, including the report
of the Worcestershire Maternity Service Review (September
2004), the Clinical Service and Finance Review (October 2005)
from Finimore Management Consultants, the Trust Strategic
Direction 2005-2008 (October 2005), summary documents relating
to Gynaecology and Neonatal Service reconfiguration, and correspondence
from interested members of staff.
Interviews were carried out over a three day period with 18
members of staff, including representatives of Obstetrics
and Gynaecology, Children’s services, Accident and Emergency,
and Anaesthetics, and incorporated the views of Consultants,
Nurses and Midwives, and Senior Managers of the Trust
Findings:
Four options were under consideration. These will be considered
separately.
Option 1. Retain existing configuration
and reinforce to continue to provide in 2009.
There was some support for this option among the Paediatricians
at the Alexandra Hospital but no conviction that in a world
in which national quality standards are likely to become ever
more stringent, maintenance of the service would be possible,
whatever the investment. The neonatal service is currently
not attractive to prospective staff –medical or nursing- and
there is reportedly no realistic prospect of approval for
a Level 1 neonatal service, which might have aided recruitment.
Anxiety was expressed about the viability of an A&E Service
in a hospital without an inpatient paediatric service but
such models are being introduced elsewhere, and with daytime
paediatric cover and a Paediatric Assessment Service from
0800 till late, most interviewees thought this issue could
be overcome with safety.
The Obstetric Service is under considerable pressure and is
unlikely to grow sufficiently to justify an expansion of staff
numbers with the commensurate skills maintenance unless there
was a regional redistribution of the service, and there is
no indication that such a wider reconfiguration is being discussed.
The overwhelming consensus of the interviewees was that this
option was not viable and even if the status quo could be
maintained in the short term, it would simply delay the inevitable
and continue the present uncertainty indefinitely.
Option
2: Centralise Obstetrics and Neonatal Care at WRH and maintain
elective and emergency gynaecology on the Alexandra and the
WRH site.
This option leaves un-stated the disposition of 24 hour inpatient
paediatrics, but recommends that (inpatient?) Obstetrics and
Neonatal services move to WRH.
The central theme of this option will be dealt with under
Option 4 below.
The particular issue in relation to Obstetrics and Gynaecology
is the maintenance of an emergency gynaecology service on
the Alexandra site. Apart from urgent ERPOC for disorders
of early pregnancy which can either be planned and incorporated
into an elective day care list, or have a daytime list designated
for that purpose (depending on the numbers), emergency gynaecology
is generally of low frequency and is usually amenable to stabilisation
and transfer. With a large A&E Department on site, there
is always a risk of e.g. a collapsed ectopic presenting, and
special arrangements would have to be in place for such contingencies
if there was not 24 hour emergency cover on site. A review
of the number of out of hours emergency gynaecology cases
over the past few years should indicate whether there is a
need to retain an emergency facility on the Alexandra site
and if this number is of low frequency then it should be possible
to move emergency gynaecology to WRH, ensuring that robust
transfer arrangements are in place for the occasional patient
in need.
Option 3: Centralise Obstetrics,
Emergency Gynaecology and Neonates but maintain 24 hour general
paediatrics on both sites. The
issue of retaining 24 hour general paediatrics on site is
beyond the remit of this paper and the issues for Obstetrics
and Gynaecology are essentially the same as for option 4 below.
Option 4: Centralise Obstetrics,
Emergency Gynaecology and Paediatrics with a Paediatric Assessment
Unit at the Alexandra site operating 0800 -2100
The Obstetric Unit at Alexandra Hospital
is currently under pressure. Staffing at Consultant level
consists of two substantive Obstetricians and Gynaecologists,
one Gynaecologist, and (soon to be) two locums, one of whom
is above the establishment figure and is created to address
CNST delivery suite cover requirements. The other locum position
is currently filled by a substantive Consultant who took up
appointment in March 2006 but has resigned to take up another
post and will be leaving in June 2006.
The number of deliveries is reasonably stable at about 1800,
but due to the difficulties in maintaining neonatal cover,
all deliveries of less than 36 weeks are transferred in utero
to WRH or elsewhere. This is likely to affect the quality
of applicant for Consultant positions in the future and may
also affect training opportunities.
Midwife recruitment and retention at the Alexandra hospital
is very good.
Quality of care remains good but there is little margin, and
if the requirements for delivery suite cover are made more
stringent, e.g. in relation to the number of hours of direct
consultant cover on delivery suite, or in relation to non-obstetricians
providing such cover, then the service will become unsustainable.
Comment
Options 4 above would be the most optimal
from an Obstetric and Gynaecological point of view. The viability
of Option 3 will be considered elsewhere.
Inpatient care is a small though important proportion of Obstetrics
and there would still be opportunity to maintain much of the
maternity services at or near the Alexandra Hospital.
There were divergent views expressed about Midwifery Led Units,
both in relation to their safety and as to whether, if established,
they should be on the Alexandra site or on a separate off
site location or indeed located in both the north and the
south of the county. There are many examples of MLUs from
around the country and the Trust could review examples of
these before making any final decision. The Trust view is
likely to be influenced by recent experience but this is peripheral
to the main decision regarding centralisation of inpatient
services and should not be allowed to cloud the issue.
The requirements regarding medical staffing, incorporating
inter alia the European Working Time Directive and CNST, make
the sustainability of smaller units difficult. If staff numbers
are increased to take account of this, then the issue of skills
maintenance will arise. One of the advantages of a single
unit will be the establishment of a single on call rota, a
benefit which would be lost if emergency out of hours work
were to continue at the Alexandra Hospital. There are definite
economies of scale to be gained with a single larger unit
and numerous development opportunities could arise. The Trust
is wise to be considering options at this point, before quality
issues arise, rather than as a reaction to unachievable demands
or clinical governance failure at some point in the future.
A number of significant issues
were identified from the interviews.
- Although the Trust has produced
a Strategic Direction document, none of those interviewed
were aware of Trust strategy with regard to Women's and
Children's services.
- There is little sense that there
is a coordinated corporate view from senior Executives.
- A strong leadership role from senior
and middle management would be welcomed.
- There is an inability on the part
of most of those interviewed to clearly articulate the intended
benefits of centralisation of Women's and Children's Inpatient
Services. A proposal based on the negative issues of unsustainability
or declining quality is less convincing than a clear annunciation
of benefits to be realised as part of an overall Trust strategy.
- Finance is declared as the main
driver for change by a significant number of interviewees.
When challenged, there was little idea how or when savings
might be made and it is unlikely that in the short term,
any of the options being considered would produce savings.
- The almost unanimous desire expressed
by the interviewees was for an end to uncertainty about
centralisation of services.
- If a decision was to be made that
the Trust would go to public consultation with a proposal
for centralisation of Woman's and Children's Inpatient Services
it would have overwhelming support from the staff groups
interviewed. Even those who would wish, for whatever reason,
to retain inpatient Obstetrics and Paediatrics on the Alexandra
site, indicated that they would cooperate with the new configuration
once a decision has been reached.
Recommendations
- Refine and communicate the Trust
strategy on reconfiguration of Women's and Children's Services.
- Ensure alignment of senior and middle
management around the strategic direction.
- Use the leadership role of Executives
and managers to embed the Trust strategy throughout the
organisation.
- Clarify the benefits of reconfiguration
such that staff members will be informed enough to acts
as advocates to the public.
- Put the role of finance in an accurate
context so that it is not used inappropriately in either
a positive or a negative context.
- Hasten the process/option appraisal
towards decision making to eliminate the uncertainty which
is becoming corrosive.
- Ensure that staff members know that
the Trust recommendation is just the first step, and that
consultation with the SHA, PCTs, OSC, MPs, media, and ultimately,
the public will shape the final outcome.
- Have confidence in both the process
and the Trust strategy because there is far more support
than opposition.
Nick Naftalin OBE FRCOG
22nd May 2006 |
