Maternity and Paediatric services at Northallerton Hospital

At a private meeting on February 7 the Hambleton, Richmondshire and Whitby Clinical Commissioning  Group decided to downgrade the maternity and paediatric services at the Friarage Hospital, Northallerton.

The Group decided that instead of having a 24-hour consultant-led service at the Friarage children will only be treated at that hospital from 10am to 10pm seven days a week. Children who are very sick will be referred to the nearest major hospital for specialist inpatient care.

An extraordinary meeting of North Yorkshire County Council’s scrutiny of health committee will be held on March 14 to discuss whether the Group had properly examined alternative options. These are outlined below.

14.12.2013:

Proposals to downgrade the maternity service at the Friarage Hospital, Northallerton  by the Hambleton, Richmondshire and Whitby Clinical Commissioning Group (HRWCCG) could lead to the complete loss of that facility, according to a report1 prepared for Richmondshire District Council. The report goes on to show how, for £200,000 each year, it would be possible to retain the present excellent maternity and paediatric services at the Friarage Hospital.

The alternative model for the maternity and paediatric services put forward by Richmondshire District Council (RDC)  led by Coun John Blackie, has received the support of local MP, William Hague, who stated:

“It is a much more attractive option than the proposed downgrade of maternity and paediatric services at the Friarage Hospital and it deserves the most careful scrutiny by the CCG (Clinical Commissioning Group) with a view to making it work.

“I applaud the work that has been done to create an alternative proposal and it if is not adopted I and many other local people will want to know in great detail why it cannot be made to work.”

The RDC report, which includes that alternative model for the future provision of children’s and maternity services at the Friarage, has been compiled by Richmondshire district councillors John Blackie and John Robinson, and by the district council’s scrutiny support officer, Penny Hillary.

Coun Blackie, who is leader of Richmondshire District Council (RDC), visited six hospitals2 similar in size to the Friarage, and occasionally was accompanied by Coun Robinson and Mrs Hillary. The HRWCCG has put forward two options for the future of the maternity and paediatric services at the Friarage which, it argued, would ensure the sustainability of these. Both options were for a midwife-led unit for women with low risk births and to provide community midwifery and outpatient services locally.

At its meeting on November 20 the RDC decided that neither of the two options put forward by the HRWCCG would meet the healthcare needs or the local communities of Richmondshire and, therefore, rejected them. It stated that patient choice had not been taken into account, and that the proposals were not in the interests of the local community nor in the interest of local health services.

At present the Friarage has a consultant-led maternity unit, which the RDC report pointed out, provides a first class service, an excellent safety record and enjoys the full confidence of the communities it serves. The report adds that the options put forward by the HRWCCG would have a significantly detrimental impact on the services provided to the women, children and families within Richmondshire and Hambleton in the future.

And the removal of consultants from the unit would not only mean the loss of the gynaecology service at the Northallerton hospital but increase the danger of losing the midwife-led unit as well.

According to this report the number of births at Hartlepool Hospital fell from 1,680 to 300 a year after it changed to a midwife-led unit in 2006. The Royal College of Midwives has warned that midwife-led units with fewer than 300 births a year are unlikely to be financially viable.

So the RDC report states:“The experience at Hartlepool casts a shadow over the long term future of any freestanding midwife-led unit  established at the Friarage, as it had a higher number of births when consultants were present than the Friarage has now, and the retention rate for a midwife-led unit birth is only 300.

“Nearly 1,300 (a year) choose the Friarage where they can currently have the option of a high tech or low tech birth. They do not have to make a choice about safety because the safety record is excellent and they know a consultant is on hand if needed.

“It is important to note that midwives need to maintain their skills too and too little activity at a midwife led unit would soon lead to a deterioration of skill base, a problem with staff retention and more importantly the safety risk to mothers and babies.”

The RDC report explains: “In order to achieve sustainability there is no dispute that the situation does have to change because people are retiring or have retired and they need to be replaced. In addition the service should have had investment in it before now but the Trust has relied on the goodwill of the present consultants to carry the service up to this point.

“It is considered that the situation in paediatrics (at the Friarage) has been exacerbated by chronic understaffing and underfunding for several years by the South Tees Hospitals NHS Trust.”

When the Friarage was merged with that Trust in 2003 local residents were assured that being part of a larger Trust would enable a greater range of services to be maintained at the Northallerton hospital, and that the Trust was committed to retaining healthcare services there which would benefit the local communities.

Instead the Trust expects to invest in the services at the James Cook University Hospital in Middlesbrough so as  to provide sufficient capacity for an increase in patients, both from the new housing developments in Teesside and from the Dales when the units at the Friarage are downgraded.

At the consultation meeting in Hawes to discuss the two options put forward by the HRWCCG Fran Toller, the head of maternity services at the South Tees Trust, stated that the patient experience of mothers-to-be whilst in confinement at the James Cook University hospital was just “adequate”.

The RDC report states: “A solution to address the capacity problems experienced by the James Cook University Hospital would be to promote giving birth at the Friarage. The slightly similar smaller faculty with an excellent safety record and an ethos of a family circle approach to care would be the ideal place to have a memorable and unpressured birth experience. .. This will increase the number of live births at the Friarage, maintain/improve the skills of the clinical staff, and will balance sustainability at both hospitals.”

The option preferred by the HRWCCG would also mean there would be no consultants available for the paediatric unit. Instead there would be just a short stay paediatric assessment unit at the Friarage. This would be open five days a week from 10am to 10pm with the last child being seen no later than 8pm.

The RDC report states: “Our visits to various small hospitals indicate that the busiest time for patients to arrive at their paediatric unit is between 6.00pm and 11.00pm at night. To set the time at 8.00pm for the last child to be examined cuts the service off from the greatest number of its potential users. Our visits also indicate that the numbers of patients arriving at the paediatric units throughout the day and evening at weekends is very little different to those on Monday-Friday.”

The HRWCCG has also stated that under both options there would no longer be a high risk obstetric service or a special care baby unit at the Friarage.

The RDC report gives the example of a child or baby in Thirsk requiring a journey of over 40 minutes to reach an open access paediatric unit as compared to 15 minutes now. The parents in that situation might even have to call for an ambulance, rather than taking their child to a hospital themselves.

But those in Upper Wensleydale face even longer journeys as the RDC report points out: “The distance from Hawes to the Friarage Hospital at 38 miles is already a long enough journey for a woman in labour. There have been a number of occasions when expectant mothers have given birth to their babies in lay-bys on route to the Friarage. The idea of them having to travel another 22 miles to James Cook is totally unacceptable to them.”

It adds that it is understood that the recommended safe transfer time from one hospital to another when a mother is experiencing difficulties giving birth is 30 minutes – and yet even with no road closures on the A19, the journey from the Friarage to Middlesbrough can take longer than that. In the past three years the A19 has been closed 18 times with some closures lasting several hours.  The RDC report states:

“It appears the local NHS is prepared to take these risks to patient safety on board to downgrade the service at the Friarage on the back of a case they claim to have been devised on grounds of patient safety.”

It points out that the Yorkshire Ambulance Service is frequently not reaching call-outs within eight minutes in rural areas of North Yorkshire and the lack of facilities at the Friarage could lead to more people calling for ambulances.

And it is not just expectant mums and parents with children who would be affected by these longer journeys. Those visiting them at the James Cook University Hospital will incur considerable extra expenditure in both fuel and car parking costs and time to reach and return from Middlesbrough if they are unable to use the proposed free bus service from Northallerton.

Army families living at Catterick Garrison would also be affected – even though the military GP practices which serve them did not appear to have been included in the discussions about downgrading the facilities at Northallerton.

As the RDC report points out, when the Duchess of Kent hospital at Catterick Garrison (which had a maternity wing) was closed down in the 1980s the Army families were told: “Do not worry – there will always be the Friarage for maternity.”

The report adds:“Research shows that the structure of the population amongst the MoD families in Catterick Garrison, the largest Army Garrison in Western Europe, is heavily weighted towards young families. The peace of mind of the soldiers who serve our Nation overseas… has been completely overlooked in the consultation.”

One of the key arguments for downgrading the Friarage Hospital is that it would cost £2.7million to upgrade to a consultant-delivered service. This was described in the RDC report as an unnecessary and extravagant upgrade aimed at bringing the units up to the standard of the Royal College Guidelines.

The Royal College Guidelines provide staffing recommendations which are not even met by the James Cook University Hospital.

The RDC report notes that the £2.7 million would be offset by the £2 million of lost patient income to the South Tees NHS Trust as many patients would chose to go to hospitals not administered by the Trust if services were downgraded at the Friarage. There would also be costs of about £500,000 to cover the free bus service from Northallerton to Middlesbrough and the additional ambulance service required.

Then there was the question of how much it would cost to increase the capacity at the James Cook University Hospital which has ranged from £1 million to £10 million. This, the RDC report states, gives credence to the statement from the South Tees NHS Hospital Trust that “taking into account both changes in cost and likely loss of income the Trust’s financial position will be adversely affected by all of the options considered.”

The children’s and maternity services at the Friarage have already been upgraded to 1st class status thanks to a multi-million investment into the facilities at that hospital several years ago. “Judged by the experience of the other small hospitals …. You could continue a very safe and sustainable 24/7 consultant-led service for £200,000 annually,” the RDC report states and adds:“The South Tees NHS Trust suggests that the main problems at the Friarage stems from recruiting staff who want to work at small hospitals, and also the clinicians not overseeing enough work to maintain their skills, particularly in paediatrics.

“However our evidence confirms that other small hospitals find ways to recruit staff, plan complaint rotas, maintain skills and carry out forward planning well in advance of staff retirements.”

It was noted that one of the features of the hospitals which were visited was the absolute buy-in by all the staff and the management so as to retain the best services for local communities. And the RDC report states:

“There needs to be a change in culture at the (Friarage) hospital particularly amongst the consultants and the management.”

It adds:“Our model is based on the South Tees Hospital NHS Trust undertaking genuine initiatives to promote and encourage additional patient footfall for the 24/7 consultant-led maternity services at the Friarage.”

The Trust would also have to encourage consultants to take part in a high level of rotation, which according to the RDC report, is something those permanently based at the James Cook University Hospital have had little appetite for.

The RDC report accepted that there were few training posts on the rotas of the small hospitals that were visited. But those hospitals got round that by using Speciality Doctors and also Clinical Research Fellows if close to universities.

The RDC Model put forward for the Friarage includes using Advanced Nursing Practitioners (otherwise known as Specialist Nurses) as part of a bespoke solution particularly as there is a lack of middle grades in the Friarage’s paediatric service. It could take up to three years to train a midwife or a paediatric nurse up to such a level. The South Tees Hospital NHS Trust would need to identify potential candidates from its own nursing staff and embark on a training programme immediately.

“Whilst the training programme is being established it may be necessary to employ a generalist consultant paediatrician to backfill, and we understand from our enquiries that there are a reasonable number of quality generalists available for recruitment at this time.”

The consultants recruited to serve at the Friarage would be required to live within 20 miles of the hospital and to take part in an on-call rota. None of the six hospitals visited had experienced any problem with recruiting consultants.

The RDC Model envisages that its proposed staffing structure would allow the vitally important 24/7 open access and acute open access services for children with complex health conditions, and the special care baby unit service to continue as they are now. It would also call for the South Tees Hospital NHS Trust to investigate the establishment of a Young Persons Unit like that at Yeovil District Hospital.

Endnotes

1.Response to Proposals within the Consultation Document on Options for the Future of Children’s and Maternity Services at The Friarage Hospital Northallerton and Our Model for the Future Provision of Children’s and Maternity Services, November 2013.

The full report, with the RDC Model and appendices can be viewed at www.richmondshire.gov.uk

2. Hospitals visited:

In October 2012 – North Devon Hospital, Barnstaple, Yeovil District Hospital, Dorset County Hospital

In October 2013 – Borders Hospital, Melrose, Dr Grays, Elgin, West Grampian, Dumfries and Galloway Hospital

And also Bassetlaw Hospital, Worksop

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