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Copies of this letter were sent to the two chairmen and the non-executive members of the Joint Committee as well as the Chief Executive in the lead up to the 20th December meeting.
Re: Meeting of the Joint Committee on Thursday 20th December
I am writing this letter to the chairmen and all non-executive members of the Joint Committee who will be meeting on Thursday to decide on the future configuration of the maternity services within East Sussex. My reason for writing is that I feel certain that the Joint Committee will ratify the recommendations of the Chief Executive.
What right do I have to challenge your decision? Although now retired I do have some experience of participating in the development of proposals for service changes and consultation processes. I was the Director of Public Health at what was then the Eastbourne Health Authority for about ten years and prior to that, an equivalent post at Hastings for about five years. Previous to that I worked for several years as a senior medical officer in the Research Division of what then was the Department of Health and Social Security.
I should make it clear at once that I am writing completely independent of any pressure group. Indeed, I do not know whether or not one unit is preferable to two or vice versa. What does concern me is the validity of some of the advice and information you have received from the executive body. I am also aware from my experience of being an executive director, how difficult it is for non-executive directors to challenge the views of “professionals”.
My discontent began with the publication of the consultation document. I have read many consultation documents and I have to say that this is by far the weakest I have ever seen. I shall point out only two objections I have with it. Firstly, it contains the bald statement “We have looked at the status quo. We are firmly of the view that it does not meet the criteria.” It is completely unreasonable for NHS managers to put forward a set of options, all based on a single consultant-led unit model, without clearly demonstrating why a service with consultant units in both Eastbourne and Hastings is not a possible option. Personally I would have preferred to see a few two unit options, which then could later have been subjected to a formal options appraisal process. Secondly, in the Foreword to the summary version of the document (over 18,000 copies distributed) the chairmen stated “The fact that bigger maternity units are safer and more effective is an important issue to consider in this consultation.” I do not know who advised the inclusion of this statement, but it is not correct. For procedures such as surgery, for pancreatic and oesophageal cancer, abdominal aortic aneurysm and paediatric cardiac procedures there is reasonably strong evidence of a relationship between volume and improved patient outcomes. I have been unable to find any studies relating volume and outcome in obstetrics. This is hardly surprising as caesarean section is hardly a high-technology procedure. Unfortunately, putting a statement like this in the most prominent position in the document will have seriously misled the readers. Almost game, set and match for a single unit!
I shall now turn to the papers for the meeting on Thursday.
Agenda item 11
Section 2: The case for change
“Consultant staff are being stretched across two sites and are unable to offer significant labour ward presence.”
My understanding is that there are currently 8 wte consultants. There used to be 10 but 2 resigned and the Trust considers it prudent to hold off on recruiting to the substantive vacancies whilst the future of obstetric-led maternity services is under discussion. Perhaps that is why consultant presence on the labour ward is inadequate. The Trust is one of relatively few Trusts achieving CNST level 3 status. Requirements for this include “Set consultant sessions on the labour ward; target is 40 hours/week Monday to Friday. The consultant’s work plan will indicate no other commitment during the labour ward session.” “Out of hours on-call (1800-0800 hours and at weekends). The consultant must be available for the labour ward within 30 minutes. At weekends a daily ward round and either a physical or telephone round in the evening is required, which would increase commensurate with workload.” If this was achieved in the past to meet level 3 requirements, why not now? If the consultants really are unable to offer significant labour presence then I would argue that the service is unsafe. Two locum consultants should be appointed at once!
“There is less availability of experienced middle grade staff. Middle grades are able to take clinical decisions and seek advice appropriately. This is essential for the safe operation of the service. More experienced middle grade staff would be attracted to working in a centre with a more varied case mix and a more robust consultant presence.”
This may be so, but I suggest that recruitment depends more on the reputation the unit has for the quality of its training. This does not depend on the size of a unit. If recruitment really is an intractable problem, has the appointment of staff grade doctors/associate specialists been considered? One advantage is that they are not trainees but permanent posts, which increases stability within the obstetric team.
“There are unplanned closures of both units caused by staffing difficulties and other operational pressures.”
I would like to draw your attention to the minutes of the Hastings and Rother Professional Executive Committee of 13th September. Dr Zaidi reporting on the current situation of maternity services at the two hospitals is reported as saying that the services are stretched for safety; significant issues being experienced by midwifery, He said this was due to changes including Agenda for Change, annual leave allowances and patient expectations. No further midwives could be appointed as the number of midwives was considered to be up to the establishment level. I believe that if corrective action is available, it is completely irresponsible to be operating a service at the “margin of safety”. It is obviously an immediate priority to appoint additional midwives! At a conference earlier this year Sir Ian Kennedy said that when doctors and midwives considered a maternity service to be unsafe they should pressure management to remedy the situation. If management failed to take the appropriate action, the clinicians should refer the situation to the Healthcare Commission. Why are the consultants and midwives accepting the current level of midwife establishment?
It seems to me that the present number of consultants and midwives is creating a self-imposed situation that demonstrates that to continue to have obstetric units in both Eastbourne and Hastings is not possible and a move to a single site is therefore necessary.
Difficulty maintaining CNST level 3 status. Maternity Matters indicates that ‘there is a strong possibility the CNST will increase the standard to 60 hours’ (of consultant presence) – this is well in excess of what is being achieved now and difficult to achieve across two sites under any circumstances.
There will be no difficulty in maintaining CNST level 3 across two sites. When the NHS Litigation Authority decided on the consultant staffing criteria for CNST it drew on the RCOG document “Towards safer childbirth” and adopted the RCOG’s standards in that document. “The trust should determine which category it is by referring to the RCOG guidelines as set out in Towards Safer Childbirth Section 4.2 (extract attached). The staff cover required is determined by the definition within figure 3.”
There is no reason to think that the Litigation Authority will change its previous position and it will continue to draw on RCOG advice. When Maternity Matters was being written it was the draft version of Safer Childbirth that was available and on that basis the CNST standard would increase to 60 hours. However the definitive version of Safer Childbirth has now been published and the staffing level guidance is different from that in the draft guidance. If two units are retained the CNST standard will be 40 hours presence in each; if a single unit 60 hours presence.
Difficulty introducing the EU Working Time Directive in 2009 which will require shorter hours of working and further reduce the availability of medical staff.
I have been informed that both obstetrics are already fully-compliant with the EWTD as it will be in 2009.
Section Six: Post consultation analysis
Non-financial option appraisal
I have just a few comments on the options. I have never understood why Options 1 and 2 were put forward as they were really non-starters. I guess it was thought that including only two options would not be acceptable. Personally I believe that at least one two-site option should have been included. Some of the options were very similar and it would have been sensible for the proposers of similar options to have got together to explore the common ground between them and possibly propose a single joint option. I am thinking in particular of Options 5b, 12 and 13. I was the proposer of Options 10 and 11 and having presented my options to the New Options Assessment Panel, Prof. Stephen Field asked Michael Wilson, on his behalf to contact those who had put forward Options 6, 7, 10, 11 and the MSLC to see whether they would wish to work together in developing a joint approach. I very much welcomed this but despite a reminder to Michael Wilson, I heard nothing further.
I am very disappointed only to see a summary of the results of the non-financial option appraisal. I cannot ever remember seeing a report containing an option appraisal in which the results were not shown in full. To me this seems a clear lack of transparency.
Section Seven: Chief Executive’s conclusions and recommendations
1. Safety issues
I absolutely agree with the first paragraph which states that it is important for the minority of women who experience significant complications that their care is delivered in an obstetric unit. Unfortunately, when there is no longer a consultant-led unit in Eastbourne, some women living in the area who would have chosen a hospital birth in Eastbourne will be unwilling to have their baby in Hastings and opt for delivery at home or in the midwife-led unit in Eastbourne, so exposing them to greater risk. Some of these women will be women who are advised to have their baby in the consultant-led unit in Hastings. It must also be borne in mind that the RCOG, on grounds of safety, have recently said that midwife-led units should be co-located with consultant-led units. The proposed midwife-led unit in Eastbourne is a free-standing unit. Fortunately, the risk to an individual mother is small but over time a mother having her baby at home or in the midwife-led unit will lose her baby, or even her own life. Unfortunately, the nature of obstetrics is such that unexpected emergencies do occur and for some of these, immediate obstetric help is needed.
As far as the difficulty of providing adequate training opportunities for junior doctors in a small unit is concerned, I would challenge this RCOG view. With two consultant-led units there only one tier of junior staff will be required but a single unit will be required to have two tiers of junior staff. The individual junior doctor’s training opportunities will therefore be similar. The opportunities will possibly be fewer in a single unit as perhaps as many as 600 mothers will opt for delivery in Brighton and more mothers will choose home and midwife-led deliveries than would be the case if two consultant-led units are retained. As far as senior staff maintaining their skills is concerned, I have referred to this earlier in the letter; there is no evidence that larger obstetric unit are safer. The fact that middle-grade trainees have performed nearly all the obstetric procedures within the labour ward is an indication of the lack of technical difficulty in obstetric practice. I can think of no other specialty in which consultants have played such a little part.
2. Recruitment
I accept the arguments presented here but the difficulties could be regarded as challenges. Doctors deciding where to apply for a consultant post are influenced by many other factors than mentioned here. Some people prefer small units because they would be part of a small closely knit team. For permanent posts it is lifestyle factors (housing, schools etc) which are likely to be of most importance.
3. Consultant presence
From the available evidence it does seem clear that consultant presence increases safety. What is the mechanism for this? Data from the “Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) reports throw some light on this. Over 77% of the intrapartum deaths reported in the fourth and fifth CESDI reports had substandard care and, in 52% of these cases, alternative management would have made a difference. The critical comments acknowledged that in 95% of cases there were failures in three main areas: failure to recognize the problem, failure to act appropriately and failure of communication. It seems to me that this is a training issue and whether there is 40 hours or 60 hours of consultant presence will matter little; 40 hours presence is more than sufficient for the necessary training.
However, in this section of the chief executive’s report it is claimed that 60 hours consultant presence is safer than 40 hours of consultant presence. I know of no evidence about this at all. Indeed, I was surprised when at the meeting to consider the new options; Michael Wilson said “National evidence, our own research and local advice indicate that increasing consultant presence from 40 to 60 hours significantly improves patient outcomes.” If this claim is correct then all two-site options can immediately be rejected. On the other hand, if the statement is shown to be false, there are serious implications which I must leave to you. I wrote to Mr Yeo on the 30th November asking for the evidence for this statement but have not yet had a reply.
“The Future Role of the Consultant” states “New data from the National Patient Safety Agency suggest that severe foetal distress events are more likely to occur after midnight than after 08.00 hours.” It seems therefore that the speedy availability of a consultant out of hours is crucial. The CNST standard for this is “the consultant on call should be available within 30 minutes.” Presumably the consultants living in Eastbourne will be part of the on-call rota. With the unit in Hastings they will be unable to meet this standard. This will make the only remaining consultant-led unit in East Sussex less safe than it was before.
There is an interesting converse to this. If it is necessary for a consultant to get to a mother in trouble within thirty minutes, it would seem equally necessary for a woman in trouble to get to a consultant within 30 minutes. For many women having their baby at home and for women in the midwife-led unit in Eastbourne, this will not be possible if there is only one consultant-led unit.
4. Training status
I have referred to this above.
5. Anaesthetics
If adequately staffed and they are not at present (see above) the present two units are considered safe. They have Level 3 CNST status and therefore considered safe by the Litigation Authority. There is therefore no need to have dedicated anaesthetic support on the present sites.
6. European Working Time Directive
I have referred to this above.
7. Reliability
I have referred to the insufficient number of midwives employed by the Trust above. This is a self-inflicted wound which creates an unsafe service, leading to closures.
Conclusions
I have criticized the consultation document and challenged many of the statements in the Chief Executive’s Report. The whole process seems to be very much an exercise in fitting the facts to support a belief.
My main concern is that you may have placed undue reliance on some of the “facts” given in this report when you carried out the option appraisal. In particular, to what extent you were influenced by:
1. Michael Wilson’s claim “National evidence, our own research and local advice indicate that increasing consultant presence from 40 to 60 hours significantly improves patient outcomes.”
2. Michael Wilson’s statement “we are operating at the margins of safety.” and the Chief Executive’s statement in his Report “Consultant staff are being stretched across two sites and are unable to offer significant labour ward presence.”
3. The difficulty in maintaining CNST level 3 status if two consultant-led units were retained.
4. Difficulty in implementing the EWTD in 2009.
The following are important and you may not have been made aware of them.
1. The safety of a free-standing midwifery-led unit in Eastbourne. The advice from the RCOG is that midwife-led units should be co-located with consultant-led units.
2. The difficulty (impossibility?) with a single unit of meeting the CNST standard “the consultant on call should be available within 30 minutes.”
All I ask is that if you believe that you would have scored the option appraisal differently, then you take whatever action you feel is appropriate. I appreciate that this would be very difficult for you.
In the interests of transparency, the justification of Michael Wilson’s claim “National evidence, our own research and local advice indicate that increasing consultant presence from 40 to 60 hours significantly improves patient outcomes.”
should be made available. Also in the interests of transparency the full results of the Option appraisal should be published.
Yours sincerely
Dr J G Leece
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