Presentation from and discussion with health officers on the following items concerning maternity services:
· Demand and capacity levels, Capital investment, Impact on Essex births
· Service quality, Workforce strategy, BHRUT gateway review process
Minutes:
Health officers gave an overview of the decision making process regarding the maternity proposals and clarified that the final decision on the proposals, including to close maternity at King George, would be taken at a meeting of the NHS North East London and the City board to be held on 7 March 2013. If approved, it was expected that closure of the maternity unit at King George would take place in the week of 19 March.
External assurance processes had been carried out on the proposals and NHS London had also reviewed the recent Care Quality Commission (CQC) report on maternity at Queen’s. Officers explained that, with recent expansion of capacity at Homerton and Newham hospitals, a reduction had been recorded in the numbers of births booked at BHRUT. Assumptions made about the choices women would make as regards their hospital of choice had been broadly correct and it was felt that this reduction of births seen at BHRUT would allow the closure of maternity at King George.
The maternity capacity at Queen’s Hospital was planned to be 8,000 per year or an average of 22 deliveries per day. It was anticipated that 20-25% of deliveries would be by caesarean section, 10.-20% would use the new Queen’s birthing centre and 55-70% would take place on the main labour ward. Officers were confident that 8,000 births could be undertaken safely at Queen’s. There had been a steady increase in the number of women using the Queen’s birthing centre. This was expected to see 18 deliveries per week by April and 25 births per week by July 2013.
It was expected that Queen’s as a whole would see 7,500-7,800 births per year in 2013/14 including approximately 250 births from Essex. Essex commissioners wished to increase this figure to 4-500. It was also anticipated that up to 1,200 births per year from Barking & Dagenham and Redbridge would now take place in Newham and Whipps Cross.
Newham Hospital currently had capacity for 7,300 births per annum, 20% of which were carried out at the hospital’s midwife led unit. Officers felt that the hospital did therefore have the capacity to cope with future scrutiny. Whipps Cross would see approximately 5,700 deliveries in 2013/14 and bookings would be closely monitored to ensure this was kept to. The phase 2 development would see capacity rise to 6,000 births while a capacity of 8,000 births would be available following the phase 3 development although this would not be completed for 2-3 years.
Any rise in population from young families moving into the Olympic Park would be covered by maternity units at Homerton, Newham and Whipps Cross. Population estimates were monitored and assumptions had been based on higher estimates of birth numbers than the GLA forecasts. Planning was also undertaken to cope with predicted spikes in demand for maternity services such as that due to the Olympic Games held in London.
A Member pointed out that many Essex residents also used Whipps Cross Hospital. A representative of Barts Health felt that this could be safely catered for at Whipps Cross and added that the heads of midwifery met on a weekly basis to look at numbers of maternity bookings. Much of the stage 3 redevelopment scheme at Whipps Cross would in fact be ready by the end of 2013, hence allowing a higher birth capacity at the hospital. Officers confirmed that it was not the intention to change any of the Essex maternity flows. Mothers from the Buckhurst Hill area in particular would continue to have priority booking at Whipps Cross.
It was emphasised that the number of births taking place at King George Hospital had gradually been reduced and that it would be difficult to continue to staff all of the Queen’s labour ward, midwife led unit and maternity at King George beyond the end of March. Any pregnant women that presented at King George A&E would be treated but these were likely to be few in number. Women would also be transferred by ambulance to Queen’s if necessary.
A proportion of births at each maternity site were likely to be premature or multiple births etc. Transfers could be arranged to the Royal London Hospital if a level 1 neo-natal unit was needed. The capacity of neo-natal services had also been considered as part of the maternity review.
As regards caesarean sections, a lot of work had been undertaken nationally looking at the reasons why these rates had increased in some areas. The health officers wished to reduce the c-section rate to that seen outside London, although it was expected that the rate across North East London would fall over time. The average rate for the sector was currently 24% although it was expected that this would reduce over time. The issue of elective c-sections was covered by clear NICE guidance and it was necessary to investigate the reasons for these as they may be offered for e.g. mental health reasons.
Health officers agreed that it was not safe to run a maternity service if there was not an A&E on the same site and it was for this reason that maternity at King George was proposed to be closed prior to the closure of A&E at that site. Officers accepted that the quality of the A&E service at BHRUT remained a challenge.
As the number of births at BHRUT had reduced, it was felt that the number of midwives at the Trust could also be lowered. On balance, it had been decided that it would be safer to bring forward the closure of King George Hospital maternity. The final Gateway Report on these issues would be shared with the Committee.
It was accepted that the original proposals consulted on having up to 10,000 births per year at Queen’s but it was later decided it would be better to rebalance maternity services across North East London. There was careful management of maternity bookings at hospitals but no formal capping of numbers. There was operational guidance available for dealing with booking limits being reached and this could be shared with the Committee.
Officers felt that more partnership work was needed around the issue of pregnant teenagers as there was currently only a small team of midwives at BHRUT dealing with teenagers.
The changes in maternity catchment areas had, in the view if the health officers, received positive feedback and statistical information on birth numbers could be shared with the Committee on a quarterly basis. An extensive quality assurance process had supported the proposals and this had included discussion with both mothers and staff on birthing units. The Gateway Review on BHRUT maternity had also been reviewed by the relevant Maternity Board. There had not been a need for a Gateway Review at Whipps Cross as there were less concerns about the quality of maternity services there although a similar assessment had been undertaken.
A total of 25 midwives had been transferred via the TUPE Regulations from BHRUT to Newham Hospital. The reliance on agency nurses had been lowered at Newham and maternity services had also benefitted from the opening of the Barking Birthing Centre in December 2012. There was also now better discharge planning and an improved customer care training programme for Newham maternity staff.
The midwifery establishment at Whipps Cross had also been increased and four universities also provided student midwife placements at Barts Health. Agency staff use at Whipps Cross was also in the process of being discontinued. Joint working had been undertaken by the hospitals on maternity catchment areas. Ultrasound scanning had also increased at both Whipps Cross and the Barking Birthing Centre. A maternity bereavement service was also being developed.
The midwifery establishment at Homerton had been increased in order to maintain the required ratio whilst accommodating some extra births from Waltham Forest. There was also more consultant cover on the delivery suite and an additional ward had been introduced for post-natal beds.
Health officers emphasised that they were happy to continue an ongoing dialogue regarding the maternity changes and to bring further updates to scrutiny. In officers’ view, details of the proposals were clearly given in the Health for North East London business case. Information on issues such Whipps Cross patient flows would also continue to be reported to the Waltham Forest Health Scrutiny Committee.
It was accepted that home birth numbers had dropped with the opening of the midwife led units in the sector but health officers were keen to offer the widest choice to all women. This included more promotion of home births as an option.
There had been fifty births at the Queen’s birthing centre since it opened on 8 January, of which half had been water births. The unit had seen high levels of breast feeding initiated as well as a financial saving from the reduced use of epidurals etc. The latest Care Quality Commission report had found significant improvements at Queen’s maternity and in a December survey (of 250 women on the post-natal ward) 96% had said they would recommend Queen’s maternity services. All women at Queen’s maternity received 1:1 care during labour. There had also been a reduction in the number of complaints received concerning the maternity department.
The survey results had been lower as regards cleanliness of the labour ward and work was in progress around this with the BHRUT contactor – Sodexho. Members agreed that cleaning was of vital importance in a hospital. Specific cleaning issues raised included the lack of shiny floors and cleanliness of toilet areas.
Data was collected on all non-hospital births. It was hoped that people’s good experiences in birthing centres over the coming years would lead to more home births in the longer term. It was confirmed that there was one birthing pool on the main maternity unit and further pools could be transferred to the birthing centre if required.
It was explained that the Care Quality Commission inspections were unannounced and that BHRUT held monthly clinical quality review meetings to monitor numbers of births, c-sections, staff vacancies and other issues. The Gateway Process for BHRUT maternity had been more about scrutinising plans for service quality and safety. It was accepted that there were still unknown factors in the modelling as the population of North East London was constantly changing. The overall birth trend however remained in an upwards direction.
The Committee AGREED to take further updates on the maternity changes in 6 and 12 months and to scrutinise the BHRUT Gateway Report when this was available.
The Committee also RECOMMENDED that health officers should work more closely with planners and other relevant Council departments to ensure that increases in demand for maternity services were catered for.