Agenda item

10:05

 

At the request of the Committee, Paul Brennan, Director of Clinical Services, Oxford University Hospitals Foundation Trust (OUH) and Andrew Stevens, Director of Planning and Information, OUH, will attend to answer further questions on the contingency Plan for Maternity and Neonatal services at the Horton Hospital. The purpose of this is so that the Committee can be assured that there are satisfactory reasons for invoking emergency measures to temporarily close the Obstetrics Unit at the Horton General Hospital.

 

This will include evidence of efforts made by the Trust to maintain a consultant-led maternity service at the Horton and discussion about the risks and impacts of closing the Obstetrics Unit.

 

The OUH report on its contingency plans which was first published for the Committee’s 15 September 2016 meeting is attached for reference, together with various background information (JHO4).

Prior to consideration of this item the Committee was addressed by the following speakers:

 

Valerie Ingram

 

Valerie Ingram informed the Committee that she was the administrator of the Facebook page ‘Save our Horton’ and communicated with just over 16,000 members on a daily basis. It was her view that Banbury and the catchment area was growing at an unprecedented level and key to the Core Strategy was sustainability, adding that to allow the maternity unit to be downgraded even temporarily was contrary to those principles.

 

She stated that Oxford was not close to Banbury and very difficult and expensive to get to. She added that in 2008, the Independent Reconfiguration Panel had deemed that the distance between Banbury and the JR was too far and not safe, stating that this was as relevant today as it was then and in fact transport had worsened nowadays making it even more difficult to access services.

 

She informed the Committee that a recent FOI request made in June had revealed that a blue light run from Banbury to the JR revealed an average time of 43 minutes, which did not take into account loading times at either end. Furthermore that an emergency C Section, category 1, was recommended to take place within 30 minutes; and the clock did not begin ticking until the doctor had agreed the procedure, adding additional time to be factored in, but which was not included in the Trust’s contingency plan. She added, moreover, Chipping Norton Midwife –Led Unit (MLU), when in difficulties, tended to send their patients to the Horton as it was easier to access. The outcome of this would be that this option would be removed, thus increasing the risk to patients, and overloading the JR. She further stated that the JR had been on divert on two occasions the previous week and Warwick had the week before, thus highlighting existing pressure. She added her view that GPs and ambulance staff in the Banbury area were not happy with the proposals.

 

Valerie Ingram also suggested that downgrading to an MLU would possibly see the removal of the on call 24 hour House Consultant anaesthetist, thus bringing into jeopardy the Children’s ward and Accident & Emergency. The Trust has made no guarantees that this position would remain and FOI requests had gone unanswered.

 

She stated that, in her view, recruitment had been ‘lack lustre and appalling’ and it had taken letters from Facebook members to get the adverts back onto the system.

 

She referred to a proposal that had been made to the Trust which would utilise existing facilities, retain staff and utilise the services already in Banbury, which had been refused. At the Trust’s recent AGM the Trust had commented that agency staff would be employed if staff did not wish to be moved to Oxford. She commented that the same should then happen for the doctors, that locums could be employed in Banbury in the interim period until doctors could be found. She concluded by stating that the residents in the Banbury area wanted equality of care and ‘were being treated as second class citizens and expendable collateral.’

 

Keith Strangwood

 

Mr Strangwood began by referring to a petition (which was not submitted to the meeting) which was in circulation and which had accrued around 18,000 signatures to date. He also referred to the Trust’s statement that there was no alternative to the temporary closure of the Hospital’s Obstetric service, due to safety reasons, stating that the risk to mothers and babies was an even greater risk. He added his view that the advertising for the vacant posts was ‘more than inadequate’ as it had only appeared in NHS Jobs and no other site up until the end of September, and the first serious attempt at advertising in the British Medical Journal did not happen until August 2016. Mr Strangwood also referred to the pressure on the JR of the additional 1,000 births. He asserted that the ‘whole proposal’, including the lower number of births at the Horton had been engineered by the Trust. He concluded by requesting the Committee to refer the temporary closure to the Secretary of State.

 

Dr Peter Fisher

 

Dr Fisher informed the Committee that when he worked at the Horton he was one of 10 consultants. On his retirement there were approximately 40. The hospital had been allowed to develop an integrated service with the area’s GPs. This was no longer as effective since many consultants had been moved to the JR. Later the OUH had moved these staff to the JR. He added that it was very significant that the number of applicants for posts as Clinical Research Fellows in Obstetrics had fallen since the beginning of 2015, but advertisements for a different type of middle grade staff had not been placed until April 2016.  As a result, the earliest the service could re-open was January 2016. He concluded that throughout there was uncertainty and the people in north Oxfordshire were bewildered. There were a series of questions that needed to be answered and the only way to receive answers was via referral to the Secretary of State.

 

Sarah Ayre

 

Sarah Ayre explained that she had been employed as a midwife at the Horton Hospital up to last year. She wished to convey the concern felt by the midwives who had successfully served mothers and babies in the north of the county, for the wellbeing of the mothers and babies affected by the proposal. The midwives strongly supported all models of care which supported the Horton. They also feared that the new proposals would not be a temporary measure. They felt that the contingency plan was unsound. A main area of concern was that, despite the presence of a 24 hours a day ambulance, the JR was too far away from the Horton for safety. She added that the staffing levels outlined in the contingency plan ignored NICE guidelines and the Trust was ignoring crucial timings required to provide the service safely. She urged the Committee to refer the contingency plans to the Secretary of State for a full and frank examination of the proposals that were both ‘insulting and negligent’.

 

At the start the Committee were advised of the following by Nick Graham, Chief Solicitor, OCC. He advised that this was an emergency closure on the grounds that it was a threat to patient safety and welfare; and therefore the duty to consult did not apply. However, he advised that under the legislation, the Committee had the powers to still refer to the Secretary of State if it was not satisfied with regard to the adequacy of the reasons given for emergency. He further advised that some of the proposals might be caught up in the broader context of future change for which a major consultation was planned to take place in the New Year. He advised that this would not prejudice the Committee’s ability to make a referral.

 

The following representatives attended:

 

-       Paul Brennan, Director of Clinical Services, OUH

-       Andrew Stevens, Director of Planning & Information, OUH

-       Veronica Miller, Clinical Director, Women’s Services Directorate, OUH;

-       Catharine Greenwood  – Consultant in Obstetrics & Fetomaternal Medicine, OUH;

-       David Smith, Chief Executive, OCCG

 

Paul Brennan began by giving an update on the situation. He reported that the recruitment process was ongoing, and as soon as a full complement of staff were in place, then the Unit would be re-opened, together with a definitive agreement with SCAS for a 24 hours a day ambulance to be situated at the Horton. He further reported that currently the Trust was down to three doctors, making it unsafe to operate the Obstetric service. Since the last meeting of this Committee, four doctors had been interviewed and had all been offered and had accepted their post. However two of the doctors were not registered with the General Medical Council and this would take a minimum of 6 weeks. Victoria Prentis MP had offered to assist with the process as far as she could. One of the doctors required a period of induction to enable him/her to work independently. The outcome of this was that 2 doctors would not be available until the New Year to carry out operations. He added that a further advertisement was out at the moment and the closure date was that day, 4 applications had been received to the advert. He added that the most risky area that of the special care nurses, which was a difficult area to recruit in across the country. An advert was out at the moment. Once all the doctors were able to operate independently and the special care nurses recruited, then the Trust would re-open the Unit.

 

Mr Brennan gave his reassurance that the 24 hour ambulance was an additional vehicle which had been secured by the Trust in response to concerns raised by the public.

 

In response to a question, Mr Brennan confirmed that the salary range and banding for the consultants posts comprised a percentage increase in salary and a £5k premium to make them more attractive.

 

Andrew Stevens stated that he had worked for the Trust for 17 years and had been proud that Obstetrics had been kept going at the Horton since the loss of the accreditation in 2012. He added that other Trusts in the south of the country had lost their service, notably, Buckinghamshire, Berkshire and Gloucestershire. Furthermore, for training posts, the vacancy rate of just below 25% was replicated across the county. He added that the problem of safety had to be faced, if there were an insufficient number of doctors then the service could not be provided.

 

Catharine Greenwood stated that she had worked on the labour ward for over ten years. She added that other units had closed across the area, for example, in Royal Berkshire. That service had been transferred to the Horton or to surrounding areas, such as Basingstoke.

 

Veronica Miller referred to the costs to run the neonatal network which had not come over. There was in the region, an improved network and beds would be made available for premature babies, level 3.

 

A member asked why the numbers of births had reduced from 1723 in 2013 to 1466.Veronica Miller explained that a national guide to complex pregnancy which had to be adhered to. The rise in 2013 had been the result of a period of refurbishment at Chipping Norton Hospital. Catherine Greenwood also explained that the recognition for training for the Horton had been removed in 2012. Sometimes even consultant-led services did not meet the needs of women at the Horton and they had to go to the JR anyway. She added that there had been a reduction in numbers for higher risk births going to specialist teams as a result of national guidance.

 

When asked about whether the JR had ever been on divert, Catharine Greenwood stated that she had not known it to happen. A member asked if some mothers had not been given the option to use the Horton, which might have then lowered the birth figures. She asked if the Unit would remain in Banbury in the future. Veronica Miller responded that the maternity service was proud that mothers were given choice. She added that nowadays pregnancies were more complex for a number of reasons and there had been many studies and much evidence on the subject of keeping mothers safe and about how to look after them. The Horton did not have specialist teams in situ and it worked across the county when it needed to gain access to them.

 

With regard to the issue of recruitment a member asked why, if it was known that a consultant was to retire or leave, that a recruitment agency had not been approached? Mr Brennan responded that nobody had resigned in 2015 and the first doctor had resigned in February 2016. He added that the Trust had gone to the Agency and asked them to fill 4 posts. Unfortunately they had been unable to provide any suitable applicants. In response to a question, Mr Brennan explained that currently, 3 doctors were in place for the next week, but 1 of these was leaving, 4 doctors had been recruited and required induction training, 2 required registration with the GMC and 1 required a visa application. Therefore reopening would be in the New Year at the earliest. Furthermore, whilst he was pleased that 4 posts had been offered, it had to be recognised that, in reality, doctors were applying for multiple jobs. They preferred to go to Units where there were more births. Many wanted to become consultants following the Article 14 Caesarian route. With there just being 3 births a day, the Horton could not provide the training and expertise they needed. The Trust was trying to rotate doctors through the JR to make the post more attractive for doctors. When asked if they were recruiting applicants with a view to reopening the Unit, Catharine Greenwood responded that they were. Appointees might need to work at the JR in the first instance, but when there were sufficient numbers appointed to the Horton that would be their main place of work.

 

A committee member asked for some idea of other options considered, for example, the question of the rotation of staff from the JR – and whether this could be with agency doctors. Mr Brennan responded that doctors at the JR were in training and therefore not permitted to go to the Horton as it was not accredited for training. Andrew Stevens reported that funding for the innovative post ‘Clinical Research Fellow’ (CRF) which had been created to try to keep the Obstetric Unit going since 2012, came out of the Research budget. He added that there were no CRF’s now – the OUH was recruiting to Trust posts only. A member asked if there were other acute rotations at the Horton likely to be at risk in the forthcoming year. Mr Brennan responded that there were no rotas at risk at the moment, although it was impossible to predict the Deanery questioning viability for training. He added that a future area of concern might be the Accident & Emergency Department, but there were no problems there at present. David Smith stated that the OCCG was satisfied that, at this stage, this emergency action to close the Unit down had been taken because there was no other option. The Trust could not recruit doctors.

 

A member asked if there was sufficient staff to look after the increased numbers of babies taken from the Horton to the JR. Mr Brennan responded that 6 members of staff in the Special Baby Care Unit had decided to transfer to the JR to provide sufficient numbers with which to run the service. 3 members of staff had decided to stay at the Horton and 1 was an adult trained critical care nurse and had asked to stay at the dependency unit.

 

With regard to travel issues, a member of the Committee asked about the safety for mothers and babies when being transferred down the A34, which did not have a good accident record, and also what the travel times were from the Horton to the JR. Catharine Greenwood stated that the Trust had based its plans for temporary closure on NICE guidelines (made public in 2011) which suggested that for low risk mothers, it could be safer to deliver in an MLU as long as this is within 45 minutes of a consultant-led unit – the Horton met this criteria.

 

A member referred to Appendix 3 of the risk assessment, asking firstly where it was factored in that the clock only started to run when the ambulance arrived at the JR. Secondly, the NICE guidelines used kilometres, not miles, and there was the addition of a leading time of 15 minutes. Catharine Greenwood responded that nobody pretended that a category 1 C section could be offered in the Midwife Led Unit ( MLU). She pointed out that mothers in other MLU’s did not have access to category 1 C sections. Mr Brennan added that loading time did not apply as the ambulance would already be there.

 

A member asked if it would be appropriate to use the air ambulance to transfer women to the JR. Mr Brennan explained that this would not be possible due to flight paths which would have to be put in place. Andrew Stevens stated also that it would be less appropriate for maternity cases because it would take longer to mobilise it and load. Paul Brennan explained that, for people living in Banbury, major traumas, stroke, heart attack were all blue lighted to the JR nowadays. With regard to the route, SCAS had a control system which diverted to the most appropriate route. He added that many ambulances took the route down Banbury/Oxford Road via Islip, and arrived within 40 minutes. A Committee member commented that another route used was via Deddington and along the bus lane to Kidlington, which could take less than 30 minutes. Mr Brennan commented that data provided had shown that on a blue light run from the Banbury area, 88.4% would arrive within 30 minutes and 100%  either less than, or equal to 45 minutes.

 

A committee member asked whether equipment was currently being moved to the JR. Catharine Greenwood explained that it was because women in Banbury were having to travel to the JR. She reassured the Committee that it would be moved back when the Unit was reopened. A clear inventory had been taken. In response to a question about whether the JR would have sufficient theatres, Mr Brennan stated that an extra theatre had been brought in to use for C sections, with a capability of 22 sessions rather than 20 as now. In addition to this two extra rooms (on top of 5) had been converted to clinical use. Two extra delivery rooms were also being created and would be ready the following week. The Trust had moved people out of an office to make space for mothers after they had given birth. There was also capacity for two more rooms to be converted for the same purpose. He stressed that the Trust was doing its best in the face of this emergency.

 

The Chairman then summed up the evidence relating to the grounds for emergency. These were:

 

·         The timing of the closure, given the imminent reduction in consultants at the unit.

·         A recruitment drive that had failed to deliver, although the Trust had not ceased its recruitment efforts. Appointees were being given the option of extending their contracts to make it more attractive.

·         There was no pre-determination with regard to the Transformation Plan consultation – maternity services would be part of longer term proposals in the Transformation Plan.

·         The question of travel times had been thoroughly explored – 88.4% in 30 minutes and 100% in 45 minutes meets 2007 NICE Guidelines.

·         A special ambulance would be available 24 hours a day at the Horton to transfer complex cases to the JR.

·         A decline in birth numbers at the Horton was related to an increase in risk factors during delivery and more people being advised to go to the JR.

·         Three other free-standing MLU’s in Oxfordshire – the results are safer – less at risk from medical intervention, although 25% transfer to consultant – led units.

·         Provision of two obstetric-type rooms plus two extra birthing-type rooms. The equipment had been moved to the JR, but could be moved back to the Horton. This had met the challenges by increasing space and staff.

·         Rotation of doctors with the JR had been considered as CRF posts had come to an end.

·         High risk patients were advised to go to the JR before they entered labour, so there was less need to transfer complex cases during labour, reducing risk.

 

The Chairman asked each member of the Committee in turn if each were satisfied with the reasons given for the emergency situation the Trust found themselves in, at the same time advising that if a member was not satisfied, then evidence was required for non-satisfaction. A vote was then taken and it was AGREED (by 5 votes to 3) that:

 

(a)   on the basis of the evidence provided by the Trust, not to refer the Trust’s decision to temporarily close the Obstetrics Unit at the Horton to the Secretary of State on the basis that it was satisfied that OUH had adequate reasons for acting without consultation on the basis of urgency relating to the safety or welfare of patients or staff but to monitor the situation carefully in the meantime; and

 

(b)  to request regular updates on the status of consultant-led maternity provision at the Horton and the recruitment of obstetricians.