Options Appraisal: Reconfiguration of Obstetric and Maternity Services in Cumbria On 18-20 November 2014 1 Undertaken by: Mrs Cath Broderick Mrs Sue Eardley Dr Anthony Falconer Ms Joy Kirby Ms Jaki Lambert Dr Andrew Leather Dr Romesh Rasanayagam Dr Nic Wilson On behalf of Royal College of Obstetricians and Gynaecologists 27 Sussex Place Regent’s Park London NW1 4RG Tel: +44 (0)20 7772 6200 Fax: +44 (0)20 7772 0575 Website: www.rcog.org.uk Registered charity no. 213280 2 Contents 1. REASON FOR REQUEST .............................................................................................................................. 5 2. NAMES OF REVIEW TEAM MEMBERS ........................................................................................................ 5 3. TERMS OF REFERENCE ............................................................................................................................... 6 4. BACKGROUND INFORMATION .................................................................................................................. 6 5. MATERNITY DATA FOR CUMBRIA ............................................................................................................ 12 5.1. MATERNITY DATA FOR NORTH LANCASHIRE .......................................................................................... 12 6. MATERNITY SERVICES - STANDARDS AND CO-DEPENDENCIES ............................................................... 14 6.1 Configuration of maternity services within the UK ................................................................................ 14 6.2 Standards of excellence, workforce issues and service provisions ........................................................ 16 6.3 Current configuration of Maternity services .......................................................................................... 21 6.4 Summary and drivers for report: ............................................................................................................ 24 7. PROCESS OF THE REVIEW ........................................................................................................................ 26 8. FINDINGS AND ANALYSIS ......................................................................................................................... 27 8.1 Workforce and Staffing ........................................................................................................................... 27 8.2 SAFETY AND QUALITY .............................................................................................................................. 37 8.3 PATIENT AND PUBLIC NEEDS ................................................................................................................... 48 8.4 RCOG LITERATURE REVIEW: .................................................................................................................... 52 9. OPTIONS APPRAISAL ................................................................................................................................ 54 10. OPTIONS ................................................................................................................................................... 55 11. CONCLUSIONS .......................................................................................................................................... 60 12. OVERARCHING PRINCIPLES AND RECOMMENDATIONS .......................................................................... 61 12.1 Whole systems approach ........................................................................................................................ 61 12.2 Patient safety ........................................................................................................................................... 61 12.3 Leadership and cross-professional working ............................................................................................ 62 12.4 Options .................................................................................................................................................... 63 12.5 Recommendations ................................................................................................................................... 64 13. SIGNATURES:............................................................................................................................................ 65 14. APPENDIX: ................................................................................................................................................ 66 One: Timetable of three day visit .................................................................................................................... 66 Two: HES Data ................................................................................................................................................. 70 Three: Documents and data obtained:............................................................................................................ 73 Four: Specific unit Data ................................................................................................................................... 74 Five: Summary of Key messages from CQC Reports from 2014 with emphasis on maternity provision ........ 75 Six: RCOG Literature Reviews .......................................................................................................................... 77 3 Seven: Additional data from Interviews and Observations ............................................................................. 83 Eight: Tabulated Options Appraisal ................................................................................................................. 86 Nine: Differences between MLUs and CLUs .................................................................................................... 96 Ten: Service Standards .................................................................................................................................... 97 Eleven: Anaesthetic staffing for NCUHT .......................................................................................................... 99 4 1. REASON FOR REQUEST This review has been commissioned by NHS Cumbria Clinical Commissioning Group and NHS Lancashire North Clinical Commissioning Group in order to provide an options appraisal for the reconfiguration of Obstetric and Maternity services based on information provided by the CCGs, Hospital Trusts and on interviews undertaken during the visit. It is important to appreciate that some of the work of this review was performed at a similar time to the Kirkup Independent investigation into events that occurred at University Hospitals of Morecambe Bay NHS Foundation Trust involving maternity services between 2004 and 2013. However, the commissioning of this work and the terms of reference were different. No members of the assessment team were privy to the findings or conclusions of the Kirkup report which was published on 3 March 2015. 2. NAMES OF REVIEW TEAM MEMBERS Lead Assessor Obstetrician and Gynaecologist Dr Anthony Falconer Retired Consultant Obstetrician and Gynaecologist Plymouth Hospitals NHS Trust Immediate Past President Royal College of Obstetricians and Gynaecologists Co-Assessor Obstetrician and Gynaecologist Dr Andrew Leather Consultant Obstetrician and Gynaecologist Ipswich Hospital NHS Trust Co-Assessor Neonatology Dr Nicholas Wilson Consultant Neonatologist, Clinical Lead for the North Central & East London Neonatal Network Whipps Cross Hospital, London Co -Assessor Paediatric Representative Mrs Sue Eardley Head of Invited Reviews, Royal College of Paediatrics and Child Health Co-Assessor Anaesthetist Dr Romesh Rasanayagam Consultant Anaesthetist with an interest in obstetric anaesthesia Brighton and Sussex University Hospitals NHS Trust Co-Assessor Midwifery Joy Kirby LSA Midwifery Officer East of England Co-Assessor Midwifery Jaki Lambert Senior Research Associate (Midwife) Centre for Maternal and Newborn Health, Liverpool 5 Co-Assessor Lay Cath Broderick Chair of RCOG Women’s Network 3. TERMS OF REFERENCE The aim of the independent review is:  To identify clinically sustainable and safe service options for the delivery of obstetrics and gynaecology services for the women of Cumbria.  To define the clinical interdependencies particularly in relation to obstetrics and midwifery, anaesthetic and high dependency care, surgical support, imaging and neonatal and paediatric services required to provide a network of women's care.  To present recommendations that over time will improve the provision of sustainable services that would be acceptable to the local population and for women in particular.  To present an options appraisal (including risks) in attracting and sustaining a workforce which is sensitive to the particular social and geographical challenges presented in this remote area of England.  To make recommendations based on the findings of the review. 4. BACKGROUND INFORMATION Population Health, Economics and Inequalities1 4.1 Cumbria is a county containing half a million people, with 5 000 deliveries a year and a geographical area of 2 600 square miles. It is unusual in its size and rurality and for these reasons provides many challenges for health care delivery. The health of people in Cumbria is varied compared with the England average. Overall, deprivation is lower than average, however there are some high levels of rural and urban deprivation, with areas of the county falling into the 10% most deprived nationally. Deprivation is particularly severe in the urban areas of Barrow and West Cumbria. 15.4% of children in the county live in poverty, which is below the national average of 21.3%. However, in one ward in Copeland the percentage of children living in poverty rises to 49.2%. Although deprivation is most prevalent in Cumbria’s urban areas there are also hidden pockets of deprivation in some of the county’s most rural communities. 4.2 Cumbria’s overall performance in a range of health and wellbeing indicators disguises significant inequalities in health outcomes. There is a 19.5 year gap between the wards with the highest and lowest life expectancies in the county, with life expectancy in some areas 8.4 years below the national average. Health outcomes in Cumbria are poorest in Copeland, Carlisle and Barrow whereas Eden and South Lakes have high levels of health and wellbeing. With the exception of Eden, all districts have problems around 1 http://www.cumbriaobservatory.org.uk/elibrary/Content/Internet/536/675/4356/41996121025.pdf 6 alcohol misuse. Poor mental health is also an issue for the county with incidences of neuroses, self-harm and suicide higher than those nationally. 4.3 Within Cumbria the majority of the population live around the 'edge' of the county and, despite being a largely rural county, many live in sizable communities, geographically isolated from each other. 4.4 Barrow has a population of around 70 000 and Whitehaven and Workington have around 25 000 each. However, Barrow has a more diffuse rural community. Barrow has a population of around 70 000 and Whitehaven and Workington around 25 000 each; although this area has a more diffuse rural community. Carlisle has a population of around 75 000. Carlisle, Whitehaven and Barrow are isolated from any major medical school or tertiary medical centre, although Carlisle has good transport links - north to Scotland and, south to Lancaster via the M6.To the east of Cumbria are Newcastle and Sunderland. To the north, Scotland provides a totally different organisation of health care. To the south of the county, Lancaster, which is in North Lancashire has a population of around 114 000 and is an important hub for South Cumbria’s medical provision.1 Lancaster has easier access to tertiary centres in Preston and Manchester through the M6 corridor and has a new medical school, based at the University of Lancaster. 4.5 The major occupations and employers in the county of Cumbria include tourism, the NHS, agriculture, Sellafield Ltd (nuclear reprocessing) at Whitehaven and BAE systems (British multinational defence, security, shipbuilding and aerospace company) at Barrow. Unemployment in Cumbria is higher than the UK average but is falling at a faster rate. There are potential expansion employment opportunities within BAE and Sellafield, but the exact timing is unclear. Local industry needs high quality medical provision to attract the highest calibre recruits. 4.6 Within the county of Cumbria the road and transport links are poor and transfer between communities is an ongoing challenge. Transport links are only very rapid down the north-south corridor that is the M6. Despite the geographical magnificence of the county, Cumbria feels isolated from large conurbations and this is said to be one of the major attractions for those who choose to live there. 7 Health Services in Cumbria and North Lancashire 8 4.7 Cumbria is primarily served by the following NHS Trusts: Cumbria Partnership NHS Foundation Trust provides community services (e.g. district nursing), some specialist physical health services (e.g. neurology and diabetes) and community and inpatient mental health and learning disability services. The Trust works across Cumbria, and also provides a limited number of specific services to the north Lancashire area. North Cumbria University Hospitals NHS Trust provides a range of secondary care services, and some tertiary services, from Cumberland Infirmary in Carlisle (CIC) and West Cumberland General Hospital (WCH) in Whitehaven. The Trust primarily serves the Allerdale, Copeland, Carlisle and Eden localities of Cumbria, as well as providing a small volume of patient activity to Scottish residents. Northumbria Healthcare NHS Foundation Trust is in the process of acquiring North Cumbria University Hospitals NHS Trust and this is expected to take place once this Trust is taken out of special measures. University Hospitals of Morecambe Bay NHS Foundation Trust provides a range of secondary care services, and some tertiary services, from Furness General Hospital (FGH) in Barrow and Royal Lancaster Infirmary (RLI) in Lancaster and a more limited range of services from Westmorland General Hospital in Kendal. The Trust primarily serves the Furness and South Lakes localities of Cumbria, as well as the population of NHS Lancashire North CCG. North West Ambulance Service provides patient transport and emergency ambulances to the population of Cumbria, as well as the wider geographical area of Lancashire, Cheshire, Merseyside and Greater Manchester. 4.8 Commissioning for the people of Cumbria is carried out by Cumbria CCG, which is the main commissioner for CIC and WCH and for FGH and RLI for patients registered with a Cumbria or Bentham GP. 4.9 The Northern Deanery, based in Newcastle places O&G, paediatric, anaesthetic and surgical trainees in CIC. The North West Deanery in Manchester includes FGH and RLI within its portfolio. 4.10 South Cumbria services are linked through the Greater Manchester, Lancashire and South Cumbria Strategic Clinical Network and Clinical Senates. In North Cumbria the Maternity and Child Health Network is one of the main networks within the Northern England Strategic Clinical Network based in Newcastle and is made up of two key strands-Maternity and Child Health-governed by separate clinical advisory groups. Similarly, neonatal care and retrieval services are split across the county, the North-West Operational 9 Delivery Network has three areas, Cheshire & Mersey, Lancashire & South Cumbria and Greater Manchester whilst the Northern Neonatal Network has one area that covers all of North Cumbria, Newcastle, and Teesside. Additionally there are networks for adult intensive care, the North East Critical Care Network for WCH and CIC and the North West Critical Care Network for FGH and RLI. 4.11 Patients from Cumbria access a range of NHS services outside the county, particularly for elective and complex procedures, including some interventions which are not otherwise available in Cumbria. HealthWatch Cumbria works with Cumbria Local Authority to harness patient/user input and to manage the communications, consultations and evidence around health service design, delivery and improvement. This wide range of organisations and networks, all with an interest in service provision at the four sites under review understandably makes whole-county strategic planning and service design extremely complex. 10