3 x Consultant Led Obstetric Units & 3 x Antenatal Day/assessment Unit. 3 x
Alongside Midwifery Led Units. 3 x Emergency Gynaecology 24/7 & 3 x
Emergency Gynaecology Units. 3 x Major .... pathways for management of
emergencies and ...
Maternity & Child Health Review
Aims of the Review The essential areas that the review was set up to address include:• Delivering safe services • Achieving national quality standards of care • Recruitment and retention of medical, midwifery and nursing staff • Allowing for changes in employment legislation • Provision of good medical education opportunities
Four Service Review The review of the four services were split into two key work streams: 1.
Maternity, Neonatal & Gynaecology
2.
Paediatrics
•
Agreement across both work streams that where ever there is an Obstetric Unit there must be a minimum of a level 2 Neonatal Unit (HDU)
•
Requirement is that a Neonatal Intensive Care Unit (NICU), must have a Neonatal Rota separate to the General Paediatric Rota
Conclusion of the key drivers in support of the Case for Change
• Population Health Need – Reducing inequities to improve health for women, children & families by investment in early years, tackling obesity, smoking, preventing ill health and early intervention • Improving Quality & Safety – to improve safety of services and patient experience to make sure the achievement of quality standards can be sustained • Sustainable Skilled Workforce – to achieve workforce stability including compliance with workforce standards, retraining capability and developing appropriate skills • Financial – Services are financially sustainable and cost effective
Maternity, Neonatal & Gynaecology – Scenario 1 3 x Consultant Led Obstetric Units & 3 x Antenatal Day/assessment Unit 3 x Alongside Midwifery Led Units 3 x Emergency Gynaecology 24/7 & 3 x Emergency Gynaecology Units 3 x Major Gynaecology surgery in-patient (Major Cancer surgery in West) 3 x Day case gynaecology Units 3 x Neonatal Units (Clinically preferred option for Neonatal ITU to be in Central) Fetal medicine centre in East Positives / Advantages Quality & Safety Access–no change to present access and travel times Equity Patient safety - not compromised due to geographical access Minimum change - established relationships maintained, need to maximise efficiencies Patient choice MLU alongside - offers less invasive option (presently available in YGC, Wrexham will be on line 2012) Population Health Need – All services accessible to areas of greatest deprivation Financial – Does not require capital investment
Negative / Disadvantages/consequences Population Health Need Will we be able to achieve the required shift to early intervention, prevention and improve health without a whole system change Sustainable Workforce & Quality & Safety Midwifery - Requirement similar for all options (Birth Rate plus based on delivery rates) Anaesthetics - Dedicated consultant cover out of hours consultant for each unit Obs & Gynae: Maintaining Labour Ward cover at all units (Wrexham should already have 60 hours) Recruitment of trainees will remain challenging Move to a consultant delivered service (more expensive) Neonatal: Availability of Neonatologists remains unclear for short, medium and long term, Neonatal Nursing staff (2 years to train ANP) Gynae nursing: will not meet recommended staffing levels Financial – Increase in revenue to meet the essential standards
Maternity, Neonatal & Gynaecology – Scenario 2 3 x Consultant led obstetric Units & 3 x Antenatal Day/assessment Units 3 x Alongside MLU 2 x Emergency in-patient Gynaecology 24/7 (East & West) 3 x Emergency Gynaecology Assessment Units (East & West) 2 x Major Elective Gynaecology surgery (Major Cancer in West) 1 x Main Gynaecology day case Unit (Central) & some day case activity East and West 3 x Neonatal Units (Clinically preferred option – ITU in Central) Fetal medicine centre in East Positives / Advantages Quality & Safety Access – 98% within 60 minutes of a District General Hospital Equity Patient safety - not compromised due to geographical access Minimum change - established relationships maintained, need to maximise efficiencies Patient choice MLU alongside - offers less invasive option (presently available in YGC, East will be on line 2012, no plans for YG) Population Health Need – Most services accessible to areas of greatest deprivation Sustainable Workforce - Gynae nursing recommended staffing levels met Financial – Does not require capital investment
Negative / Disadvantages/consequences Population Health Need How can we make the required shift to early intervention, prevention and improve health gain? Sustainable Workforce Midwifery – Requirements similar for all options Anaesthetics - would require dedicated out of hours consultant for each unit (only Wrexham has this at present) Obs & Gynae - Maintaining Labour Ward cover at all units Recruitment of trainees will remain challenging Move to a consultant delivered service (more expensive) Neonatal- Availability of Neonatologists remains unclear for short, medium and long term, Neonatal Nursing staff (2 years to train ANP) Gynae Nursing – Increased travel for some patient to access inpatient, emergency and day case surgery Finance – Increase in revenue to meet the essential standards
Maternity, Neonatal & Gynaecology – Scenario 3 2 x Consultant led obstetric Units 2 x Alongside Midwifery led Units 1 Free standing MLU (Central) 2 x Emergency Gynaecology 24/7 2 x Major Gynaecology surgery & 2 x Emergency Gynaecology Unit 2 x Antenatal day units & Centralized Antenatal Clinic (Centre) 1 x Main Gynae Day case Unit (Central), with some day case activity East and West 2 x Neonatal Units (Neonatal Intensive Care Unit in East or Arrowe Park) Fetal medicine centre in East Positives / Advantages Quality & Safety Greater number of essential quality & safety standards would be met by concentrating on two sites Fetal medicine: Concentration of expertise and enhance services Population Health Need Greater opportunity to refocus resources, early intervention, prevention Sustainable Workforce Anaesthetics- additional anaesthetic staff would not be Needed to meet standards Obs & Gynae - 2 units requiring 60 hour Labour Ward cover Educational opportunities - enhanced and help maintain college registration for Medical staff Midwifery - Potential for greater focus on community and health improvement. Free standing MLU safe with agreed strict protocols Neonatal - Would address some junior doctor issues, fewer nurses required to meet BAPM standards Gynae nursing – achieve recommended staffing levels on 2sites Financial:– Nearer to financial balance (except for neonatal costs)
Negatives / consequences Quality & Safety Access – YGC would see a significant reduction in Births (2,400 to 500 births in MLU). All inpatient Gynae would stop. Choice – Increasing number of women choosing to have their treatment in Countess of Chester Safety concerns – Strict protocols, pathways for management of emergencies and transfers Increased demand on WAST- inter hospital transfers (4 transfers per week from MLU to Obstetric Unit) Population Health Need – Reduction of services in area of highest deprivation Sustainable Workforce-implications for staff, relocation, travel, recruitment Financial – Capital Investment required
Paediatrics – Scenario 1 3 x Consultant in-patient units (Reduced in-patient beds) 3 x paediatric assessment units 3 x Out Patient Departments 3 x Level 2 Neonatal Units Enhanced community service across North Wales Neonatal Intensive Care (Clinically preferred option Central) Positives / Advantages Quality & Safety obstetric services – allows continuation on 3 sites Access - Maintains good access for all BCUHB population Increasing consultant delivered service Paediatric Assessment units on each site may reduce emergency admissions Choice – maintains choice for patients and families Population Health Need Partnership relationships unchanged including Safeguarding arrangements Sustainable Workforce Middle grade paediatric staff will be increasingly non-training grade, giving increased continuity Minimal impact on staff e.g. relocation Finance No capital investment required
Negative / Disadvantages/Consequences Quality & Safety Ability to safely staff three units due to staff availability Training opportunities for staff not optimised Population Health Need Decreased ability to shift resources and invest in Enhanced Community Services - early intervention/Public Health Sustainable Workforce Training - Ongoing difficulty with provision of sufficient junior and middle grade paediatricians Deanary requirements Recruitment - consultants (National pressure) Finance Increased revenue cost to ensure compliant medical rotas
Paediatrics – Scenario 3 2 x Consultant Paediatric Units 2 x Along side Paediatric Assessment Units 3 x Outpatient Services Middle grade paediatrician in the Emergency Department in Central 24 hours/day Enhanced Community Services 2 x Level 2 Neonatal Units 1 X Intensive care in East or Arrow Park Positives / Advantages Quality & Safety Meet and sustain a higher percentage of essential Quality and Safety Standards Population Health Need Change in the way services are delivered, shift to early intervention particularly in the early years being a priority Workforce Sustainability Greater sustainability of middle grades and junior trainees Better training opportunities for Paediatricians Concentration of expertise on two sites Financial More affordable in relation to staffing
Negative / Disadvantages Quality & Safety Potential for increased admissions and length of stay Unable to provide Level 2 Neonatal in YGC, therefore inability to sustain consultant led obstetric unit Increased inter hospital transfers Potential delays in families accessing treatment Ensuring appropriately skilled staff in ED Population Health Need Social, psychological, spiritual implications on families Removing resources from areas of high deprivation Workforce Sustainability Primary Care – Increased workload, including OOHs Recruitment – will this be eased in West if we move to 2 sites Re-location of staff Financial Potential for knock on costs to family, staff and partners Cost of Community based services Capital investment required on two sites
Maternity, Gynaecology & Neonatal Interdependencies Essential Paediatrics
Paediatric cover for Neonatal Level 2 (HDU) on all sites where there is an Obstetric Unit
Anaesthetics
Anaesthetic 24/7 for Labour Ward (C-Sections & Epidurals)
Critical Care (Adult)
Access to HDU & ITU for Obstetric and Gynaecology patients
Surgery (Colorectal & Urology)
Clinical opinion is that Gynaecology must have direct access (on site) to these specialities for both elective and emergency
Emergency Services (ED)
Further Discussion
This is considered desirable for Obstetrics
If no 24/7 Obstetric & Gynae on site pathways to ensure the safe management of women presenting via ED
Paediatric Interdependencies Essential Obstetrics
Paediatric cover for Neonatal Level 2 in all obstetric units
Emergency Services (ED)
If no Paediatric Unit on site, middle grade 24/7 in ED Requirements for RSCN support and opinion
Anaesthetics
Airway management, Stabilization of critical ill children prior to transfer, anaesthesia, pain management
Surgery
Further Discussion Neonatal Intensive Care requires a separate rota
If no paediatric surgery takes place on site, need to consider how skills are maintained to support children in ED If no paediatric unit, no ward, staff to care for any children post operatively ENT opinion for airway management
Summary of the Consequences for 3 sites V 2 sites 3 sites Population Health Need Can we achieve the shift from acute to community, tackling health inequalities, early years and early prevention agendas Quality & Safety Without investment how can we move towards meeting the recommended standards for quality & Safety Sustainable Workforce Recruitment, compliant rota’s, and training opportunities unchanged Finance Additional recurrent funding to increase staffing for all 4 service areas across Medical, Midwifery and Nursing staff
2 Sites Population Health Need Will the change in services to the third site facilitate the changes needed. E.g Paediatric emergency admissions reduce, Caesarean section rate reduce, tackle inequalities Quality & Safety Greater number of the quality and safety standards will be achieved by concentrating resources and expertise on two sites Increase in travel and transfers Sustainable Workforce Re-location of staff Improved training opportunities Finance More affordable within the present recurrent funding Requires capital investment
