Agenda item

To receive a briefing on the Start Well programme and proposals to reorganise maternity and neonatal services in North Central London.

Anna Stewart, Programme Director for Start Well, introduced the report for this item and was joined by Clare Dollery, Medical Director at Whittington Health NHS Trust and Vicky Jones, Medical Director at North Middlesex University Hospital NHS Trust.

Anna Stewart provided an overview of the NCL (North Central London) Start Well programme, a long-term piece of change work to improve maternity and neonatal and children’s surgical services. A public consultation was in progress which included details of options to reduce the number of maternity and neonatal units in NCL from five to four:

• Option A would involve the closure of services on the Royal Free site in Hampstead but remain open at the Whittington Hospital site. This was the preferred option based on the modelled flows of patients and the expected number of staff that would need to be move to a new location.
• Option B would involve the closure of services on the Whittington Hospital site but remain open at the Royal Free site.
• In both cases, the services at UCLH, North Middlesex University Hospital (NMUH) and Barnet Hospital would remain in place.

The proposals were based on a case for improving services and meeting best practice standards against a backdrop of declining birth rates and increasing complexity of both women giving birth and babies who needed care. The changes were not about reducing funding and around £40m of capital investment had been earmarked for the remaining sites. The ICB strongly believed that, by having a smaller number of units, staffing resources could be better used to meet quality standards.

In addition, there were separate proposals for:

• The closure of the birthing suites at Edgware Birth Centre, due to declining use with only 34 births in the last financial year.
• The streamlining of pathways for paediatric surgical care with the consolidation of some surgical care at Great Ormond Street Hospital and day case surgery at UCLH.

The public consultation was due to run until 17^th March with several events having taken place in Haringey already. There had been an unprecedented amount of hard-to-reach groups as part of the integrated impact assessment and the data was being used as part of the improvement programme. The Start Well team were keen to hear from a wide range of voluntary and community sector voices and any recommendations from the Panel on local groups would be welcomed.

Anna Stewart, Clare Dollery and Vicky Jones then responded to questions from the Panel:

• Cllr Connor expressed concerns about the existing provision of services given the latest CQC ratings for maternity services at the Whittington Hospital, which was rated as ‘requires improvement’ and at the NMUH, which was rated as ‘inadequate’. Particular areas of concerns raised in the CQC report on the NMUH included staffing issues, a lack of detailed treatment records and failure to implement lessons learned from incidents.

-       Regarding the NMUH, Vicky Jones acknowledged that the CQC report highlighted failings that they were acting to rectify. The visit was in May 2023 and since then there had been a five-day visit from NHS England to inspect services and provide further insights. She also acknowledged that staffing was clearly a big issue, as highlighted in the report, but 20 new midwives had started in the department since then which had made a substantial difference to staffing levels. This had enabled additional focus on an appropriate level of training, sharing/embedding lessons when things had gone wrong and addressing pockets of poor culture that had been identified in the report. There was also a specific piece of work on organisational development, including external support, which was being monitored on a monthly basis by the Board. Triage processes were being regularly audited to demonstrate compliance with standards. Overall, the issues described in the report were improving and this was demonstrated through audit data.

-       Regarding the Whittington, Clare Dollery explained that key areas for improvement in the CQC report were completion of training modules for medical staff and safeguarding training, both of which were now in place, and risk assessing women attending triage, for which a systematic traffic light approach had been implemented and would soon be followed by moving onto the BSOTS national system. The leadership of the unit had received a ‘good’ rating and the good team working between obstetricians and midwives, including a co-mentoring programme, had been highlighted. She also cited the FGM clinic and the ‘Ockenden cafes’ initiative, which helped staff to discuss safety issues, as other examples of positive work. 

-       Anna Stewart added that NCL had an active maternity and neonatal system in which all the providers worked together to foster a learning environment and share good practice.

• Cllr Iyngkaran expressed some sympathy about the CQC ratings as the majority of maternity units nationally were rating as ‘requires improvement’ or ‘inadequate’. However, he requested further details on what was being done to address staffing, culture, training and infrastructure issues and also about water births at NMUH.

-       Vicky Jones said that the increase in midwife numbers had gone a long way to manage shortages and that obstetrician staffing was good. There had been positive feedback about the culture of obstetricians and midwives working together. In terms of infrastructure there were very large rooms which were state of the art. Across the organisation, mandatory training was above the standard. There was still some life support training to complete where the target of 90% had nearly been reached. There had been a specific issue around training to ensure that everyone could undertake an evacuation of the water birth area if required and now all staff had completed that training.

-       Clare Dollery said that, in advance of the CQC inspection they had agreed to fund six new consultants, five of which were now in post with locums in other areas. On culture, the CQC report has acknowledged that staff felt supported, valued and respected, focused on the needs of women receiving care, promoted equality and diversity, provided opportunities for career development and had an open culture in which concerns could be raised. There was also positive commentary about working with Maternity Voices partners. With regards to mandatory training, the staff groups highlighted were all now compliant.

• Cllr Iyngkaran asked whether the Trusts had pushed back on the CQC ratings or any of the issues raised. Vicky Jones and Clare Dollery both said that the usual factual accuracy checks had been completed with corrective data provided to the CQC where necessary.
• Asked by Cllr Brennan for further details on the use of capital funds for modernisation, Anna Stewart explained that, under Option A, the vast majority of the funds would be used to upgrade the unit at the Whittington or, under Option B for the Royal Free. Under either option, some funds would also be made available for other hospitals and there was some additional capacity available at the NMUH that could be used for an increased flow of cases. 
• Cllr Mason asked about recent complaints and any whistleblowing and also raised concerns about communications between staff on the ward and with patients.

-       Vicky Jones said that acting on complaints was important and that the Maternity Experience survey was a particularly useful source of feedback. The NMUH had only scored below average on 2 of the 36 questions and the scores had improved from previous years, including on communications issues. The NMUH was highly rated on partners being able to stay overnight on the ward which many families valued. On whistleblowing, the executive team had received letters from staff, but they had shared their names which was a positive sign that they felt able to highlight concerns directly. On communications, the obstetricians and midwives had regular discussions in huddles on safety issues and other points throughout the day.

-       Clare Dollery said that they thought deeply about complaints and how they could be used to improve. The Whittington also had results from the Maternity Experience survey and areas of improvement had included people feeling that they were given appropriate advice and support at the start of labour, information about risks during labour and feeling that their concerns were taken seriously. The CQC had said that the Whittington worked closely with Maternity Voices partnerships who could raise issues when required. They were also carrying out various training programmes, including for maternal and neonatal emergencies.

-       Anna Stewart added that the engagement with patient and resident groups, including specific concerns of various minority groups, was driving the thinking about changes and mitigations that would need to be put in place.

• Referring to pages 30 and 32 of the agenda pack, Cllr O’Donovan noted that under Option A there were projected to be 1,525 Haringey deliveries at NMUH but under Option B there would be 2,146 and asked how this additional capacity would be accommodated. Anna Stewart explained that the sizes of the units that would be closed were different with around 2,500 births per year at the Royal Free compared to just under 3,500 at the Whittington so there would be a larger redistribution under Option B where the Whittington would be closed. Not all cases would go to NMUH but it did have some spare capacity that wasn’t currently being used. There had been close working with the relevant Trusts on the modelling approach for both options.
• Asked by Cllr O’Donovan whether they could reach all the resident groups listed on page 48 of the agenda pack, Anna Stewart said that over 100 community meetings and staff meetings had been held across the five NCL boroughs and also Brent and Harrow, which could potentially be impacted by the changes. Some specific focus groups had also been commissioned through a specialist partner working with asylum seekers, homeless people and communities identified as being impacted geographically due to their proximity to the hospitals. There were also direct mailings to a significant sample of residents in these areas.
• Asked by Cllr Opoku how the ethnicities were defined, Anna Stewart said that these were based on the framing and terminology used by the specialist partner and that the modelling had involved looking at groups based on travel analysis and catchment areas and then overlaid with groups that had poorer outcomes in terms of maternal health.
• Cllr Peacock observed that there was an issue in the Northumberland Park area with Somali women not presenting for prenatal treatment. Anna Stewart confirmed that there had been two or three focus groups with Somali women with experience of using local services in Haringey.
• Cllr Iyngkaran queried the impact on residents of moving some paediatric services. Anna Stewart said that this had been covered in the integrated impact assessment and that, while there were cost implications in terms of travel, these cases typically involved children who were already being admitted quite far afield, including to the Royal London Hospital or the Chelsea & Westminster Hospital. Colleagues from emergency departments considered that the current pathway did not work well for staff or parents and so, through a surgical assessment unit, the pathway could be smoothed with automatic acceptance rather than staff going through a process of phoning around to find a bed.
• A local resident spoke about her experience as the parent of a disabled child who she said was failed by maternity services. She said that, due to the severe nature of her son’s disability, they needed to make frequent journeys for appointments and asked about the impact on families such as hers if journey times would be longer and costs higher. Anna Stewart explained that the cases impacted by these changes were predominantly for one-off surgeries rather than for children with complex needs which was a separate pathway. The wider implications of the changes on families would be included in the report following the consultation.

Cllr Connor summed up the Panel’s conclusions which included support for Option A as outlined in the report. She also reiterated concerns about the NMUH’s CQC rating for maternity services and said that the Panel should continue to receive further information about the investment to improve services at the NMUH and other hospitals as a result of this programme. Finally, she highlighted the need to consider any unintended consequences of the changes that might emerge from the consultation and, in particular, any concerns raised by residents about transport issues and how these would be offset. (ACTION)