Monday, January 14, 2013

No room at the Inn? Maternity Department Capacity in NE London

Neil Zammett writes
The last few months have seen the publication of a number of key documents relating to the future capacity on maternity departments in NE London. These are listed at the end of this blog.
These are all substantial documents which together show how maternity services are going to be provided over the next three years and provide more limited information on the situation in seven year’s time. They do not all cover the same ground, and some are much more detailed than others. This makes piecing the material together to give a full picture a very substantial task in its own right.
As this is a long blog the headline facts and issue are summarised below:
At a glance
· Forecasts have changed and are less certain but birth rates in NE London are still rising and numbers are likely to be about 40,000 per annum in ten years time.
· In the long term, ten years time plus, six rather than five maternity units are likely to be needed, particularly if an 8000 delivery “cap” is introduced.
· Under current plans over 50 midwives will be lost at BHRUT. These valuable staff may be lost to the NE London health economy.
· Only BHRUT has a maternity workforce plan. None of the other trusts have plans available to address the shortfalls in consultants and midwives.
· The original plan assumed that developments at Whipps would be completed before King George closed. These have yet to be agreed.
· Without further significant capital expenditure NE London will run out of maternity capacity very quickly unless the unit at King George is retained.
· The failure to close the A&E department at King George adds weight to the case for retaining a maternity unit there.
The Forecasts
All agree that the number of births per annum in NE London is going to rise over the next three to seven years; the question is by how much. The original DMBC from 2010 which was the basis on which the decision to close the unit at King George was made used a single forecast of 36,784 for 2016-17 based on a projection of historical births. These were then apportioned between hospitals using assumptions based on existing flows and a variant based on allocating women to their nearest unit.
This however was a five year forecast from a 2010-11 base year. No ten year forecast was included in the plan but doubling the five year forecast would give a figure of 44,217 for 2019-20.
The more recent paper has revised these forecasts to reflect the slowing of the rate of increase in births and now gives two figures based on high and low estimates of the increase in future birth rates. This would give a low figure of 32,940 by 2016-17 and a high of 34,435. The corresponding figures for 2019-20 would be 34,778 and 37,593.
Given the elapsed time however these are three and seven year forecasts. To get five and ten year projections from a 2013-14 base an extra two years growth, say 2000 deliveries would need to be added. This would give a figure of just under 40,000 births in ten years time as an upper estimate.
To complicate matters further, the later paper introduces the concept of a permanent “cap” on deliveries on any one site to 8000. Previously the idea of capping had been limited to short term limits on BHRUT. If accepted this would mean that the five proposed units in NE London would have an absolute limit of 40,000 deliveries per annum. Current capacity is estimated at 30,927
Capping therefore has a direct link to the number of units and is a major policy development which has not been subject to any wide discussion and was certainly not included in the original decision-making process. It also reduces the flexibility in provision. If births exceed 40,000 then six units not five will be required.
Given the uncertainty in the forecasts and the introduction of capping the need for flexibility in the short and long term plans is magnified.
How this affects the individual units.
This again is a complex area because the capacity of individual units depends on both the numbers of staff available and the physical constraints of the unit; theatres for caesareans, delivery rooms and so on. All of this is explored in some depth in Geoff Sanford’s paper. He comments:
“Demand is likely to exceed capacity at most hospitals at some point in the next five years. Much of this demand can be met in the short term by increases in workforce and introducing new ways of working such as co-located birthing units and increasing home births. However there will probably still need to be an increase in the physical capacity for deliveries in the sector to meet the demand in the medium long term.”
Queens and King George
BHRUT have very advanced and detailed plans for the closure of the unit at King George and the introduction of the 8000 births cap. These include a schedule for reductions in staffing levels to match the workload. Table 14, page 15 of their Maternity Transition plan shows that WTE midwives are planned to reduce from 321 in October 2012 to 268 the following year, some 53 staff. This is subject to review every quarter to make sure the service remains safe.
In addition one Consultant, one middle grade and one SHO will be shed from the medical establishment.
There is adequate infrastructure at Queen’s for up to 9000 deliveries per annum.
Whipps Cross
The unit here is considered to be at full capacity with 5,700 deliveries. This is why new proposals to divert Waltham Forest women to the Homerton have been introduced to make way for Redbridge women displaced from King George. Any long term increase in capacity would be dependent on a capital scheme which is currently with NHS London. Lead time would be at least two years.
Geoff Sanford comments “... demand is likely to exceed this year’s capacity in 2013-14.” This is particularly interesting as the assurance process for the closure of King George shows Newham as green. Staffing is obviously the key issue at Newham although there are some issues about theatre capacity as well.
The Royal London
This unit has been under pressure because of a “spike” in births in Tower Hamlets. Outturn in 2011-12 was 4460 deliveries. There is no MLU a present and this would be one route for longer term expansion.
The Homerton
Geoff Sanford reports that the Homerton can deal with future demand and possibly increase beyond its current 6000 capacity.
What is worrying about this is that, as with all the units referred to above apart from Queens, the Maternity Workforce Strategy shows that there is a very significant shortfall at the unit in both midwives and consultants, 58 and 13 respectively up to 2016-17.
Workforce Planning
The Maternity Workforce Plan, a broad brush document produced by NELC in May 2011, shows all trusts as having very significant staffing shortfalls for both consultants and midwives. The only Trust to have a detailed workforce plan is BHRUT which is currently the best staffed. The others have no available plans and In particular there is no indication of how the 98 hour cover target for consultants and more aspirational 168 hour target are going to be reached.
The situation with midwives is even more bizarre with BHRUT planning to lose over 50 staff while other units still have very large shortfalls. This will mean moving births away from a well staffed unit to ones which are worse off.
Will there be room at the Inn?
The answer to this question is; in the long term only if there is significant further investment in maternity services and the total number of births remains below 40,000 per annum. It looks very possible that this figure will be exceeded in ten years time and that a sixth unit will be required.
In the short term the capacity of units is likely to be limited to around 31,000 unless staffing levels can be improved. Given that the demand forecast for 2013-14 is 31,071 to 31,415 the situation is going to be very tight indeed particularly with the reduction in flexibility created by the cap of 8000 on Queen’s.
Women may have to travel further to have their babies and possibly change units at short notice because of daily spikes in demand. Under these conditions they will have no choice and it is possible that women may have to access units outside NE London in significant numbers.
The quality assurance process introduced by NELC reconciles demand and capacity for Newham, BHRUT and the Homerton for 2013-14. The outline of the process is shown in paragraphs 1.5 to 1.9 of the “Update of Maternity Services.” The paper lacks detail however and in particular staffing numbers and their relationship to quality standards. It refers to working towards the defined standards rather than achieving them.
Given the significance of the staffing issues, and the comment in Geoff Sandford’s paper that at Newham demand will exceed capacity in 2013-14, the reconciliation with additional workload should be in the public domain.
There is a danger of the commissioners being seen to have double standards where BHRUT is expected to meet targets because of the pressure to close the maternity unit at King George and other units are not. This is even more galling because of the efforts BHRUT have made to recruit staff including the overseas drive. If these 53 midwives and three doctors are lost to the NE London health economy they could be impossible to replace.
How this relates to strategic plans
The plans for maternity services were not drawn up in a vacuum. In particular they were closely linked to proposals to close A&E at King George. To date it has not been possible to close the department and it now seems likely that it will remain open for the foreseeable future. This is tied up with the development of a long term financial model (LTFM) for BHRUT which is proving problematic.
Barts Health is also experiencing financial problems and across NE London there are issues with the level of debt/investment much of which is tied up in very expensive PFIs. There has to be a question mark about the financial viability of new investment at the Royal London and Whipps sites. Without this however NE London will soon run out of maternity capacity.
The zero cost option of using the maternity facilities a King George as a long term sixth unit has not been considered, although this would provide the necessary flexibility and resilience. It would also help to retain over 50 valuable midwives in NE London.
As the stalling of the A&E closure plans at King George illustrates only too well; there are grave dangers in trying to do too much too quickly, what you can do safely in five years you cannot do in two.

“Planning for future maternity Capacity in NE London” (Geoff Sanford). First tabled at the JHOSC, 8th January 2013
“BHRUT Update” (Averil Dongworth). To be presented to the Redbridge HSC, 16th January 2013
“Update on Maternity Services” (Helen Brown). To be presented to the Redbridge HSC, 16th January 2013.
To these should be added the following earlier documents:
“Maternity Workforce Strategy for NE London” May 2011. First tabled at Redbridge HSC, 22nd October 2012.
“Decision making Business Case (DMBC)” Presented at JCPCT meeting December 2010.

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