Monday, September 2, 2013

An Action plan for Maternity and A&E

Neil Zammett Writes
Maternity promises by NELC
The news from the CQC inspection of Whipps sent alarm bells ringing in Redbridge and Waltham Forest and woke everyone up to some very unpleasant facts about services. For Maternity in particular, the independent conclusions of the inspectors contrasted sharply with those of the ‘Gateway Assurance’ process carried out be NELC (North East London Primary Care Trust) before the service at King George was closed.
A survey of Redbridge women undertaken for Health4NEL showed overwhelmingly that they wished to go to King George. Nevertheless a significant number of Redbridge women were diverted to Whipps Maternity when King George closed on the understanding that the service there would be of an equivalent standard at least in terms of staffing levels and basic ‘readiness’.
The Gateway Assurance process was supposed to ensure this, although Whipps was only included at the last minute, but two major points of concern have now emerged at Barts Health: the time consultants are present on the labour ward and the midwife to birth ratio. The process was supposed to have confirmed a plan to achieve 98 hour consultant cover per week and a ratio of 1:30.
Bart’s Health however are currently operating at a much lower consultant cover level, certainly at Whipps and are working to a trust wide ratio of 1:32 for midwives. There seem to be no clear plans to increase this-certainly not in the short term.
The CQC report shows however that service quality at Whipps is deficient in a number of other important ways as well. The local and national press have described the “... catalogue of failings” which include unsafe equipment, uncaring staff and women in labour being diverted to other hospitals because there were not enough beds.
In addition to these very serious concerns the whole of the maternity service at Bart’s Health is going to be subject to a further inspection by CQC because of its high emergency caesarean rate.
It is very hard to see how this squares in any way with the Secretary of State’s commitment not to close until local services are of a good standard.
In fact the worst fears of local people have now been realised and the warnings that the closure of the service at King George was being rushed and the Gateway Assurance process skimped have been borne out by events.
Following the Lewisham judgement there is now an important legal angle as well because if local services were, and are, not of a good standard then the original commitment of the Secretary of State has not been met and the NELC decision may be unlawful. Certainly those board members and GPs who supported the decision have something to answer for.
Risks around A&E
If maternity is problematic the situation with A&E at King George is steadily becoming riskier. A clinical review commissioned by the three outer London CCGs is underway. It is led by an external expert primarily looking at medical staffing and the feasibility of a night closure at King George but the broader aspects of a possible night closure also deserve some attention.
How this proposal came about is shrouded in mystery. Letters from the Chief Executive of BHRUT would suggest that it arose as part of the radical thinking advocated by CQC in their report on their June visit. Recent enquiries have revealed that it was part of an overall plan to close King George presented at the June 4th Barking and Dagenham Health and Well Being Board. The plan was written by the BHRUT Medical Director Dr Mike Gill and appears to be a response to the previous CQC visit in late 2012.
This plan has not been to a public BHRUT Board meeting or the Redbridge Health Scrutiny Committee. Its formal status is therefore unclear and it is pretty much an outline document, although there is a chart which clearly shows King George closing at night in August 2013 and finally in Quarter 2 2015.
What is very surprising is that none of the formal documents; the business case for the A&E extension/conversion at Queen’s and the Long Term Financial Model (LTFM) have not been put into the public domain by BHRUT. These are essential building blocks of both the closures at King George and BHRUT’s Foundation Trust application.
Given the scale of what is proposed proceeding publicly just on the basis of Dr Gill’s outline document in my view is totally unsound in governance terms and we all need to see these other more substantial documents.
There is also the impact that any changes will have on the emergency care services across East London. Although eight ‘blue light’ patients a night at King George does not sound much; if all were admitted with an average length of stay of 3.5 days some 28 beds, say a ward, would be required. Given the number of beds BHRUT have already closed it is hard to see how existing services would cope particularly with the winter approaching.
We also need to be clear about processes for consultation. Just recently a letter has been circulated following a routine monitoring visit by Redbridge Health Scrutiny Members to BHRUT making it clear that members were not “on board” with the night closure when the BHRUT Chief Executive had told the Urgent Care Board that they were.
At senior level people should know the difference between a conversation and an agreement and this embarrassing episode points up the need for proper consultation and communication through established structures.
As with maternity, what seems to be happening is a rush to close the service based on the old Health4NEL plan which is now largely discredited in terms of its efficiency and workload projections.
A way forward
Whether Redbridge Council seek a judicial review of the NELC decision is a matter for them but at a practical level we should all be calling for a level playing field in terms of standards of maternity care in East London. Central to this is a clear statement of current staffing levels, booking and deliveries for all of the units. We also need to see the plans to meet the targets set by NELC and to start with an understanding of what those targets were and how they were to be monitored.
This is all the more important because BHRUT now have consultant cover of 98 hours and a midwife to birth ratio of 1:29, the best in London. It means that some Redbridge women have been transferred against their wishes to a lower standard service and this is a disgrace.
Redbridge Council has asked for a review of A&E services across East London and they are to be congratulated for doing this. What we need is a proper long term plan and more urgently a plan for this winter which takes account of the pressures on all A&E departments.
In summary what we should be doing for maternity is:
· A schedule of activity and staffing levels for all the units in East London
· A clear statement of expected standards
· Plans to achieve these standards
· Checking to see if the NELC decision is lawful
· Considering other options to achieve the standard of service promised to Redbridge women
And for A&E:
· A winter plan for 2013/14 for the whole of East London
· A long term plan to 2024/25 for A&E services

· The BHRUT LTFM and A&E extension business case to be published

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