Report into Paediatrics at UHMBT Introduction Professor Sir Alan Craft and Dr Alastair Campbell were commissioned by NHS Cumbria to undertake a review of the current and future safety and stability of paediatric services in the University Hospitals of Morecambe Bay NHS Trust, with particular reference to Furness General Hospital. This process was initiated by NHS Cumbria as part of its supportive measures to assist the University Hospitals of Morecambe Bay NHS Trust in making sustainable quality improvements. There have been a series of widely reported incidents, largely surrounding maternity and newborn services at Furness General Hospital. In addition there have been historic difficulties in staffing the paediatric department at the Furness General Hospital over the past few years. In 2009 the University Hospitals of Morecambe Bay NHS Trust commissioned Dr Andy Mitchell, Medical Director of the London Strategic Health Authority, to review children s services. His report included a review of the current pressures facing paediatrics nationally and these are not reiterated in detail in this report. Dr Mitchell was subsequently asked to provide a second report on paediatric services for the whole of Cumbria. His report contains an excellent review of the background and of the external pressures leading to increasing challenges for Furness General paediatric services. There have been several recent work streams initiated which have led to developments in paediatric services. In addition, there have been a number of incidents, largely in the maternity/newborn arena which have led to regulatory action by the Care Quality Commission, Nursing & Midwifery Council and by and Monitor The difficulties of staffing the paediatric department have been evident for several years and this is due to a variety of external factors which are common to many small and/or isolated units across the UK. Those that impact directly on Furness General Hospital are the shortage of sub-consultant grade staff to fill rotas and a withdrawal of most trainees from the hospital, largely because of lack of training opportunities. 1
Both of these factors need to be explored in more detail as part of the improvement programme initiated by the new, senior leadership the University Hospitals of Morecambe Bay NHS Trust. In the absence of an alternative, sustainable solution to these historic issues, a paediatric services at the Furness General Hospital may be required to move to a consultant-delivered service. This has been recognised and a plan devised to move to a consultant deliveredservice which does not rely upon sub-consultant grade staff. Initially the review team were asked by the University Hospitals of Morecambe Bay NHS Trust to provide support to the Paediatric Clinical Director, Dr Owen Galt, in implementing the plan which had been devised. A preliminary visit by the review team suggested concerns with the proposals and that a comprehensive review of paediatric services across the Trust should be undertaken, including community services and the established need to develop a greater role for primary care in the integrated delivery of paediatric care in the Furness area. Subsequent to a two day visit on January 9/10 2012, NHS Cumbria have requested that the review be extended to all paediatric services in Cumbria. Terms of reference will be developed to incorporate this expansion. The review team will undertake further visits if required but believe that there is a need to report on their preliminary findings and to suggest a plan for hospital care of children for Furness General Hospital. This, therefore, is the purpose of this report. Current Position The Furness General Hospital is a small unit serving a limited population largely in the town of Barrow in Furness with a satellite population of around 10,000 further north on the Cumbria coast at Millom. Barrow is located on a peninsula with a single road in and out. At times, traffic can be very busy and this can impact on journey times. The next hospital with a full paediatric unit is at Lancaster (Royal Lancaster Infirmary) which is a journey time of approximately 60 minutes depending on the time of day and traffic. Helicopters are occasionally used but these only operate in daylight hours. There are around 1,300 deliveries each year in an obstetric led unit and there are 2,300 ward admissions and 700 day cases. Present staffing; There are currently six consultants, one associate specialist and two FY2 doctors. Two of the consultants are currently not working or are on restricted duties. 2
The present pattern of work sees current staff working on a rota which provides a consultant delivered service with consultants sleeping in at the hospital at night. One of the consultants only does occasional nights. When the associate specialist is on duty they are covered by a consultant living at home. The FY2 doctors are sometimes on the night duty rota and there are plans to combine them with the GP trainees in obstetrics to provide cross cover. In view of the fact that a doctor on call could have simultaneous emergencies in A&E, the ward and the maternity unit, a back up rota of a consultant at home is in place but not remunerated. There is good quality and appropriately trained nurse staffing in the children s ward and in out-patients. In the maternity unit there are trained midwives and neonatal nurses. The A&E department is staffed by two to three consultants, six associate specialists, two staff grades, three GPVTs and two FY2s. Most staff in A&E, including nurses, are APLS trained and there is a plan to have all trained within the next 6 months. Within the hospital there are 14 anaesthetists many of whom have regular experience of anaesthetising children down to the age of three-years. They are currently led by a doctor who has considerable experience of children. The plan is to increase the paediatric consultant numbers to eight and the extra posts were shortly to be advertised at the time of this review. Maternity and newborn Much of the recent regulatory action focussed on Furness General Hospital has been around maternity and newborn services. These have resulted in several major external reviews and an action plan to address the issues identified. External support is being provided also from Liverpool. The paediatric review team were impressed with the strengthening of maternity services which is currently underway and the new cross-bay director of maternity services was reassuring in describing the action taken. Newborn care is undertaken by SCBU nurses with medical input from the consultant paediatricians. Until very recently all babies under 32 weeks gestation were transferred o but raising this to 34 weeks was being considered at the time of this review. We heard some 3
concern from the consultant obstetricians that this may lead to a withdrawal of their training recognition. We did not undertake a major review of newborn care as part of this review. Concerns identified at visit In effect there are three doctors on the consultant-delivered rota at nights. Some consultants are doing much more than others with one supplying 40 per cent of night-time cover. Consultants have no compensatory rest and, on the rota that we saw during our review, there were occasions when one doctor was on call for four days and four nights. The consultants on this rota have not formally opted out of EWTD nor has it been suggested that they do so. There is now a formal back-up rota for multiple emergencies but the robustness of this arrangement needs to be considered. There seemed to be a much larger number than expected of children admitted to the paediatric ward and the Director of Public Health s report for Cumbria compared asthma admissions across Cumbria and Furness General Hospital stood out as having an unusually high number. The long-established need for a greater primary care role in delivering integrated paediatric services in Furness is a key component in addressing this and other care anomalies. Safeguarding is a high profile issue and one which crosses hospital and community boundaries. We met with the named nurse for safeguarding. She also has responsibility as a practice educator and her duties for both extend across the whole Trust. This is an important post which needs to be strengthened. There appears to be poor provision of CAMHS services. The community services appear poor and fragmented with a single acute Trust having to relate to community paediatricians in two separate provider Trusts i.e. South Cumbria and North Lancashire What was good? Excellent general paediatric facilities. 4
A plan to reorganise neonatal/maternity facilities. A strongly committed nursing workforce. A major improvement in midwife provision. Strong commitment across the hospital to the special needs of children and to do their best for them. We met with two local GPs who are also part of the new Clinical Commissioning Group. We were impressed with their knowledge of the paediatric issues and their commitment to ensure a safe and sustainable service. Possible solutions The agreed plan of the Trust is to run paediatrics as a consultant delivered service. This is based upon on other similar models elsewhere in the country. Some of these have been successful and are providing a safe and effective service. The University Hospitals of Morecambe Bay NHS Trust has cited Salisbury as the main model that they are trying to emulate. This review does not believe this will provide an appropriate long-term solution. Salisbury is a larger unit, about twice the size, and not as isolated as the Furness General Hospital. It still runs a three tier service with a full rota of FY/SpR1-2 doctors and five SpRs. There are eight consultants and they work no more than 12.5 hour shifts with a day off after a night on call. Their commitment is in line with EWTD and they do not exceed the maximum number of annualised hours.they believe that if they did not have the other two tiers that they would need at least 11 consultants. Most of the other units with new ways of working are also not comparable. We therefore think that even if the University Hospitals of Morecambe Bay NHS Trust is able to recruit good doctors to the advertised posts there will not be sufficient to properly support a sustainable consultant delivered service according to EWTD. A preferred solution NHS Cumbria has demonstrated its commitment to making sure doctors and nurses in the University Hospitals of Morecambe Bay NHS Trust have the right tools to deliver modern, safe and sustainable care. 5
The review understands that, through the new leadership regime in place at the Trust, a two-tier approach is being taken to service improvements which can be characterised as: - Doing the basics better. The hospitals trust has created a programme office to implement improvements identified by regulators. - Planning future services. The hospitals trust has identified the need for radical change to deliver sustainable, safe and effective services into the future, As a contribution to future services planning, this review submits the following for consideration as part of that process with respect to paediatric services at the Furness General Hospital: 1. That there should be a move towards a consultant delivered service. 2. That thought should be given to an be 8 till late (or similar) service with a consultant staffed ambulatory/observation unit during the day. 3. During out of hours it could be considered to have nurse led overnight care. Any child requiring more than nurse care should be transferred to Lancaster. 4. Emergencies out of hours could be dealt with by a combination of advanced nurse practitioners with consultant back up from home. 5. Acute emergencies could be dealt with by APLS trained A&E staff and anaesthetists who would be able to resuscitate and stabilise whilst a paediatrician was called from home. 6. There is good experience from others who have tried such a model that much emergency activity can be brought within hours if the public and primary care are fully informed of what is available and when. 7. There would need to be significant buy-in and training for A&E and anaesthetic staff. 8. With regard to maternity and newborn care we recognise that a separate review of maternity services is being undertaken. 9. We welcome the move to increase the cut-off gestational age to 34 weeks and this should limit the need for paediatric involvement. 10. Further selection of pregnant mothers to ensure that only low risk deliveries occur in the Furness General Hospital would further diminish the need for consultant paediatric input. 11. A significant re-design and investment in primary care services in Barrow should be taken forward in order to achieve a sustainable, integrated service for children. 6
Conclusion We consider that the present paediatric service at Furness General Hospital requires reform to make sure it remains safe and sustainable for the future. The proposed solution of providing a 24-hour consultant delivered service with eight consultants may be impractical due to the lack of junior staff. A 24 hour consultant only delivered service would require at least 10 or 11 posts. However, there would be insufficient work to occupy such doctors when they are not on call. We recommend that consideration be given as part of future service planning to changing Furness General Hospital paediatrics into an 8 till late (or similar). We recommend that thought and debate should continue to be given to the type of maternity service which would best suit the population of Barrow and district. We also strongly support a significant re-design and investment in primary care services as a critical component to a sustainable long-term solution for children s services in Barrow. We believe that the only way to provide a safe and sustainable service for the future is to agree a realistic plan and work towards its implementation. Alan Craft Newcastle Retired paediatrician Emeritus Professor of Paediatrics Former President Alastair Campbell Preston Retired paediatrician Former Medical Director RCPCH April 2012 7