North Wales Maternity, Gynaecology, Neonatal and Paediatric service review SBAR Report phase 1 Maternity, Gynaecology & Neonatal services Situation The Minister for Health and Social Services has established a National Clinical Project that will drive further improvements in maternity, neonatal and acute paediatric services across Wales. The national project is being taken forward through 3 clinically led groups based on the groupings of the LHBs in Wales and will report to WAG in December 2010. The Board of the Betsi Cadwaladr University Health Board agreed to instigate its review of maternity and child health services in North Wales in July 2010 to support the national project. This local review includes maternity, gynaecology (as it is inextricably linked through obstetric care), neonatal and paediatric services and will aim to answer the following question: Key question What is the best service model for North Wales which ensures, high quality, safe, sustainable and affordable maternity and child health services? The review project is managed by a Project Board with areas of work divided in to 2 operational work streams; 1 to focus on Maternity (including Gynaecology) and Neonatal services and the other Paediatric services. Partnership working with BCU staff and their trade union representatives, colleagues outside of healthcare and service users and their representatives will underpin the decision making process during this review. This process will generate viable options and identify the preferred option for a service model that will ensure high-quality, safe and sustainable services. The review Project Board will report its findings and recommendations to the public meeting of the BCUHB Board in November 2010. Background During the first phase the following work has been undertaken, supported by Public Health Wales: Initiated collection of epidemiological and relevant demographic data to provide a profile of the North Wales population likely to be affected by any alteration to the current service model A comprehensive literature search of publications relating to maternity, neonatal and gynaecology services A profile of present acute and community services An assessment of current performance against national targets as detailed 1
within the Annual Operating Framework (AOF) 2010/11 including upstream prevention, access, efficiency and productivity, workforce and sexual health An evaluation of compliance with current and foreseeable requirements of the European Working Time Directive in obstetrics, gynaecology and neonatology An assessment of compliance with national standards including the National Service Framework for Children, Young People and Maternity Services; NICE guidance; British Association of Perinatal Medicine Neonatal Standards; Screening standards; Healthcare Standards for Wales; Maternity Improvement plan; Royal College guidelines etc An assessment of financial pressures and constraints Accumulation of clinical evidence which shows whether the present model is or is not sustainable i.e. service closures, transfers, etc. Assessment Quality, patient safety, national standards, waste limitation, estates infrastructure, clinical capacity, access to emergency care and the need to financially manage with certainty are the main drivers for change and constraints within which we are working to deliver maternity and neonatal services. The following analysis of these drivers and constraints has been undertaken. Standards & Evidence Demand There has been an overall 15% increase in births since 2005. During 2008, there were 7,348 births recorded across North Wales. This represents a 7% increase compared to a UK average of 3.3%. In 2009, the total number of births was 7,114. Number of maternity admissions in 2009/10 was 13,850 which was a 20% increase compared to the 2006/07 total of 11,066. Preliminary figures for 2010 show an increase on 2009 activity. There is a high cost implication for Welsh patients who are currently choosing the Countess of Chester for their delivery. This incurs higher costs due to the English Payment by Results tariff. During 2009/10, there were 548 births in the Countess of Chester Hospital to North Wales residents. North Wales presently operates a network for neonatal care which includes its 3 District General hospitals and neighbouring English providers. This helps to maintain a service at peak periods when demand for neonatal care exceeds the capacity of any one or more unit. The smallest neonatal network in England is based on a minimum of 12,500 births a year. The total number of births in North Wales is presently around 7,000 a year. 2
Neonatal Transfer Activity East Central West Closures 9 (2009 only) 14 1 Transfers out (in 8 (2009 only) 63 (collected 63 utero) from Patient Administration System) Transfers in 41(2009 only) 45 (collected 0 Admission to ITU (Maternal) West Transfers out (in utero) from PAS) 7 (2009 only) 6 7 Central East Chester Liverpool Arrowe Park 35 9 3 6 10 Information for the other two units is not available. Central and East do transfer babies out for capacity reasons and to access tertiary services. All these transfers necessitate taking staff away from their units to accompany the transfers, thereby depleting staffing levels for some hours during each shift. North Wales have received some funding from WAG for a transport service. Between January and July 2010 the neonatal units were closed to admissions for 83 days due to lack of staff and the high dependency levels of the babies. In terms of total length of time closed, the neonatal units were closed for 308 hours in 2005, 849 hours in 2008 and 2,621 hours in 2009 The number of Level 3 (Intensive Care) days required in the North Wales neonatal units has increased from 2,050 in 2007 to 2,457 in 2008, and 2,677 in 2009. The period of closure ranged between 8.5 hours and 20 days. Demand for gynaecology services in North Wales continues to grow. Number of referrals for a new gynaecology outpatient appointment in 2009/10 was 5,416 which is an 15.8 % increase over the last 3 years Number of emergency gynaecology admissions in 2009/10 was 3,029 a figure which has been constant over the last 3 years We are presently looking at demand from other areas e.g. North Powys Equity There are issues around equity of access to the 3 sites, but the current configuration of services allows for 98% of the population to access emergency hospital services within 60 minutes. Maternity Standards Birthrate Plus is an acknowledged benchmarking tool to set optimum staffing levels and to determine compliant staffing level across North 3
Wales. This is currently not being achieved. The Royal College of Midwives/Royal College of Obstetricians and Gynaecologists have issued guidance stipulating that the Band 7 Labour Ward shift leaders should be supernumerary. This standard is currently not being achieved. Each unit has had to develop an action plan in response to the Wales Audit Office Report on Maternity Services in Wales. The maternity service in North Wales is still subject to Welsh Risk Pool assessment, and in 2009/10 scored 93%. In addition to any focus on obstetric and midwifery staff, consultant obstetric units require a 24-hour anaesthesia and analgesia service with consultant supervision, adult high-dependency and access to intensive care, haematology blood transfusion and other district general hospital support services and an integrated obstetric and neonatal care service. The guidelines for Obstetric Anaesthetic Services 2005 is currently not being achieved, e.g. a minimum of 8 consultant anaesthetist daytime labour ward sessions is required to meet the standards at Ysbyty Gwynedd. Obstetrician staffing levels: Since 1999, there has been an acceptance that 40-hours Labour Ward cover is required from obstetricians at each of the current sites. Current guidance in Safer Childbirth recommends that the 40-hour cover be replaced with 40-hour presence in all units with over 2,500 births, and that this should be mandatory if the unit accepts high-risk pregnancies. Furthermore and crucial to the continued provision of safe services across North Wales it is recommended that units providing between 2,500-4,000 births a year should provide 60 hours of consultant obstetrician presence by the end of 2009. Currently, the 3 units are able to provide 40-hour cover, although achieving this standard does necessitate the use of locum and agency consultant staff. Neonatal Unit Standards The all Wales neonatal standards reflect the aspirations of the Toolkit for High Quality Neonatal Services (2009) outlined a series of staffing levels for a Level 3 Unit which are currently not achievable within the medical workforce in North Wales. These standards include: 24-hour availability of a consultant neonatologist whose principal duties, including out-of-hours cover, are to the neonatal unit; 24-hour cover of resident experienced support for sole cover of the neonatal service and associated emergencies; 24-hour cover for provision of direct care with sole responsibility to the neonatal service. Safeguarding The Safeguarding agenda underpins and is integral to the provision of services. Legislation and guidance is reported and monitored by a number of mechanisms including the Health Care Standards; Standard 17 and the National Service Framework (NSF); Standard 2 4
Annual Operating Framework (AOF) WAG requires all Health Boards to achieve performance and improvement targets set down in the AOF. This includes improvement in access times, achievement of patient activity targets and delivery of a balanced income and expenditure position. Each of the three sites has made progress in increasing gynaecology day case activity. However there is concern that the target of 72% for gynaecology is unachievable, with local benchmarking suggesting that a total of 56% is more realistic. Access Target 98% waiting< 26 wks for treatment Actual BCU 99.1% of Gynaecology patients waiting< 26 wks for treatment Access Target 100% waiting< 32 wks for treatment Actual BCU 99.81% of Gynaecology patients waiting< 32 wks for treatment Access Target 95% waiting< 4hrs in A&E Actual BCU - 92% of Gynaecology patients waiting< 4hrs in A&E Access Target 99% waiting< 8hrs in A&E Actual BCU - 99% of Gynaecology patients waiting< 8hrs in A&E Efficiency Target 2.8 days average length of stay for Gynaecology elective care Actual BCU average length of stay for gynaecology elective care was 3.2 days Efficiency Target 1.2 days average length of stay for Gynaecology emergency care. Actual BCU average length of stay for gynaecology emergency care was 1.7 days. Efficiency Target 56% Admissions on Day of Surgery Actual BCU 62% Admissions on Day of Surgery Efficiency Target 1.3 new to review ratio Actual BCU 1.2 Gynaecology new to review ratio (inc chronic disease) Efficiency Target 5% DNA new rate Actual Gynaecology 6% DNA new rate Efficiency Target 7% DNA review rate Actual Gynaecology 8% DNA review rate Workforce There is an insufficient number of Obstetric and Gynaecology junior doctors to staff the number of rotas and comply with European Working Time Directives, there is no expectation that this will change in the future. The service must be staffed from within existing medical and nursing staff resource. Since April 2010, the Women s Clinical Programme Group spends over 100k per month on locum medical posts to ensure compliant rotas; Labour Ward cover, and the delivery of performance targets, this is largely as a result of recruitment difficulties for trainees in particular. BCU is unable to meet the recommended staffing levels for nursing and midwifery for its maternity and gynaecology services: - A recent Wales Audit Office report demonstrated that the 3 gynaecology wards in North Wales are under-established. 5
- A Wales Audit Office report highlighted that midwifery staffing fall below recommended levels, the new Health Boards in Wales should undertake an assessment of their staffing requirements for the delivery of safe and high-quality services. Birthrate Plus (BR+) has been implemented across North Wales, and provides a benchmark for the current services and how they are configured. The minimum recommended midwife-to-woman ratio is 1:28 for the provision of a safe level of service to ensure the capacity to achieve oneto-one care in labour (BR+ evaluation data). The midwifery total care ratios for services with a more complex case mix must be determined locally after case mix (social and clinical determinants) and external workload assessments are undertaken. This may mean a lower midwifeto-woman ratio up to 1:25. Currently, across BCU, there is a shortfall of 23 full time midwifery posts according to BR+ standards (which have been acknowledged as a WAG target). Staff sickness absence within Maternity Services is 5.3% against a target of 4.5% A further requirement of the AOF is that over the next three years there is a 10% reduction in staffing on Agenda for Change Band 5 and above with a reflected increase in staffing on Bands 1 4. Within maternity services, this can be achieved through the introduction of the Maternity Support Worker role. Nurse-staffing levels at the neonatal units in North Wales are significantly under-established. To meet standards, an additional 35.88wte (whole time equivalent) staff would be required ( 1.2m). A local professional judgement model estimates that 18.19wte nursing staff would be required ( 523k). It is essential to ensure that all staff have the skills and competencies to undertake any new, extended for changed roles. For this reason training and education will be a critical and integral part of the review recommendations Medical staffing for neonatal units (as part of the paediatric rota) are under-established when benchmarked against recommended College of Paediatricians guidelines. For North Wales, the situation is: Consultants: Recommended 24 Funded posts 13.2 Middle grades: Recommended 32 Funded posts 16 Junior doctors: Recommended 32 Funded posts: 26 Current Financial Position Annual budget for Maternity, Gynaecology and Neonatal Services is 29,520,614 against which there is an overspend as at Month 4 of 1,042,110 being 10.71% of the budget 6
Maternity Services and Neonatal Services are required to deliver between a 6% and 7% Cost Improvement Programme in 2010-11 to achieve financial balance, being 1,836,727. To the end of Month 4 (July) savings of 40,669 have been delivered. Budget forecast position over next three years Cost Improvement Programmes of between 6% and 7.5% will need to be delivered to ensure a recurrent break even position is delivered which is a statutory requirement year on year. The significant challenge faced by the organisation to deliver the statutory break even position should not be underestimated. it will require significant change in the way we deliver services, when approximately 94% of our expenditure relates directly to pay. External Contracts BCULHB have external contracts with various providers for Maternity & Neonatal Services totalling 3.2 million, we are reviewing whether some services could be provided more economically within North Wales. Through the review there is potential to provide a wider range of safe services closer to the patient s home. Estates Recovery rooms in obstetric theatres require a major upgrade. Very few delivery rooms meet national standards (i.e. have en-suite facilities). Overall fabric of maternity units is good, although there are capacity issues in Ysbyty Glan Clwyd (6 delivery rooms); and Wrexham (7 delivery rooms). The 8 delivery rooms at Ysbyty Gwynedd can accommodate current demand. There are 4 home from home birth units, with, 1 along side a midwifery led unit across BCU National Childbirth Trust environmental audit Recommendations In considering the work undertaken during the first phase, the Project team recommend that the stakeholder group considered the following at the first event on 9 th September 2010: The population Health need The case for change based on evidence within this report Generation of a range of viable options that could potentially delivery high quality, safe and affordable maternity, gynaecology, neonatal and paediatric services for the population of North Wales. 7