Agenda item

Mr G Douglas (Chief Executive, Maidstone and Tunbridge Wells NHS Trust), Ms G Duffey (Head of Midwifery Services, Maidstone and Tunbridge Wells NHS Trust), Dr C Unter (Consultant Paediatrician, Maidstone and Tunbridge Wells NHS Trust), Ms J Thomas (Director of Service Redesign NHS West Kent ), and Mr J Ashelford (LINk) were in attendance for this item.

 

(1) The Committee had before them a background paper prepared by the Research Officer to the Committee on the Maidstone and Tunbridge Wells NHS Trust Service Redesign together with Briefing Papers prepared by the Maidstone and Tunbridge Wells NHS Trust and NHS West Kent.  Circulated separately to the Committee was a copy of the Minutes of Maidstone Borough Councils External Scrutiny Committee on 13 October which had reviewed the issue of Maternity Services in Maidstone as a Councillor Call for Action

 

(2)       The Chairman explained to the Committee that this session was intended to be an opportunity for the Committee to look at the whole service redesign for the Trust although he was aware of the specific interest in the maternity service provision.   He intended to look at all other elements of the service redesign first and then concentrate on maternity services.

 

(3)       Mr Douglas took the opportunity to inform the Committee that last week the Care Quality Commission had carried out an unannounced inspection and no issues had been raised.  This was a major step forward for the Trust.   Mr Douglas added that in relation to the Declaration of Standards for Better Health, the Trust had fully met the health care standards. As a result it was virtually impossible for the Trust to be assessed as “weak” at its next review.  This was the result of an enormous amount of work over the past two years.

 

(4)       Mr Douglas then gave an update on progress with the new Pembury Hospital.  Building was 4 to 5 months ahead of schedule which provided a buffer for any delays that occurred during the winter months.  It also gave more time to embed, equip, and make the hospital ready for occupation.   He also informed the Committee that the new Hospital would be the most environmentally friendly hospital when it opened.  It had been built with sustainability in mind e.g. it would be partly powered by wood chip burners using locally sourced fuel.

 

(5)       The Trust had been working with colleagues at Kent County Council (KCC) in relation to the transport infrastructure and transport links, especially bus services.  It was unfortunate that despite lobbying of the Government by both the Trust and KCC, the work on the Castle Hill bypass was programmed to start at the time when the hospital opened.  The Trust had also worked with Tunbridge Wells Borough Council to increase the number of car parking spaces especially for visitors at the new hospital. The Committee noted that the Trust would shortly be publishing its green transport plan. 

 

(6)       In relation to the Maidstone Hospital site the roof was now on the new endoscopic training centre.  The Committee were advised that the Trust’s strategy depended on a number of factors coming together with the moving of some services from the Kent and Sussex Hospital, Tunbridge Wells to Maidstone. This would give the Trust the ability to start to introduce local services for Kent residents who currently have to go to London hospitals for specialist cancer treatment.  

 

(7)       Mr Douglas stated that the Strategic Health Authority had approved the Trust’s capital plans for the centralisation of pathology.  Laboratory services would move from Medway Hospital, Pembury Hospital and Preston Hall in to the centralised unit. This was important for the new cancer centre.  Funding had also been approved for the midwifery led unit at a nursing home near Maidstone Hospital.  There would also be two state of the art laser therapy machines at Maidstone and Canterbury Hospitals, these were the only ones outside of the bigger London hospitals.

 

(8)       In response to a question on when the public were likely to be able to have up to date information on where services, not located within the new Pembury Hospital, are to be located, Mr Douglas stated that the location of a number of services had already been agreed. He added that the pain management service would be based at Pembury but a service would be provided at Maidstone as well.  In relation to the diabetes service, this would be located in the Assura building in the centre of Tunbridge Wells and rheumatology and neurology based in Pembury.  Decisions remained to be taken on the location for outpatient physiotherapy and neurology rehabilitation services which were planned to be located in local community hospitals.  The Trust was close to having a cohesive location plan for all services.  Mr Douglas undertook to make sure that the future location of services was made known to interested parties, including the Committee.

 

 (9)      Regarding the way in which the Trust was assessed by the Care Quality Commission, Mr Douglas explained that they made a self assessment, rather like the Ofsted process. Officers made a declaration and it was peer reviewed. Stakeholders such as the Health Overview and Scrutiny Committee and the LINk were usually invited to contribute to the process. Most health organisations did not receive a visit from the Care Quality Commission. However, the Maidstone and Tunbridge Wells NHS Trust had received more regular visits from the Care Quality Commission (which took over from the Healthcare Commission) than any other organisation. 

 

(10)     In relation to the journey time between Maidstone Hospital and Pembury (as opposed to Tunbridge Wells) Mr Douglas stated that he did this journey regularly at different times of the day and he usually did it in less than 30 minutes. He added that an ambulance using its blue light would do the journey in less time.  There were occasions when Colts Hill was congested but he believed that a blue light ambulance would probably still make this journey in 30 minutes.   Mr Douglas said that Pembury hospital was a superb site for an emergency hospital because its road communications are good.  He added once the Castle Hill dualling was completed it would be very good and if there was a Colts Hill bypass it would be excellent.   Doubts were expressed by a number of Members that the time quoted for travelling between Maidstone and Pembury hospitals was very optimistic.

 

(11)     Mr Ashelford (a LINk governor and Chief Executive of the Hospice of the Weald) expressed the view that the whole transport issue needed to re-considered.

 

(12)  The restoration of the pain clinic at Maidstone following representations from the public was welcomed.  The importance of ensuring reasonable access to clinics for those patients that need to attend a clinic on a regular basis was emphasised. 

 

(13)     Mr Douglas stated that the Trust hoped to mount an information campaign in the next few months to dispel the myths around the reconfiguration of services.   The majority of people who visited hospitals were outpatients and there would be no change for them.  When looking at where services were provided it was necessary to look at the economics.  He added that outreach clinics were likely to be based in Community Hospitals.  

 

(14)     Mr Douglas invited all Members of the Committee to visit the new Pembury Hospital and Maidstone Hospital to look at the facilities and receive a presentation showing how the services linked together.

 
(15)     Ms Thomas informed the Committee that at a meeting on 26 November 2009 the West Kent Primary Care Trust (PCT) Board had received the PCT Strategic Commissioning Plan and Community Strategy in which the future use of community hospitals was discussed.  She added that the PCT Strategy was about having a better profile of services in more local locations.  The PCT’s analysis showed that there is a large population from the Sevenoaks area, Edenbridge and Crowborough, that use Maidstone and Tunbridge Wells’ services. On that basis the PCT have proposed some changes.  The PCT have discussed having a larger profile at local hospitals.  The PCT would be engaging the public to see where services could be developed and located.  Ms Thomas said that the PCT were aware of the importance of locating clinics locally for people with long term conditions who had transport difficulties.

 

(16)     In response a question on whether there would be consultant led services provided at both Maidstone and Pembury or whether these would be shared, Mr Douglas explained that consultants working across sites tried to plan their work so that they spent the day in either Pembury or Maidstone.  There were currently occasions when consultants needed to travel between sites and they could be affected by adverse traffic conditions, this would still be the case with the service redesign. 

 

 (17)    In response to a question on whether there was reluctance on the part of consultants to work in various community hospital locations, Mr Douglas replied that the Trust had not experienced any major problems getting consultants to run clinics in community hospitals.  It was in the Trusts’ interests to promote outpatient services in order to bring work into the larger hospitals.

 

(18)     Ms Thomas explained that the NHS in West Kent was waiting for information from the Department of Health on tariff changes. They wanted to ensure that they get the most from their money. As part of the Strategic Commissioning Plan there was an incentive to adopt best practise at a local level.  Regarding total care pathways, the PCT were trying to stimulate the local market, by were working with clinicians to move more services closer to the patient. 

 

(19)     Dr Eddy (LINk Member) raised a number of issues relating to transport.  These were firstly the pubic being able to get to hospitals for outpatients appointments and day care, and secondly, ambulance emergency transport from the patients location to the most  appropriate hospital, and finally transfer between hospitals by ambulance if a problem occurred, for example during childbirth.  He asked what input the ambulance service has had into the decisions around this.  Mr Douglas confirmed that there had been a lot of dialogue with the ambulance service and they were supportive of the Trust’s plans.  The Trust was working through protocols with the Ambulance service.  As part of the design of the new hospital there was provision to turn ambulances around as quickly as possible.   Mr Douglas undertook to supply information to the Committee on the work the Trust had undertakenwith the Ambulance service

 

(20)  Ms Thomas reminded the Committee that many of these issues, including the transport issues raised by Dr Eddy, were ones that the Independent Reconfiguration Panel had asked to be resolved prior to the implementation of the reconfiguration of orthopaedic services.  In July 2008 the Board had considered the issue of transport. The Board had established a group that included members of the Maidstone branch of the BMA, Maidstone Consultants and an invitation had been extended to the HOSC. The PCT Board was satisfied that the issues had been addressed.  Therefore there had been a very recent reconfirmation of the adequacy of arrangements.  Ms Thomas said she would be happy to make the Board papers available to the Committee. 

 

Redesign of maternity services

 

(21)     Mr Datta, a consultant obstetrician at Maidstone Hospital, emphasised the risks for mothers in having to travel distances in an emergency situation to access services and asked what the trust were doing to minimise the risk

 

(22)     Mr Pentecost (a retired consultant) stated that he had figures provided to him by another consultant at Maidstone Hospital, Jonathan Goodman, which indicated 1 in 3 women being transferred during labour.

 

(23)     Mrs Whittle referred the Committee to her personal experience regarding having to travelling to Maidstone to give birth.  Mrs Whittle raised the issue of women who were not assessed as high risk but needed to have emergency caesarean - she assumed would have to be transferred from the Maidstone birthing unit to Pembury and expressed her concern at the risks involved with this transfer.   She also asked what consultation had taken place with midwives.

 

(24)     If there was not going to be a full consultant led maternity service at both hospitals then there were serious concerns for expectant mothers which needed to be addressed.

 

(25)  Ms Duffey (Associate Director of Midwifery at both Maidstone and Tunbridge Wells) explained that the birthing centre would not replace the maternity suite.  The birthing centre was for mothers who were assessed as low risk and who could also deliver at home.  Currently 6% of births took place at home and midwives were well equipped to provide care.  Throughout labour, risk continued to be assessed for women who were delivering in the birthing unit which was staffed entirely by midwives.  Referring to the transfer rate  of  30% which had been quoted, Ms Duffey explained that transfer did not necessarily occur because of an emergency, some transfers occurred because of a delay in labour or lack of progress or because the mother required pain relief that was not available in the birthing unit.  The Trust would continue to provide maternity services close to home and make provision for those at high risk to give birth in a facility with a consultant available. 

 

(26)     Dr Datta explained that some women who had been classed as low risk may go to a birthing unit but they become a high risk in a matter of minutes.  There is therefore a disadvantage to giving birth in a unit that does not have a consultant.  Also the Maidstone birthing unit does not have a foetal assessment unit.   

 

(27) Ms Blackmore expressed concern that epidurals cannot be given at birthing units; if this was required there would a journey of at least 30 minutes.  She referred to the original decision that had been taken 5 years ago, at the time this looked good on paper but with hindsight it did not seem to work.  She asked that the Trust look at the whole reconfiguration again.

 

(28)     Mr Pentecost expressed the view that to move the mother requiring an epidural was dangerous and to make a women to wait any length of time and then to be taken by transport to Pembury was cruel.

 

(29) A member of MASH (Maidstone Action for Services in Hospitals) gave the example of his daughter who due to complications after giving birth had  to have an emergency hysterectomy at Maidstone, expressed the view that had his daughter had to have been transferred to Pembury she would have died.  He asked that this service redesign be looked at again and the people of Maidstone be given the chance to express their views. 

 

(30)     Councillor Mrs Wilson (Member of Maidstone Borough Council and Vice Chairman of MASH) stated that she and everyone she represented were concerned about the issue of maternity services.  MASH had worked constructively with the Trust on this one issue and MASH were of the view that it need to be reconsidered.  Maternity was not an illness, it was a natural function but at times things go wrong.  She asked what the implication of ambulance turnaround times was and how long would it take an ambulance to get to the birthing unit if there was not one on standby.  She referred to official figures from the Office for National Statistics for 2007 which showed Maidstone as the district with the highest number of live births, Maidstone also had one of the highest under-18 conception rates in the county with a growing population.  There were also three areas of multiple-deprivation.  She stated that her understanding was that often early conception and deprivation often led to a higher complication rate in births.   She stated that there had been changes over the past 5 years and therefore the service redesign should be looked at again. 

 

(31)     Mr Douglas acknowledged that the Trust have had a constructive dialogue with MASH and that they had listened and responded to concerns regarding pain management and trauma and orthopaedic services.  The Trust had looked at their plans 5 years ago and had taken into account population growth.  He reminded the meeting there were midwife led units in Canterbury and Dover.  He suggested that Members go and look at these facilities and talk to staff and users.  This was not a radical and new service and it existed in other parts of the country.  Women had a choice between a midwife led and consultant led unit.  One measure of success was to make sure that the mother to be was clear about the risks and the options available.  The Health Overview and Scrutiny Committee when it responded to the consultation on Women’s and Children’s Services five years earlier had recommended that the midwife led unit should be located off the Hospital site so that it was clear to people that they were not going into a hospital but into something else. 

 

(32)     Ms Duffey referred to the document “Maternity matters” which talked about what women want.  What they want is choice, either home birth or midwife or consultant led service.  Ms Duffey said in 2011 women would be offered that choice.  The birthing unit at Crowbough had been open 20 years and the local population were supportive of services from that unit.  In terms of an epidural, this required an anaesthetist. She pointed out that an epidural was the only form of pain relief not available in a birthing unit.  Many women having a first baby want an epidural, so in these circumstances she indicated that she would suggest that this woman goes to one of the consultant led units e.g. at Pembury.

 

(33)     Mr Douglas stated that it was about providing more specialist, better quality, services at Pembury.  The aim was to provide the best level of service in Kent, if not in the south east of England.

 

(34)     Ms Thomas stated that the PCT’s had brought together a collaborative group to discuss how the PCT and Trust could deliver the choices set out in “Maternity Matters”.  This Group included all providers including independent   midwives.  Ms Thomas added that the two Trusts wanted to assure themselves that their projections were up to date.  The PCT wanted to commission choice for women – with birth at home, a midwife led unit, or a consultation led unit.  She added that in approving the business case for the new Pembury hospital, the Trust was past the point of no return regarding capacity of 4,500 – 5,000 births.

 

(35)    Dr Unter (Consultant Paediatrician at Maidstone for nearly 20 years and Medical Director at the Trust up until 5 years ago).  He felt that Children’s services had not been mentioned.  He understood the issues and why it had been proposed to move the inpatients unit to Pembury.   Due to the change in the service, for example more day care cases and services provided as close to home as possible, the amount of work in the paediatric unit had decreased and the European Working Time Directive had lead to more staff being required.  There was a need to have a critical mass to ensure that there was the highest level of service.  Another factor was that fewer people were choosing to specialise in paediatrics and therefore there were fewer training posts.   It was not practical to try to staff two units which is why it was proposed to centralise services on one site; it was better to have one service that worked than two that were falling apart.  There would be outpatients and assessment services for children morning to evening at Maidstone and 24-hour services at Pembury.

 

(36)     A Member asked if the inability to attract paediatricians related to salary, the uncertainty caused by the service reconfiguration, or a national shortage.  It was confirmed that there was a shortage of trained paediatricians and that there were currently vacancies at Maidstone and Tunbridge Wells as there were nationally.

 

(37)     Mr Kenworthy (Member of LINk) stated that there was a problem with the road infrastructure in this area of Kent; it was inadequate to meet the current population needs today.  He sat on three different health-related committees there had been a lot of discussion regarding transport at each of these.  He referred to the Ambulance Trust and the work to centralise services at Paddock Wood.  This would save 2,000 hours of paramedic and ambulance crew time.  They were working towards approximately 76% of 3 minute response times on Category A calls.  Response posts would be set up in certain areas where access was an issue.  This and other improvements would solve some of the problems we have been talking about in relation to ambulance travel times to Pembury. 

 

(38)    Mr Lyons acknowledged the improvements to services at Maidstone Hospital and understood the wish to centralise services to create a world class hospital but he believed there was a need to look again at the obstetrics unit to take into account the large catchment area.

 

(39)     Mr Daley stated that one of the key issues appeared to be the removal of the consultant service from Maidstone, if this was added to the service at Maidstone the Committee would not be having this discussion.  He suggested that consideration could be given to using the staff skills that will be available at Maidstone from 2011, under the remote supervision of a Consultant at Pembury giving advice in real time via the instant link between the operating theatres in Pembury and Maidstone.  A decision could then be made as to whether to transport the patient to Pembury or to have a general surgeon deal with the situation at Maidstone, maybe under the supervision of a consultant by real time video link.   He gave the example of the complexly new services called laparoscopic service which worked well with operation being directed by a surgeon at another site.  He suggested that the Trust be asked to look at the feasibility of this suggestion.

 

(40)     Cllr Mrs Wilson stated that the Trust were making the same points that their previous Chief Executive Ms Gibb had made.   She stated that 4000 women wanted consultant led services on both sites and she asked the Committee to refer this matter to the Secretary of State.

 

(41)      The Chairman acknowledged that this issue was a serious one and that the Committee did have the power to refer this matter to the Secretary of State; however this power needed to be exercised responsibly.  He asked for advice from Mr Wickenden (Overview, Scrutiny and Localism Manager).  Mr Wickenden stated that although the Committee did have the power to refer this matter it was not an action to be taken lightly.  He advised the Committee to enter into a dialogue with health colleagues and stakeholders before deciding whether or not to refer this matter to the Secretary of State.  If the Committee decided to refer this matter today there was a possibility that it would be dismissed as there had been no attempt to seek a local resolution before making the referral.

 

(42)     Ms Blackmore stated that in Sussex there had been three proposed reconfigurations, two had not taken place.  She questioned whether it was possible to have a world class hospital with a second class maternity service.  If this service redesign was not financially driven and the public want the obstetrics service, why was it not possible to have an obstetrics service on both sites.

 

 

(43)       Mr Douglas emphasised what the Trust were trying to achieve at Pembury and that patient safety was driving everything.  The new hospital at Pembury would provide the best level of patient safety.  He acknowledged that there was an issue regarding patients getting to Pembury from Maidstone.  In the Trust’s Business case it was accepted that Ashford and Medway would take some of the births from areas adjoining them.  However, Pembury would not only be offering a service that was the best in south east and safest but he believed once the hospital is open that it would be the hospital that people would choose to go to, not only from Maidstone but also from East Sussex.  There was a need to put the services together to achieve a critical mass at Pembury.   He would investigate the feasibility of Mr Daley’s suggestion regarding utilising a video link for consultant support.  

 

(44)      Ms Duffey stated that there was also the issue of recruiting staff, it was difficult to recruit obstetric staff and they had to use locums on a regular basis.  Recruiting midwives had also been an issue, and although they were currently fully staffed there would be a shortage of midwives in future due to the aging population.  She stated that as a woman who had had children she supported this service redesign.

(45)    Ms Thomas referred to this emotive issue and the strength of feeling in the local population.  This had never ever been about finance; it was about the delivery of patient safety and having an open process to ensure choice for women.  As a result of this it might not be possible to deliver every single service in every single place. It is worth looking at this issue again if the Committee are considering a referral.

 

(46)    Ms Blackmore suggested delaying the decision until the new road is built and asked whether it was possible to delay the decision and supported investigating Mr Daley’s suggestion of using a video link. 

 

(47)     The Chairman stated that if the Committee were considering challenging this redesign then they needed to make sure that they had the evidence to put before the Secretary of State.  He suggested that a Sub Committee be established to look at this matter in detail and report back to the Committee in February, either at the programmed meeting or at a special meeting.  This would put the Trust and the PCT on notice to consider the issues that had been raised. 

 

(48)      There was discussion about whether a Sub Committee was the best mechanism to look at this in detail rather than the whole Committee

 

(49)      Mrs Whittle expressed her support for Councillor Wilson’s suggestion that this Committee should refer this matter to the Secretary of State. 

(50)      Mr Daley urged caution as a referral to Secretary of State was a course of last resort.  The Committee had been involved with this matter for five years and two years ago had made a referral to the Secretary of State.  The Independent Reconfiguration Panel had supported the Trust’s proposal and therefore unless there is something new then the likelihood was that any referral would be unsuccessful.  He added what we have now is a general acceptance of the majority of the reconfiguration following some concessions. We have the women’s and children’s service and specifically maternity services to consider.  The Trust should now consider the discussion today and the points raised and look at these with the Sub Committee.  Mr Daley seconded the motion put forward by the Chairman.

 

(51)        Ms Blackmore agreed that it was important that the Committee have the evidence gathered by the Sub-Committee before making a decision on whether to refer this matter to the Secretary of State for Health and she expressed a wish to be part of this Committee as a District Council representative on the HOSC.

(52)      Mr C Smith emphasised the importance of exploring every avenue before the Committee considered whether to take the serious step of referring this matter to the Secretary of State.   He also expressed concern about the time factor and the importance of ensuring that the new hospital was up and running in 2011.

 

(53)       Dr Eddy expressed the view that information from the Ambulance Trust would be a key element in the deliberation on this issue

 

(54)      In response to a question of who would be on the Sub-Committee, Mr Wickenden requested delegated authority, in consultation with the Chairman, spokesmen and stakeholders to decide the membership of Sub Committee.  Mr Horne reaffirmed his previous comment that there was no reason why the Committee should not have an extra meeting to hear the results.

 

(55)      RESOLVED that:-

 

a)     the Committee thank colleagues from the Maidstone and Tunbridge Wells NHS Trust for the information that they have provided on the provision  of services across the Trust and the redesign following the opening of the new Pembury Hospital in 2011;

 

b) a small Sub Committee be established to explore in greater detail with the heath organisations within the health economy the rationale of the provision of women’s and children’s services to establish whether this best meets the needs of patients who look to the Maidstone and Tunbridge Wells NHS Trust for these services and to report back to a meeting of this Committee in February 2010;

 

c) the Overview, Scrutiny and Localism Manager be given delegated authority in consultation with the Chairman, Spokesmen and stakeholders to determine the membership of the Sub Committee referred to in resolution (2) above; and

 

d) the Committee accept the Trusts offer to visit the Maidstone and Pembury Hospital sites and the necessary arrangements be made for these visits as soon as possible.