Agenda item

Dr Sarah Montgomery (GP Clinical Commissioner), Lindsey Stevens (Head of Midwifery, East Kent Hospitals NHS University Foundation Trust), Helen Buckingham (Deputy Chief Executive and Director of Whole Systems Commissioning, NHS Kent and Medway), James Ransom (Lead Commissioner Maternity Services, NHS Kent and Medway), Sara Warner (Assistant Director Citizen Engagement, NHS Kent and Medway), Dr Neil Martin (Medical Director, East Kent Hospitals NHS University Foundation Trust), and Dr John Allingham (Medical Secretary, Kent Local Medical Committee) were in attendance for this item.

(a)       The Chairman introduced the item and explained that the Committee had a combination of written updates and discussions on this item for over a year, along with individual members having got involved in the work between formal meetings. This was in addition to the valuable work of the HOSC Liaison Group. HOSC made no response to the consultation, though individual Members may have, and so has taken more of an overview/assurance role during the entire process. Both the Boards of NHS Kent and Medway and East Kent Hospitals NHS University Foundation Trust have made their decision, namely Option 1 on the consultation paper, and so it is for HOSC to consider this decision and express any further views.

(b)       Colleagues attending from the NHS were welcomed and offered the opportunity to explain the decision which had been reached.

(c)        NHS representatives began with outlining the four tests which service changes in the NHS had to meet. These tests were clinical evidence, support of GP commissioners, patient choice supported, and wider engagement, including the HOSC. The NHS locally believed that all four tests had been met along with five criteria they had set themselves.

(d)       The first of these criteria was quality and safety, particularly in the context of the impact on safety at William Harvey Hospital given the increasing popularity of its birth centre, decreasing use of the standalone midwifery led units and 1.6% year on year increase in the birth rate. Achieving the standard of 1:1 midwife care during labour was non-negotiable. The second criteria was for services to be as accessible as possible so that there was more certainty around accessing hi-tech than lo-tech services. The third criterion was maintenance of choice, with the co-location of midwifery led units with consultant led units providing the optimum choice. Fourthly, the service needed to be sustainable in that it needed to be affordable and match a viable staff reconfiguration. Finally, it needed to ensure the safety of all women who need the service.

(e)       NHS representatives explained that the three options in the consultation were developed when all these were put together. All three involved the opening of the midwifery led unit at the Queen Elizabeth the Queen Mother Hospital in Margate, with one option closing the birthing unit at Buckland Hospital, the other closing the birthing unit at the Kent and Canterbury Hospital. Option 1, involving the closure of both, was approved by the Boards of both NHS Kent and Medway and East Kent Hospitals NHS University Foundation Trust. The public consultation had been wide ranging and the development of the consultation paper involved Members of the Committee. Greenwich University was asked to analyse the consultation results, with the conclusion that the criteria had been met. The emerging Clinical Commissioning Groups also supported Option 1.

(f)         The Chairman then invited Mr Martin Vye to speak. Although not a Member of the Committee, Mr Vye had requested the opportunity to speak on this issue. He thanked the Chairman and explained that he was a County Councillor for Canterbury and was a founder member of CHEK (Concern for Health in East Kent). He observed that HOSC had not endorsed any option before, that there had been a lot of discussion and that while he had no problem with the consultation, he asked the Committee to defer making a decision. In support, the argument was given that the direction of travel in maternity services was away from hospitalisation and there was discussion about a home birth review. It had been shown that standalone midwifery led units were not unsafe and that although use had gone down, more could be done to promote their use. The level of use at Maidstone’s unit was mentioned. The co-located midwifery led units were presented as the best option but this was not the experience of women at public meetings who spoke of a conveyor belt atmosphere. Option 1 would leave a hole knocked in the services in East Kent. A lot of effort had gone into the consultation, with a majority wishing to keep the standalone midwifery led unit at the Kent and Canterbury Hospital. There were questions around the £700k investment in terms of how much this was as a percentage of the overall budget and whether this investment was revenue or capital. It was also necessary to bear in mind the broader policy development which was taking place with GPs looking to upscale services and so would wish to offer Canterbury as a choice.

(g)       NHS representatives responded to the questions arising from Mr Vye’s comments and began by explaining that the investment accompanying each Option was over and above that received through the national tariff. The Primary Care Trust already paid the national rate and the additional money was to enable the safety critical ratio of 1:1 midwife to each birth. To ensure the plans were sustainable, the nationally recognised Birthrate+ planning tool was used. It was accepted that a small number, 11, preferred Option 2 over Option 1, but the consultation revealed other figures, such as a high level of support for service change as well as the intention of providing higher levels of care. On the issue of choice the argument was made that already 90% of births took place in consultant led or co-located midwifery led units. There were also clinical restrictions on choice. For example, midwifery led units were not as safe for women giving birth for the first time, with 40% being transferred. Home births were still being maintained and the risks were the same as for standalone midwifery led units.

(h)        Members of the Committee made a number of points and comments. A number of comments related to the length and detail of the consultation and engagement process and it was commented that lessons had evidently been learnt from the process of changing women’s and children’s services in West Kent. There was a measure of scepticism expressed by some Members as to how likely it was that Option 1 would not be the outcome at the end of the process, but it was also accepted that where safety was the driver and the natural constraints around staffing, Option 1 was the best option in the circumstances, even if there was no ideal Option. Members generally felt that there would be no benefit to deferring making a decision as deferral might bring more information but was unlikely to change the result or the reasoning. It was observed that one other major difference between the situation in East and West Kent was how united the GPs in East Kent were behind the proposals. In response to a specific question it was reported that at both Board meetings the discussion had been detailed and searching, but the decision was unanimous in both cases.

(i)         More broadly, one Member expressed the view that this was another stage in the centralisation of services at Margate and Ashford which had been foreseen 20 years previously. This change, as well as the development of trauma services at William Harvey Hospital in Ashford, meant that travel times and accessibility were a real issue. This was a view shared consensually by the Committee. NHS representatives accepted this, but wished to point out that as labour could take 12 hours, there were unlikely to be any fathers driving dangerously to transport their partner to a hospital. A small number of babies were always born before arrival (bba) in a very quick delivery but this would happen however the services were reconfigured. The NHS offered to restart the East Kent Transport Group and/or work with other fora such as Locality Boards.

(j)         In response to a specific question about planning capacity for the future, NHS representatives explained that data from colleagues in public health was used.

(k)        In response to comments about the value of the consultation, NHS representatives informed the Committee that changes had already been made and others were planned in response to feedback received during the process. Post natal care in particular had been a focus for improvement. Midwifery Care Assistants were being trained to become post-natal specialists. This had the advantage of freeing up midwifery time, and where this change had been introduced, complaints about post-natal care had gone down. Drop in breastfeeding clinics running from 8-8 were also being introduced. It was hoped these changes got rid of the conveyor belt feeling reported by some in the past as well as improve post natal care and services.

(l)         Members accepted that the proposals meant safer services for the majority, but that the minority should not be overlooked. One Member commented that in any communications and engagement plan it needed to be stressed that pre and post natal clinics were remaining in their current locations. NHS representatives explained that engagement at the heart of the process thus far and would continue to do so. Rolling out a consistent message was a key part.

(m)      The Chairman of the Committee requested the Researcher to the Committee read out a possible recommendation:

• That the Committee note the decision to proceed with Option 1 and accepts the need to secure a safe and sustainable service, and requests an update report in six months on the work which has been undertaken on improving access and engaging the affected communities and other ancillary issues, in discussion with the HOSC Liaison Group. 

(n)        Members broadly agreed with the proposed recommendation, but felt nine months would provide enough time to allow a meaningful report to be brought back to HOSC.

(o)       NHS representatives were thanked for their attendance and the recommendation approved as amended.

(p)       RESOLVED that the Committee note the decision to proceed with Option 1 and accepts the need to secure a safe and sustainable service, and requests an update report in nine months on the work which has been undertaken on improving access and engaging the affected communities and other ancillary issues, in discussion with the HOSC Liaison Group.