Maternity and paediatric services at Dr Gray's Hospital: report by CMO Advisory Group

Feasibility and comments regarding the 6 priorities for service

1. Reinstating elective caesarean sections (ELCS)

27. Reinstating elective caesarean sections (ELCS) would provide a more accessible service for women and their families. Service users would appear to welcome this as would staff members across all specialities. However it is unclear whether women and their families fully understand the implications of providing this service.

28. Our opinion is that ELCS can be provided safely at DGH with the right infrastructure, risk management and emergency process in place and assuming all staff are appropriately skilled and maintain competencies. In our view this service could resume as soon as paediatric cover is in place, and our understanding is that this cover is in hand and will be in place in the immediate short term, although questions remain about the nursing capacity to reopen a SCBU or operate transitional care beds. Once Paediatric support is in place ELCS provision could be returned within weeks. This is based on the assumption that appropriate and competent anaesthetic, obstetric and midwifery staffing is in place to deliver services. The details of the planned onsite and on call paediatric cover for neonates should be clarified with clear agreed clinical guidelines and pathways for assessment, immediate life support, stabilisation and post resuscitation care.

29. There is a need for some local discussion between the specialties to ensure cover. For example, in replacement for the GP trainee the A&E junior doctor could provide medical cover (rarely required) out of hours with back up from the obstetrician at home. In the very rare event of an ELCS requiring a return to theatre, the obstetrician has surgical assistance via a local arrangement in place. We are therefore satisfied that with the competency and risk management caveats and appropriate escalation processes in place, a safe level of staffing could be provided consistent with current acceptable standards of care.

30. There are risks to placing an ELCS service in what purports to be a CMU. There is a risk that obstetricians feel compelled to act in emergency and urgent situations when women are in labour because they are on site, rather than following the agreed model of transferring those emergency cases to Raigmore. This may then lead to unsafe situations and uncertainty. At present Obstetric staff remain on call for 'life and limb' emergencies as per the paediatric model in place and described by local staff. This creates a difficult model to describe to women, so that they can make an informed choice of place of birth. The model does not follow a generally recognised definition of CMU/ Freestanding Midwifery Unit, and is not consistent with NHSG's guidelines for midwife care. There is therefore a need, at the point at which the new model is introduced, that this is accompanied by clear guidelines for staff on when a woman should be transferred and when local obstetric provision should be used.

31. There is also a concern that women would choose ELCS to avoid travel to Aberdeen Maternity Hospital (AMH). All groups discussed this and felt that this may emerge. Maternal request for primary C/S is increasingly common throughout the country however clinicians should continue to provide full information of risks and benefits applicable to the women's individual situation in providing advice in relation to C/S. This would need to monitored.

32. From the figures provided, returning a ELCS service to DGH would see 50-80 additional babies per year born at DGH rather than AMH. The obstetric staff are keen to resume this service and they believe that to restart ELCS at DGH is safe. They fear losing skills if unable to operate regularly, reduced job satisfaction and potential problems with senior staff retention /recruitment. The midwifery opinion is that the risk is as outlined previously, difficulty in communicating informed choice and introducing a level of risk not normally found in a traditionally operating CMU.

33. The reinstatement of elective caesarean sections at DGH requires:

• Confirmation the paediatric cover is in place
• Agreement with staff in A&E that their resident doctor will provide medical cover for post C/S patients out of hours.
• Clear pathways for who is being referred for emergencies and when local obstetricians are to be called on.
• Clear protocols and guidelines on emergency transfer.

2. Increasing number booked for birth at CMU to 35% of total bookings (currently 25%).

34. The criteria for CMU intrapartum care are consistent across NHS Grampian and are similar to CMU guidelines throughout the country. We would caution and advise against any alteration to these. If alteration is unavoidable, this should be undertaken only after an assessment of risk and risk mitigation. NHSG are hoping to achieve a rate of 35% of women delivering in the CMU, however this is an ambitious and possibly unrealistic target based on rates in other CMU's across Scotland. It also must be acknowledged that there will be a high percentage of transfers for primigravids, (36 % - Birthplace Study 2014).

35. Setting such a target may have unintended consequences and may lead to 'overselling', or a lack of objectivity in place of birth discussions. A fine balance is required when this type of target is in place, there may be perception from staff they have to achieve the target and managers may find they are focusing on the target not holistic care, maternal choice and safety.

36. Attention should also be given to ensuring options for home birth are in place, as indicated in The Best Start. The Birthplace study points to home birth as the optimum place for birth for low risk parous women.

37. Bookings should be audited regularly to ensure that all women who are eligible to receive intrapartum care at DGH have all of their options explained to them, bearing in mind that some women who are eligible for birth at DGH may choose to birth in Aberdeen and this choice must be respected.

38. The fact that DGH is in the unique situation of having a CMU service with obstetricians available during the day and on call overnight (for gynaecology and "life and limb" obstetric emergencies ) should not allow entry (or exit/transfer) criteria for the CMU to be relaxed. It should be made clear to women who book for birth in the CMU that in most cases, if complication arise during labour, transfer to Raigmore will be arranged. Development of emergency antenatal complications will trigger referral to AMH.

39. Information about benefits and risks of all births setting should be clearly communicated to women at booking so they can make an informed choice about place of birth. This should include information on risk of transfer for both primigravidae and mutigravidae from CMU to AMH or Raigmore,

3. Reducing unnecessary transfers to Aberdeen Maternity Hospital (AMH) by reviewing reasons for maternal transfer.

40. Reasons for transfer and referral to and booking at AMH will need regular review and audit to ensure that women are not having to travel to Aberdeen unnecessarily.

41. Transfers should be reviewed by the multidisciplinary team in a non-judgemental and learning environment. This should become routine for all cases of CMU transfer. However it may undermine the clinicians if transfers are termed unnecessary in retrospect. The decision of the clinician at the time has to be respected the right environment needs to be created and an appropriate balance found to avoid a culture of fear of transferring and adverse outcomes.

42. This new service represents a big change for midwives in building safety and confidence in a new CMU service a high transfer rate would initially be expected, this is normal, until staff and women start to trust processes and their judgement.

43. The blurred lines of potential obstetric presence also need to be considered in terms of transfers or non transfers as has already been highlighted above.

4. Increasing antenatal care delivered at DGH by reviewing what specialist antenatal/postnatal services currently provided in Aberdeen Maternity Hospital (AMH) can be delivered locally.

44. Triage hours at DGH are currently 9am - 5pm weekdays only. Women are required to phone DGH for triage during these hours and phone AMH out of hours. This has caused confusion amongst some women and needs to be clarified with both staff and service users. Out of hours there is no medical cover at DGH, so if a pregnant women turns up at DGH out of hours and her care cannot be managed by a midwife, she must be transferred to AMH.

45. Telemedicine options were suggested by some clinicians however others thought that this would not be possible due to the availability of staff at AMH. It is important that DGH and AMH explore use of telehealth technology (e.g. attend anywhere) to reduce further the requirement to transfer to AMH for assessment.

46. Extending triage, day assessment and antenatal assessment clinics until 10pm was widely discussed across all groups, this would reduce the number of women going to AMH for triage especially in the early evening and be a good use of obstetric skills. There is a risk that if an emergency occurs, practitioners may be obliged to act as previously outlined, this risk exists in the current configuration. Extending the hours for triage would reduce unnecessary transfers to AMH, it would also provide women additional reassurance that if they do need to transfer it is safe and appropriate to do so.

47. Staff fed back that the higher numbers of women attending AMH for triage and assessment was creating additional pressure on staff at AMH who have, on occasion, felt required to admit women unnecessarily rather than discharging them in the early hours of the morning due to their long journey time.

48. There seems to be confusion on where pre-assessment for caesarean sections should take place. Some (all?) Women are being required to travel to AMH for assessment. Concerns were also expressed over these assessments in AMH due to long wait times, calls to be seen during the night and in some cases, and no pre-assessment being received prior to caesarean section due to capacity issues at AMH. These pre-assessments should be carried out at DGH working to NHS Grampian wide protocols and with easy communication between the professionals in AMH and DGH to avoid unnecessary travel.

49. In line with NICE guidelines women should be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. Concerns were raised by both women and community midwives regarding long inpatient waits for induction at AMH and frequent rescheduling of induction dates (one example was given of a women who was told to call back three days in a row then told that she should wait by the phone for AMH to phone her). Capacity issues were cited as the reason for this. It is important that when women who are traveling to AMH for induction, clinicians give consideration to the practicalities of distances travelled and communicate clearly with women of possible delays, where that can be anticipated to avoid premature travel. It would not however be safe at this time to return inductions to DGH.

50. KeepMUM and the Maternity Services Liaison Committee raised some concerns about early transfer home post-birth from AMH, quoting the 6 hour discharge as having a negative effect on breastfeeding rates. Whilst DGH has high rates of breastfeeding due to longer postnatal stay with midwifery support, early discharge is now the norm throughout Scotland with the focus on community midwifery support for establishing breastfeeding, support services appear to be in place from community midwives to do so, and this service can continue to be enhanced. There is potential for community services to increase support given they are now called in less frequently to cover DGH

Paediatric Support

51. It was concerning to hear that a number of jaundiced babies are having to be referred back to Aberdeen. We would recommend that the numbers of these babies are being audited and if this is the result of early discharge then there needs to be a review of postnatal guidelines that includes paediatric review in DGH and provision of local phototherapy, NG feeding if required, and breast feeding support. We suggest this is developed as Transitional Care rather than SCBU so that any elective section mothers and babies can stay together with the additional nursing support of the trained midwives.

52. We suggest that there is a nominated link neonatal paediatrician from Abderdeen who has responsibility for the DGH neonatal service and supports their education needs, QI tests of change with review for safety and outcome audits.

53. To cover the needs of babies in a maternity unit there is a need for resources that are substantially well developed in DGH with appropriately trained midwives already in post and keen to maintain their skills e.g:

• An appropriate environment for safe birth
• 'Warm bundle' or equivalent,
• Staff trained in assessment at birth and effective intervention if indicated - Neonatal Resuscitation skills
• Baby Friendly postnatal care - support for establishing feeding and early attachment
• First steps for parenting skills
• Examination of the newborn
• Recognition of the sick infant
• Stabilisation of the sick infant for ongoing care on site or for transfer
• Assessment and guideline led management of common perinatal problems including moderate jaundice requiring phototherapy, hypoglycaemia
• Preparation for home - car seat, safe sleeping, GP registration
• Post discharge support

54. Taking the Best Start and Scottish Patient Safety Programmes as national initiatives some of these requirements could be adapted to help re-establish the maternity service at DGH that is suitable for the population of Moray. There is also a need for neonatal assessment and stabilisation competencies in all the current settings possibly including Primary Care and Ambulance staff while at risk transfers in labour may be delayed or prolonged.

5. Working with NHS Highland to increase capacity in Raigmore to allow more women from Moray to receive care there in addition to the emergency transfers which have already been agreed.

55. The group agree this is a significant area for exploration and although we were unable to schedule further meetings with NHS Highland, further feasibility work is needed in this area.

56. NHSG and NHSH have agreed, via a "memorandum of understanding" that women who experience complications in labour will be transferred from DGH to Raigmore for obstetric care. However on two occasions the transfers were not accepted by Raigmore (capacity/staffing issues being cited by NHS Highland) leaving the staff at DGH feeling vulnerable and requiring women in an emergency situation to transfer to AMH. Transfer in these emergency situations should be direct and automatic and not dependant on the situation at the time in Raigmore as it would be for transfers from any NHS Highland CMU. This needs to be clearly communicated across all levels of staffing at Raigmore.

57. Staff at Raigmore reported that their capacity had also been influenced by the change in service at Caithness and so the needs of both their north and east communities are needing to be accommodated.

58. Strong consideration must be given to directing higher risk women to Raigmore for planned antenatal and postnatal care, and to allowing women to choose to birth there. It is unacceptable that women from North West Grampian have to travel to AMH and are expressly 'forbidden' from attending Raigmore. Over 1/3 of the DGH catchment area (43,000) live in Elgin, Forres and Lossiemouth (EFL) less than 35 miles from Inverness. Previously some of these woman could elect to deliver at Raigmore. This option was removed from their choices (by NHS Highland) in order to facilitate the intake of emergencies from DGH. There are many areas across Scotland which achieves this cross border working, for example in Tayside women from North East Fife have care in Ninewells and women from Lanarkshire may travel to Glasgow.

59. Capacity issues at Raigmore need to be further investigated and the development of the alongside unit should not preclude higher risk women from neighbouring areas choosing to have their care there. Consideration should be given to seeking and considering data from NHSH on length of stay, occupancy rates and birth rates in Raigmore.

60. During this interim period until services are restored to DGH, staffing resources from DGH should be diverted to Raigmore to support women from the Moray area to opt for birth at Raigmore. The barriers that prevent NHS Grampian staff from working in NHS Highland (and vice versa) must be removed:

Midwifery: DGH midwives work on the Raigmore Bank so it must be possible to redeploy underused staff in DGH to Raigmore. All Scottish midwives should be trained to the same standard and be able to work anywhere in the country across different Health Boards.

Medical Staff: Locums are quicker to appoint than substantive posts and could be advertised immediately. Joint NHSH/NHSG substantive consultant posts should be funded. These doctors could work in Inverness in the short/medium term with redeployment to DGH when the junior/resident doctor issues are resolved. There are many examples of consultant posts in Scotland that are funded jointly (e.g. recent Fife/Lothian consultant gynae-oncologist)

Capacity: Precedents are set in all Scottish hospitals , Winter bed crises happen every year. Acute surgical wards are taken over for medical emergencies. Obstetric beds could be increased at the expense of another "cold" speciality. Obstetrics is a core service and must take priority. The acceleration of the opening of the AMU at Raigmore also has the capacity to free up more space within the obstetric unit and needs to be accelerated. It is essential that safe local care for mothers and babies is prioritised even at the risk of an impact on elective non urgent surgery waiting times/ targets

61. Previously approx. 1000 women per year delivered at the obstetric unit in DGH. We estimate based on current uptake that this will drop to about 250 deliveries per year in the CMU (although NHSG are hoping that the figure will be higher). The remainder (about 750 women per year) will have to travel to AMH under the current arrangements

62. Our estimates are that if women from the Elgin, Forres and Lossiemouth (EFL) area were able to book to deliver at Raigmore this, combined with resuming ELCS would reduce this number to nearer 400.

CMU deliveries at DGH (based on current 25%)	250 women/year
Restarting ELCS at DGH	70 women/year
Elgin, Forres and Lossiemouth 'high risk' to Raigmore	250 women/year
Total "Local" Deliveries	570 women/year

This leaves about 400-450 women who will still need to travel to Aberdeen Maternity Hospital.

63. There is some anxiety within DGH and Moray that this move would jeopardise the reopening of Dr Gray's as an obstetric led unit. KeepMUM and the MSLC welcome the return of the option to deliver at Raigmore in the short /medium term but are concerned that this option may quietly become long term and that plans for the return of full obstetric services at DGH will be shelved. It therefore must be communicated clearly to service users and staff that it is a temporary short to medium solution and that the only acceptable long term solution is the return of obstetric services at DGH.

64. Urgent discussions are needed at Board level with strong support from Scottish Government to ensure that discussions between NHS Grampian and NHS Highland are progressed to reduce barriers in this area as a matter of urgency. Agreements must also be communicated clearly with staff in Raigmore and DGH.

6. Working to improve historically poor experience of trainees in O&G/Paeds at DGH.

65. We have not spoken with the Post Graduate Dean but trainee recruitment will continue to be a recurring problem every few months unless changes are made, making it difficult to run a sustainable service. The Post Graduate Dean has responsibility for training not service. Trainees should be supernumerary and can't be relied upon for service work. Therefore the service needs to consider other options for staffing a safe obstetric service without the inclusion of trainees.

66. With regards to paediatrics, there is evidence that ANNPs can provide safe alternative model of service to junior doctors. ANNPs are in short supply but they might be attracted to posts in Elgin and are likely to cost less than medical locums. Similarly APNPs should also be considered for the paediatric ward. Both ANNP's and APNPs can be trained in non-medical prescribing. Physician Assistants have a variable set of skills and specialties and should also be considered.