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

Recommendations

Following all our discussions and observations we have developed the following recommendations:

Communication:

• NHS Grampian urgently need to produce a comprehensive strategy with a clear timeline for the restoration to obstetric services. Service users including fathers and families should be involved in discussions from an early stage. This should be shared with staff and the public.
• NHS Grampian should provide clear information to women on who to contact, where they should go for triage and other essential information. This should be provided though a number of different channels and communicated to frontline staff. Daily bulletin updates could be created and widely publicised.
• All women should be given an informed choice about their options of place of birth. Women should be offered, homebirth, DGH, AMH and Raigmore as real options and their personal risk factors as well as the general risks and benefits of each type of units including, for example, information about rates of transfer (for both primigravidae and mutigravidae) from the CMU to Aberdeen and Raigmore should be clearly communicated to women at booking so they can make an informed choice about place of birth. The current leaflet is not up to date and needs urgent revision.
• NHS Grampian should provide clarity around cost of travel, accommodation and easy access to support for women travelling to AMH.
• Relations between NHS Grampian management and staff at DGH need to improve as the staff at DGH percieve a "them and us" situation. They need reassurance that they are valued and their opinions and concerns meaningfully considered. This attitude is embedded over many years and will take time, effort and a willingness to improve on both sides.

DGH Services short/medium term:

• DGH should restart elective caesarean sections only once appropriate paediatric cover is in place. A full risk assessment of this must be undertaken. We would expect this could be in place by the end of the year. Monitoring for increase in ELCS is needed once an ELCS service returns. Obstetric referral and interventions should be monitored closely if ELCS services recommences.
• DGH must maintain strict adherence to CMU entry criteria guidelines and not relax these as a result of obstetric presence until such a time as this can be relied upon for full service. However we recognise that once a women is in labour in the CMU, due to the presence of obstetricians, extreme emergency situations may be dealt with differently than in a normal CMU and we recommend that there is complete clarity for staff on professional responsibilities in these situations.
• DGH should review each transfer/referral to ensure women who wish to book for DGH are not being sent to Aberdeen unnecessarily. AMH and Raigmore should provide feedback on the cases to DGH staff in a constructive manner.
• DGH should, with caution, expand triage and day assessment hours - this would not be a CMU model though and clarity is required round roles in emergencies including ventouse practitioners.
• DGH should not consider introducing induction of labour as next step up until a round the clock obstetric service is restored.
• NHS Grampian should not implement targets for birth and bookings at DGH, this is a risky strategy and we need to learn from the findings of the Morecambe Bay report.
• NHS Grampian should audit postnatal readmissions of mothers and babies and consideration given to whether postnatal readmissions can be managed at DGH as part of a transitional care service.
• NHS Grampian must ensure all current staff have the same updated training in basic neonatal resuscitation and recognising the sick infant - Scottish Maternity/NES courses offer NLS with additional advanced skills training in line with national guidelines.

NHS Grampian/ Highland relationship:

• NHS Grampian should confirm with NHS Highland that Raigmore will take emergency transfer cases as if they were Highland women and that these can be referred straight to Raigmore without the need for negotiation. This should be communicated clearly to all staff on the Labour wards at both DGH and Raigmore.
• NHS Grampian and NHS Highland should work together to develop and implement shared clinical guidelines for Grampian, and Highland services and for both hospital and community teams will help avoid confusion and disagreement as mothers and babies are transferred between units.
• NHS Grampian and NHS Highland must work together to allow women from west of NHS Grampian area to choose to deliver there. This includes increasing capacity at Raigmore and must ensure staff can work across health board boundaries and continuity of care after discharge. These discussions may need Scottish Government facilitation and funding may also be required to facilitate this.
• Consideration should be given to seeking and considering data from NHS Highland on length of stay, occupancy rates and birth rates in Raigmore.

Long term planning for restoration of Obstetric services:

• NHS Grampian must look to engage and empower DGH staff in looking to sustainable models for the future by drawing on a variety of innovative solutions suggested by staff.
• In the longer term, the main challenge will be finding junior staff for service. The Post Graduate Deanery can't be relied upon to provide GP trainees on a regular basis. Advanced nurse/midwifery practitioners will help. The employment of salaried medical officers for general service could be considered.
• NHS Grampian should identify which staff require additional skills in Advanced Neonatal Resuscitation - NALS and update if required
• NHS Grampian should consider identifying a nominated link neonatal paediatrician from Aberdeen who has responsibility for the DGH neonatal service and supports their QI tests of change with review for safety and outcome audits.