1. Executive Summary
2. Terms of Reference
3. The Review Team
4. The Review Process
5. Nature of Current and Future Difficulties
6. Current Dilemmas
· Recruitment and Retention of Consultant Obstetricians
· Midwifery Issues
· Newborn Support
· Other Medical Staff
7. Public Concerns
· Geography and Transport
· Impact on Related Clinical Services
· Effects on the Wider Community
8. Guiding Considerations
· Risk Aspects of Obstetrics
· Assessment of Risk
· Social Considerations
· Financial Considerations
9. Key Themes
· Safety
· Quality
· Convenience
10. Option Appraisal
11. Recommendations
12. Conclusion
13. Bibliography
14. Appendices

· The provision of specialist obstetric care at Caithness General Hospital is unsatisfactory to the extent of being unsafe in the view of obstetricians currently working in the Highland Region.

· The roots of the situation lie in:

1. The low birth numbers and consequent very low work intensity.

2. Chronic and worsening difficulties in recruiting and retaining specialist obstetricians.

3. The practice of "specialist" obstetrics in the absence of any conventional neonatal care service.

· The future sustainability of the unit (even in its unsatisfactory state) is rendered virtually impossible by impending changes to employment legislation and contractual requirements and by the increasing scarcity of suitably trained specialists. The critical mass of specialists required to provide a continuous rota has increased and is set to increase further so that the workload offered by an already small number of obstetric deliveries is for each specialist wholly inadequate to support maintenance of clinical skills and professional fulfilment. The service already faces imminent disintegration which appears unavoidable even if funding and goodwill were limitless.

· These issues represent a threat to several other maternity hospitals in Scotland although they are at their most acute in Caithness General Hospital. · This situation presents enormous difficulties to Healthcare providers and is the source of deeply felt anxieties and anger among the local community for reasons which extend beyond health issues to include local economic and social concerns.

· The largest single issue for the people of Caithness and Sutherland centres on their geographical location and the logistics, and the personal and family implications, of an increased need to travel to Inverness for obstetric delivery.  Of greater importance than a loss of convenience, future reconfiguration of the service raises important questions of safety.

· The Review Group consider and recommend to the Highland Acute Hospitals Trust that the maternity service for Caithness and Sutherland should be reconfigured to provide a midwife-led normal delivery facility in Caithness General Hospital for mothers with normal pregnancies who choose to deliver there.

· Such an arrangement would be predicated on the following essential conditions:

1. The new facility would be part of a clinical network managed and supported from Raigmore Hospital and ensuring a. The regular daytime presence of a specialist who would provide support for midwives in respect of risk assessment, care planning and specific aspects of antenatal and postnatal care as well as conducting gynaecology and family planning clinics and performing appropriate elective gynaecological surgery.

b. A comprehensive planning process with development of unambiguous protocols and care pathways and the maximal implementation of support technologies such as telemedicine.

c. The educational and training support to allow midwifery staff to develop and maintain their clinical skills in realising the full scope of professional practice of the midwife as appropriate.

2. Guarantees that the base facility at Raigmore Hospital is fully capable to deal with those Caithness and Sutherland mothers who choose or who are advised to deliver there and provision of all practical assistance with travel and accommodation.

3. The ambulance transfers to Raigmore (and where necessary elsewhere) are provided by the best available land vehicles and aircraft staffed by appropriately trained personnel.

The Review Group consider that these proposals represent the best available solution to a uniquely challenging set of difficulties. They recognise the implications such changes will have for the local population. They are however firmly of the view that the consequence of current and future external pressures will be further attrition of the specialist service to the point of disintegration and that a carefully planned and managed reconfiguration of the service represents the best option for maternity care in the future.

They call on the Trust to take notice of the current and future concerns of the local population during the necessary consultation process. Whatever care pattern is implemented should be carefully monitored and audited and the Trust should be ready to exercise flexibility as changing conditions offer new opportunities to maximise safety, quality and convenience.

The Review reported here was conducted at the invitation of Highland Acute Hospitals Trust by a team consisting of two midwives, one paediatrician and two obstetricians in the light of ongoing and increasing concerns surrounding the safety and sustainability of the current Specialist Maternity Unit at Caithness General Hospital. The group were invited to consider and make recommendations on the following: a. The balance of risk between the current consultant led service and of not having this service in the future.

b. The professional sustainability of the present arrangements.

c. What model of maternity service offers the best balance in terms of safety, sustainability and accessibility for the women of Caithness and Sutherland? d. What support mechanisms need to be in place to sustain this model?

The following individuals comprised the Review Team:

a. Patricia Purton, Director, Royal College of Midwives, Scottish Division

b. Brenda Thorpe, Director of Midwifery Services, Dumfries and Galloway

c. Peter Fowlie, Consultant Paediatrician, Ninewells Hospital and Medical School, Dundee

d. Roderick Campbell, Consultant Obstetrician and Gynaecologist, Borders General Hospital

e. Andrew Calder, Professor of Obstetrics and Gynaecology, the University of Edinburgh (Convenor)

The Group have reconvened on four occasions to consider and develop the report and have consulted further with officers of Highland Acute Hospitals Trust in order to seek additional factual data, to clarify several points of information and to avoid factual inaccuracies.

The Review Group wish to emphasise unreservedly their independence from Highland Acute Hospitals Trust and to state categorically that they consider their role as bringing their various professional skills and experience to the task of endeavouring objectively to provide the best possible solution to an extremely complex set of issues.

Prior to the review visit the group were aware that these issues represent a major concern to the local population. The visit itself and subsequent developments have reinforced the strength of local feeling and have persuaded the Review Group that there is probably no issue currently of greater concern to the people of Caithness and Sutherland. The group are grateful to those members of the local community and their representatives who have gone to considerable trouble to draw their views to the attention of the group either by attending local meetings and demonstrations, by writing to the Healthcare Trust or directly to our group. At the outset the group wish to emphasise our desire to take full account of all the opinions which have informed this process and at the same time to refute the suggestions which have been articulated that we are simply agents of the Trust acting to implement a predetermined strategy.

We would wish to assure the community of our good faith in conducting this exercise. As a group we have chosen to decline any financial recompense other than travel expenses in connection with our conduct of the review.

It would be idle to pretend that the particular problems confronting those responsible for provision of maternity services to Caithness and Sutherland can be easily solved. They have been a source of difficulty for several years during which the underlying pressures and difficulties have increased. The Specialist Obstetrics Service for Caithness and Sutherland which dates back to 1966 was for many years provided by a single handed consultant. This eventually gave way to the need for shared duties such that the establishment of consultants was increased first to two and more recently to three.

Within the past five years however there have been no fewer than eight changes in personnel within the obstetric consultant complement and at the time of the review visit two of the three consultants had intimated their resignation. The remaining consultant resigned in February 2004.

It is thus clear that while it has been possible to recruit consultants to these posts, albeit mostly individuals from backgrounds rather different to those in most other Scottish consultant maternity units, it has proved consistently difficult to retain their services. It is also clear that a variety of new circumstances will add very significantly to the difficulties which have been experienced in the past. These include the requirements to conform to the European Working Time Directive (EWTD) and the soon to be introduced new Consultant Contract which is much more rigorously time-based than the previous contract.

The combined effect of these changes will be that in future it will not be legally or contractually possible for individual consultants to be available for longer periods to cover the low intensity demands which the service places on their professional skills even if they wanted so to do. The highly undesirable consequence of these changes, which particularly afflicts rural services, is that the very small workload which was already barely adequate to challenge the capabilities of a single consultant would in future require to be shared within the very much larger complement of consultant staff necessary to provide a full duty rota within legal working contracts.

It is now accepted that to provide a rota of round the clock on call duties will in future require at least eight and ideally ten individuals. This has profound implications for all acute obstetric units.

The Specialist Obstetric Unit at Caithness General Hospital needs to be viewed in the light of the overall provision of maternity care for the Highland Region. Apart from a small number of home births, obstetric confinements are conducted in five sites. The largest of these is Raigmore Hospital which handles 85-90% of the total followed by Caithness General Hospital which has in recent years conducted a little over 10% of the total. The two GP/Midwifery units at Belford Hospital, Fort William and Broadford in Skye make up the remaining 2-3% (figures provided in a review of Highland Maternity Services conducted by the Maternity Advisory Group for Highland Health Board in August 2001; Appendix 1). Over the 12 year period 1989-2000 there were just over 28,000 delivery events in Highland Region of which just under 24,000 took place at Raigmore Hospital and approximately 3,500 at Caithness General Hospital, the balance being made up of 574 at Belford Hospital and 222 in Skye. All but two of the hospital deliveries to residents of Inverness took place in Raigmore Hospital which also conducted all 2,791 hospital confinements of residents of Nairn, Badenoch, Strathspey; 93% of residents of Lochaber, Ross and Cromarty,Skye and Lochalsh and 84% of Sutherland residents.

In the two year period 2002/2003 there were 3,394 deliveries in Raigmore Hospital.  The residential locations for these mothers were: Inverness 1,274, East Highland 937, Wester Ross, Lochalsh and Skye 263, Lochaber 232, Nairn and Ardersier 232, Badenoch and Strathspey 186, Caithness and Sutherland 183 and the remaining 90 from outwith Highland Region (Appendix 2). It is thus clear that mothers currently travel from throughout the Highland Region and often considerable distances in order to give birth.

The number of deliveries in the Consultant Unit in Caithness has steadily fallen from 570 in 1966 (the year it was established with a single consultant obstetrician) to the current level of around 220 per annum.

Recruitment and Retention of Consultant Obstetricians. The difficulty of recruiting Consultant Obstetricians to work in Caithness and of providing stability by retaining their services has to be seen against a background of major changes in workforce provision across Scotland. Several factors have contributed to a serious shortage of trained specialists to fill consultant posts in Obstetrics and Gynaecology throughout the United Kingdom. The most powerful of these have been:

a. An acceptance by the Health Department of the need to increase the number of specialist posts in order to move to a consultant based service.

b. A serious misjudgement of the number of specialists necessary to staff the service. There are several reasons for this including a failure to appreciate the impact of the gender shift in the intake to the medical profession.

c. A decline in the popularity of Obstetrics and Gynaecology as a speciality. Surveys of just under 3000 medical graduates at the time of full registration with the General Medical Council have shown obstetrics and gynaecology decline as their chosen speciality from just under 1:20 such doctors in 1993 to fewer than 1:50 in 1999.

None of these problems lends itself to a short term solution. While on superficial examination it might appear that a consultant appointment in a pleasant rural part of the country, and with an extremely light workload, would be very attractive the reality is very different. In spite of the fact that the requirements for on-call availability have been markedly reduced by the increase in consultant numbers, the Obstetric Consultant posts remain unsatisfactory for the following reasons:

a. Highly trained specialists are understandably frustrated if their skills are not well utilised.

b. It is difficult to maintain clinical competence in the absence of regular, appropriate clinical practice.

c. In spite of the increased consultant numbers the on-call rota is effectively 1:2 when the third individual is on vacation or study leave.

d. The absence of junior staff requires the consultant staff to perform simple, and in some instances, inappropriate tasks which do not utilise their specialist skills; this also deprives them of the intellectual challenge which eager young trainees provide.

e. Because of the absence of backup facilities, especially neonatal support, complicated cases which would be clinically challenging and professionally rewarding are referred for antenatal care and planned delivery in Inverness.  The result of all of the above is that the incumbent consultants feel their status as specialists is diminished. In addition there are disturbing issues relating to Continuing Professional Development and Clinical Governance. There appears to be very little evidence of ongoing medical audit and none of the current consultant staff had undergone the now mandatory appraisal process which in turn feeds into the process of revalidation.

It was evident to the Review Group that the current complement of Consultant Obstetricians had become dysfunctional as a unit with poor interpersonal relationships. It was further made known to the Review Group that on occasion(s) recently one of the Consultant Obstetricians had informed Raigmore Hospital that she was unable or unwilling to meet her on-call obligations with immediate effect by virtue of stress or tiredness thereby leaving the service without specialist support.  This consultant also resigned in February 2004. This had highlighted an issue which is pertinent to the consideration of future configuration of services. It is understood that in Orkney and Shetland where there are no Specialist Obstetricians but there are Consultant Surgeons the latter have on occasion been prepared to carry out emergency caesarean sections. One of the three Consultant Surgeons in Caithness has indicated a willingness to at least consider providing such a backup but the other two in the light of discussions with their defence organisation have indicated that they would not be prepared to do this.

While it is clear that the Trust have in recent years managed to continue to fill the consultant vacancies, albeit with frequent changes of personnel, the type of individuals who have in the past and may in the future apply for these posts come from a range of backgrounds most of which are not those of mainstream, conventional UK specialists. Many have been overseas graduates who may have had a poor understanding of the realities of the current pattern of clinical service in Caithness and who after taking up these posts have tended quickly to become disillusioned and disaffected. As a result they have only remained in post for short periods.

Most telling of all are the views which have in the recent past been expressed by the general body of Obstetric Consultants in the Highland Region that the current arrangements are unsatisfactory to the extent of being unsafe.

Midwifery Issues

The Review Group were very impressed by the commitment and professionalism of the midwives currently in post and by their apparent willingness to consider flexible and constructive working practices. They are clearly committed to maintaining and developing their knowledge base and clinical skills. Several of them have attended courses for advanced life support in obstetrics and neonatal life support etc.

The midwives indicated their readiness to embrace the concept of midwife managed care and whilst currently all women are booked for consultant care they felt that a model of midwifery led care would sit comfortably alongside this. In being positive about the future they did raise some concerns however, namely:

i. Reservations regarding safety if no obstetrician is available.

ii. Specialist help more than 100 miles away.

iii. Potential for no resident obstetric cover.

iv. Issues of transfer, retrieval and transport.

The cohort of hospital based staff is made up of 14 midwives supported by seven auxiliary nurses. There are six single duty midwives in the community, two of whom are based in Thurso, augmented by other midwives who are dual post practitioners (ie district nurse and midwife). At present the number of home confinements conducted in the region is fewer than single figures per annum and concern was expressed by the midwives that altered configuration of services might in future lead to an increased demand for home confinements which could stretch midwifery resources very thinly.

Neonatal Support

Current routine support for the newborn infant is provided by midwives as elsewhere throughout Scotland. When it is anticipated that a newborn infant might require more than routine resuscitation and care, or when an unexpectedly "flat" baby is born, Dr Farquhar, Neonatal Support Practitioner is called upon. Dr Farquhar, a retired obstetrician, is available 24 hours a day but only Monday to Thursday. Through goodwill he will offer his services at other times if he is available. The post occupied by Dr Farquhar is unique to the maternity service in Wick. It is not a post seen elsewhere and is not recognised by the Royal College of Obstetricians or the Royal College of Paediatrics and Child Health. It would seem unlikely in future to conform to requirements of employment law or contractual agreement.

Other Medical Staff

In considering any reconfiguration of services thought must be given to the potential contribution of non-obstetric doctors, in this context general practitioners, general surgeons and anaesthetists.  On a national scale the active involvement of general practitioners in obstetric cases has steadily declined over the past few decades. Although general practitioner services appear to be of high quality in Caithness and Sutherland the Review Group could detect no evidence of enthusiasm for a significantly increased role for general practitioners in delivering maternity care. Even if there was such an interest this would require the acquisition of additional skills among the general practitioners and at present there appear to be no signs of enthusiasm for this. Mention has already been made of the practical difficulties of relying on general surgeons to carry out emergency caesarean sections and the same considerations probably apply to any expectation that anaesthetists might resuscitate newborn infants. Although some of the current staff would be prepared to consider such requests on a "good Samaritan" basis, this is not seen as a robust source of expert support either by the Review Group or the doctors concerned.

The local population are fully aware that the specialist based obstetric service in Wick is in difficulties and are understandably concerned at the prospect that it may be downgraded or withdrawn. Although a range of concerns were brought to the attention of the Review Group the three which are of the greatest concern are:

a. Problems of geography and transport.

b. The possibility of a domino effect on other medical services in Caithness which might result from changes in the Maternity Service.

c. Effects on the wider community.

a. Geography and transport

Caithness and Sutherland lie in the very north of Scotland and have a limited road network. Roads to some of the most remote areas are single track. The two largest conurbations, Wick and Thurso, are more than 100 miles from Raigmore the closest hospital with full maternity, neonatal and intensive care facilities. The A9 between Wick and Inverness is a poor road that is difficult and tiring to drive with only a small section of dual carriageway closer to Inverness. There are frequent accidents on this road which can also rapidly become blocked by snow in the winter. It takes at least two hours to travel between Wick and Inverness by road in ideal conditions. A significant proportion of families in Caithness and Sutherland do not own a car or do not have ready access to one. Train services between Inverness and Wick are infrequent and slow. Access by air is possible with facilities to land rotary or fixed wing aircraft at Wick Airport but the airport can be closed because of weather conditions – fog and/or snow. Consequently Wick can become completely blocked off with no method of leaving or reaching the area. During the visit the Team heard varied opinions as to how frequently this occurs.

It is acknowledged that if there were no Specialist Obstetricians in Caithness the child-bearing population would be faced with a choice of planning to be delivered by a midwifery service in Caithness or to travel to the Specialist Unit in Inverness for delivery. There is deep seated local resentment at the prospect that their children might not be delivered in their own locality. Of special concern are the undoubtedly unattractive prospects of the need to transfer mothers in labour from Caithness to Inverness if they develop serious complications. It is acknowledge that such a journey by ambulance would be extremely uncomfortable and may be clinically undesirable. The nightmare scenario which has been vividly highlighted to the Review Team concerns the coincidence of the critical clinical incident with severe weather conditions which could preclude not only road transfer to Inverness but also the use of air ambulance facilities. While that possibility cannot be entirely ruled out the statistical probability of this happening is, in the view of the Review Group, extremely small. It should, however, also be acknowledged that the need for such emergency transfer is a feature of the current service provision.

In respect of an increased number of planned confinements in Raigmore concern has been expressed about the travel costs for mothers and their relatives, about the capacity of Raigmore of cope and about the quality of hostel accommodation.

Road Ambulances

The current fleet of road ambulances provides Caithness and Sutherland with a maximum of four two-man vehicles available from Monday to Friday. The service can at times be stretched when a vehicle and crew are deployed in a long distance transfer to Inverness or elsewhere outwith Caithness and Sutherland. The vehicles are all recently acquired and up-to-date but at least some do not have the loading ramps and winches that are necessary to load neonatal transport incubators. The service is staffed with a mixture of paramedics and technicians, 80% of full time staff being paramedic trained. Working hours can be long, particularly when transporting patients to distant venues and crossing over shifts.

Air Ambulance

Access to air transport is available through the air desk of the Scottish Ambulance Service. This provides fixed wing aircraft (based in Kirkwall and in Aberdeen) and helicopters (based in Inverness and Glasgow). A Ministry of Defence helicopter may be available for life threatening episodes. Depending on the type of aircraft, their use can be limited to daylight hours or by weather conditions. At present newborn infants can be transported in any of these aircraft depending on the availability of an appropriate transport incubator. The air ambulance helicopters are not considered suitable for transporting labouring women because of lack of space in the event of a midair delivery. This situation may be improved in a year or two when a new air contract is expected to provide a better helicopter that will transport labouring women more safely.

Although flying time between Wick and Inverness is around 30 minutes (and only slightly longer Wick to Aberdeen) the overall time required to arrange and implement an air transfer, taking account of time to prepare and send out the aircraft plus the road transit time from airport to hospital means that this option may not represent a significant time saving compared to land transport.

Current Retrieval Arrangements

i. Mothers

There is no formal obstetric flying squad and there are presently no plans to reinstate such a service between Inverness and Wick. Current transports are arranged on an ad hoc basis with women being stabilised as necessary in Wick prior to transfer to Inverness mainly by road ambulance. Such women are escorted in the main by midwives with other staff contributing rarely. Such transfers are unpleasant and uncomfortable for all concerned, particularly mothers in active labour.

ii. Neonates

Transfer of newborn infants also currently relies on ad hoc neonatal transport services, principally to Raigmore, although more recently with support from elsewhere (Dundee). The National Newborn Transport Service is currently under active development and it is anticipated that within the coming year this will provide a robust service. However, even when this service is fully operational it will consist of a retrieval service only and not a flying squad designed to resuscitate sick newborn infants. Nor will it be a particularly rapid option.

b. Impact on related clinical services

If the Consultant Obstetric Service is withdrawn there may be deleterious effects on the sustainability of other parts of the medical provision in Caithness. In particular there is a fear that a reduced requirement for emergency anaesthetic provision could impact on the job satisfaction of the anaesthetists. If it became increasing difficult to recruit and retain such specialists this would have obvious impact on general surgery.  However these specialties are themselves already facing the same types of pressures as confront the obstetric service.

c. Effects on the wider community

It has been claimed that individuals or families contemplating either a move to the Caithness area or a decision to remain in this part of Scotland could be discouraged if there were no specialist obstetric facilities provided locally and that this could have a serious impact on the economy of this fragile part of rural Scotland. It has also been pointed out that the need for a larger number of mothers to arrange their confinement in Inverness may have serious social consequences for existing children during their mother’s confinement in Inverness.

Risk aspects of obstetrics

The unique challenge of maternity care provision lies in the nature of childbirth.  Although it is frequently and appropriately stressed that labour and delivery are in essence physiological events rather than pathological or clinical processes, departures from normality with the development of complications which are potentially life threatening to the mother or offspring are by no means rare. Whereas in former generations and in primitive communities today things are generally "left to nature"  (sometimes with disastrous consequences) western society has evolved a requirement that mothers in labour and undergoing delivery should have skilled assistance. Highly trained midwives play the essential role of supervising the normal birth process and recognising departures from it which may require specialist medical assistance.

Specialists in obstetrics, anaesthesia and neonatology play a crucial role in the prevention or treatment of the more serious complications which may arise. A particular source of difficulty lies in the unpredictability of when labour and delivery are likely to take place. Even when the date of conception is accurately known (and in many instances it is not) the expected date of confinement does no more than  point to the peak likelihood around which there is a wide normal distribution. A significant number of pregnancies fall outwith that normal range by virtue of premature onset of labour or failure of labour to start before 42 weeks gestation. A significant minority of women have "scheduled" deliveries in the sense of artificial induction of labour or elective caesarean delivery but the large majority of women travel to their place of confinement after labour has been recognised as having started. Because of variations in the duration of labour and depending on factors of geography and transport which determine the length of travelling time a small number of patients will deliver while in transit almost regardless of the geographical location.

This may be seen as undesirable but it should be stressed that births which do take place in unexpected circumstances are almost always by their very nature straightforward.  It is accepted that the least desirable scenario in acute obstetrics is where dangerous complications have developed which require transfer during labour or in the face of serious or life threatening maternal or fetal complications. Such difficulties are not by any means limited to remote and rural circumstances but they form a key element of the planning considerations in Caithness and Sutherland.

Assessment of Risk

Although pregnancy and parturition are physiological processes, both the mother and her offspring are potentially in jeopardy. The overwhelming majority of pregnancies end in the delivery of a healthy offspring to a healthy mother but a significant minority sustain damage and a very small minority do not survive. Epidemiologists, statisticians and clinicians have endeavoured for decades to try to quantify pregnancy associated risks. It is comparatively easy to establish overall risks for a given population by recording crude measurements such as the mortality rates of mothers and babies and (although more difficult) morbidity figures for specific complications. It is also possible to identify groups of patients who face increased risks by virtue of factors from their own medical, surgical, obstetric or social histories. Obvious examples of these would be pregnancies in women with medical disorders such as diabetes or with a previous history of stillbirth or premature delivery.

Where the science of risk assessment becomes least precise is in trying to quantify risk for the individual subject. Although an individual woman might on the basis of her past history appear to be at higher risk of specific complications this by no means guarantees that such complications will afflict the pregnancy in questions which may (in spite of the attendant anxieties) follow an entirely normal course to an entirely normal outcome. Furthermore the risk which may appear to attach to an individual pregnancy may change dramatically during its course. An entirely normal pregnancy may be complicated by wholly unpredictable adverse developments on the one hand whereas another may be seen to constitute a diminishing risk as it progresses, for instance in a woman thought to be at high risk of premature delivery whose pregnancy progresses to a gestation at which worries about prematurity no longer apply.

a pregnancy which fulfils basic parameters of normality should be cared for in pregnancy and labour by a midwife. Even in circumstances where complications may appear to be more likely the midwife should retain that central role but with clear protocols, lines of communications and facilities whereby the skills of specialist medical personnel (obstetricians, anaesthetists, paediatricians, etc) may be brought into play as appropriate.

It is thus possible to draw up a catalogue of factors which point to the need for specially tailored antenatal or interpartum care which will inform the planning process. A number of these factors would be known at the start of the pregnancy and these would include the following:

· Previous perinatal death.

· Previous caesarean section

· Previous spontaneous miscarriages

· Extremes of maternal age

· Drug dependency

· Previous preterm delivery

· Previous low birthweight baby

· Pre-existing maternal hypertension, diabetes, heart disease or epilepsy

Other complications would become manifest during the pregnancy:

· Multiple pregnancy

· Breech presentation

· Development of hypertension or diabetes

· Impaired fetal growth

· Prolonged pregnancy

Of special importance are a small group of sudden events which expose the mother or

fetus or both to immediate dangers. Principal among these are:

· Antrepartum haemorrhage

· Sudden onsent, fulminant pre-eclampsia

· Eclampsia

· Premature labour

· Umbilical cord prolapse

· Postpartum haemorrhage

The Group’s first remit of assessing the balance of risk between the status quo and a different model of maternity care provision must take account of these considerations. It is important to recognise that the current facility at Caithness General Hospital is only a "specialist unit" in the sense of employing specialist obstetricians. The absence of more than the most basic arrangements for neonatal support means that it is currently inappropriate to undertake deliveries there with complications which may lead to neonatal jeopardy. Indeed one aspect of the current pattern of care which is itself a worrying safety issue is the perception that the facility is appropriate to deliver some such cases when clearly it is not. Recent instances have been cited to the Review Group in which admission to the Caithness unit of mothers with complications did no more than delay their appropriate admission to Raigmore, thereby increasing the risks.

If the Caithness unit were to become effectively a "normal delivery unit" there would be much less likelihood of confusion as to the appropriate care plan for each mother. Social Considerations The attention of the Review Group was drawn to the social impact of more mothers having to travel to Inverness for their obstetric confinements. These issues centre on transport costs, family disruption and local accommodation provision. Although the duration of "lying-in" has steadily declined in recent years the Review Group are clear in their view that whatever model is adopted these issues require to be fully addressed.

Financial Considerations

It has been stressed at the outset in this report that the Review Group are not acting as agents of the Health Board and are certainly not, as has been suggested in the media, simply assisting the Health Board in a cost cutting exercise. Indeed the Group are clear in their view that in hoping to be able to recommend a pattern of care that is at least as good and probably better than that which has previously been provided, this may entail cost increases rather than cost reductions. Having said that, however, the Group recognise a clear responsibility that resources should not be squandered on inefficient, unnecessary and clinically inappropriate care patterns.

Before moving to consider a range of options the key themes which inform this process may usefully be addressed in greater detail. These we consider are safety, quality, sustainability and convenience.

a. Safety

Although the current service provision is quite clearly viewed by the people of Caithness and Sutherland as being both safe and of high quality this has been called into question by those very professionals who provide the service. The greatest concern repeatedly expressed by the people of Caithness and Sutherland was whether any change to or downgrading of their current maternity service would be less safe for them and their babies. Individual patients have expressed the view that their own clinical experiences in the past were such as to support the view that had there not been Specialist Obstetricians on hand in Caithness they would have lost their own lives or those of their babies. Absolutely safety can never be guaranteed under any circumstance but maternal deaths in Scotland are now mercifully exceptionally rare and perinatal deaths of babies have continued to decline. The statistics on both these tragic eventualities within the Highland Region have been, in the recent past, below the national average and it is certainly not the intention of the Review Group that this should change.

It should be self evident that were it feasible to provide round the clock availability of the highest quality clinical expertise in obstetrics, midwifery, anaesthesia and neonatal intensive care in Caithness General Hospital this would offer the best maternity service with the highest safety guarantees but clearly the same could be said for every community of whatever size in Scotland. The objective of the Review Group is to recommend the safest arrangement for maternity care possible within the current difficult and increasingly difficult strictures.

b. Quality

Maintaining Good Medical Practice, a further GMC publication, emphasises the importance of each individual "being committed to providing a good quality service and effective clinical practice". Maintaining these professional standards in Obstetrics and Gynaecology is dependent on the implementation of evidence based clinical guidelines (provided by the Royal College of Obstetricians and Gynaecologists), the regular and critical review of procedures and of individual clinical performance. These principles underpin the themes of Clinical Governance, Consultant Appraisal and Revalidation.

Despite the public perception that the current consultant led service is of high quality, a unit delivering 220 low risks pregnancies per year divided between three specialists must call into question the ability of these consultants to remain professionally competent in all important basic elements of their clinical practice. Consistent care is difficult to demonstrate in the absence of any individual or departmental audit. The absence of an ongoing appraisal system or evidence of individual continuing professional development calls into question whether consultants under such circumstances can practice efficiently and safely. The present "dynamics" within the Obstetrics Department and between it and Trust Management questions whether individuals in these posts are able objectively and critically to review their own practice and the performance of their colleagues.

c. Sustainability

There have been nine personnel changes at consultant level in the Department of Obstetrics in the last five years. At the time of the assessment, two of the incumbent three consultants were planning to leave the Department. The third has since followed. This highlights the unique problems of recruitment and retention when providing health care in rural and remote areas. Long term sustainability of a consultant based service at Caithness is questionable in view of the current difficulties and future provision of skilled manpower in the Health Service. As has already been emphasised the need to expand the consultant workforce to meet the new challenges of obstetric practice and the expectations of the public have far outstripped the availability of such specialists, a situation which is clearly going to worsen in the short and medium term. Even as recently as 10 or 15 years ago doctors seeking consultant appointments in this speciality were in a highly competitive market and many had to accept an appointment wherever they could find one. The current situation is that such specialists are now in such short supply that not only can they be highly selective in the type of posts for which they apply but they are also much more able to move from a less desirable to a more desirable appointment. This has impacted most unfavourably on remote and rural areas.

Having a consultant immediately availably locally may be seen as being of high quality and the safest option but this may be a delusion. By their own admission, these consultants feel professionally devalued, that their skill mix is chronically underused and that in the face of life threatening emergencies, their clinical abilities are pushed to the limits. It is thus entirely understandable that they may seek to pursue their career in an environment which enhances their career development and satisfaction.

d. Convenience

It is appropriate that Health Service consumers should demand a service which seeks to ensure safety, high quality and accessibility but unfortunately the last of these is often seen to attract greater prominence than the other two. The underpinning principle which should guide the current debate is that as much of the maternity care as appropriately can be should be provided locally but not at the expense of safety or quality. The first imperative should be high quality care in the safest possible circumstances.

The Review Group believe there are theoretically five possible clinical models:

a. Enhancement of existing specialist service

b. Maintenance of the status quo

c. Alternative model of provision of specialist obstetric care

d. Community maternity unit

e. Discontinuation of inpatient deliveries in Caithness

These will now be considered in greater detail.

a. Enhancement of existing specialist service

During the review visit it was suggested that women in Caithness and Sutherland deserve the same level of specialist maternity care support as their counterparts living in the large towns and cities of Scotland. In particular it was argued that there should be the full range of specialist obstetric, neonatal and anaesthetic support. This is clearly unrealistic and could not be justified on the basis of the volume of work and the rarity of the type of problems requiring such specialist support. Neither is it a practical possibility bearing in mind the existing difficulty in recruiting and retaining specialist obstetric staff. It could be anticipated that such difficulties would be at least as severe if there was an attempt to recruit paediatric staff.

b. Maintenance of the status quo

In the light of recent resignations the Trust have embarked on advertising for replacement obstetric staff. It would be wrong to suggest that there have been no qualified applicants for these posts. Although it would appear that the type of applicant is broadly similar to those who have recently been employed in these capacities it would seem that there is an option to patch up the service at least in the short term. The Review Group, however, have no reason to believe that the prospects of sustaining the service on this basis are likely to become any easier and indeed are firmly of the view that the difficulties will increase in the short and medium term. We understand that even recruiting locums is proving very difficult. Changes in terms and conditions of service for NHS consultant staff which will be implemented under the new consultant contract seem unlikely in any way to ease the difficulty of staffing units such as this with appropriate consultant personnel.

In considering the status quo mention should be made of the role played by Dr Farquhar acting as a "Neonatal Support Practitioner" having retired from his post as Consultant Obstetrician. While it is clear that the current service is fortunate to have Dr Farquhar in this capacity this is an ad hoc type of arrangement which does no more than shore up the present arrangements and would be very difficult, if not impossible, to replicate when Dr Farquhar retires.

c. Alternative models of provision of specialist obstetricians

If as we believe it will in the future be inappropriate, if not impossible, to provide a structure of Wick-based consultant obstetricians to provide the service, it is worth considering alternative models whereby the presence of a specialist in Wick round the clock, seven days per week might be provided. The options for this would seem to consist of the following:

i. That all consultant obstetricians in the Highland Region be based at Raigmore Hospital but that they take it in turns to stay in Wick for periods of a predetermined length during which they would be available to provide instant obstetric support. While on the face of it this would seem to be a possible solution there would, nevertheless, be serious practical difficulties with this model. Firstly it would presumably require a further significant increase in the number of consultants employed in Raigmore so that this type of scheme would comply with the new consultant contract and employment legislation. Secondly it seems highly improbable that the consultant obstetricians currently employed at Raigmore Hospital would be prepared to alter their contracts to accommodate such a scheme (albeit there might be contractual obligations to do so or at least to work more flexibly). In addition if such a scheme were mandatory for new appointments in Inverness this requirement could have a deleterious effect on the ability to recruit and retain any consultants at all for the Highland Region.

ii. Recruitment of a different type of individual. The idea has been mooted that consultants who take early retirement from busy urban hospital posts (often five or ten years before their natural retirement age) might be prepared to act in the style of the old single handed consultant in Wick for periods of several months or even years. It may be that special arrangements could be made to offer financial inducements to individuals to work in this way although again employment legislation may preclude it. It seems highly probable that although such an arrangement might seem superficially attractive individuals undertaking this style of working would become rapidly disillusioned. There are also serious issues concerning clinical governance, maintenance of clinical skills etc which are probably even more pressing than apply to the current arrangements.

iii. A sequence of short-term "locum" arrangements. In previous years when difficulties such as the present ones confronted the small units in the Highland Region and the Western Isles a short term "fix" was provided by recruiting a steady stream of individuals currently employed in other parts of the country who would undertake locum cover for a week or perhaps two at a time during their annual leave. This often applied to old style senior registrars or young consultants who saw this as an opportunity to supplement their income at that stage in their careers. While such an arrangement might lead to a higher calibre of individual being available at any one time such advantages seem likely to be offset by the problems of unfamiliarity, lack of long term commitment, and variable and unpredictable quality of the individuals that might be recruited.

d. The Community Maternity Unit Model

This would entail withdrawal of specialist obstetric staff from Caithness General Hospital and the establishment of a midwifery led unit which would aim to confine those women who were deemed suitable for such an arrangement. This would also require such women as were not considered to be in that category or who chose not to avail themselves of that local facility to travel to Raigmore for their confinements. It is also inescapable that under such a model a small number of women (perhaps fewer than 10 per year) as in Skye and Lochaber would require to be transferred in labour to Inverness on account of intrapartum complications. It is a matter of speculation what proportions of the future childbearing population would fall into these three categories but the Group estimate that probably rather more than half of the current expectant mothers would be recommended or would choose delivery in Inverness and slightly fewer than half would be confined in Wick.

The Group would emphasise that if such a model were to be adopted it would clearly require more than withdrawal of the consultant obstetric specialists and simply requiring the midwives to provide such a service. It would require investment in training and support for those midwives. It would also require strong clinical leadership with as comprehensive a support mechanism from the obstetric consultants in Inverness as could be provided. We would envisage the identification of a high calibre Midwifery Director and a designated Obstetric Consultant responsible for overseeing the arrangements and we would propose that every possible aspect of maternity and gynaecology care as could be provided in Wick would be so provided. This would include regular visits of consultant obstetricians and gynaecologists to conduct outpatient clinics and elective operating lists. During such visits the obstetric staff would be available to review current or potential problems in the pregnant population and to advise the midwives. Such a system would require the development and acceptance of clear guidelines and protocols. It would also be imperative that maximum use should be made of new technologies such as telemedicine and teleconferencing to offer such support when necessary.

This model would also require that the quality of ambulance transport both by road and by air should be the very best which could be provided. Arrangements for assistance with travel and high quality accommodation at Raigmore Hospital should be enhanced. Under such a model some mothers who would not be considered high risk may still choose delivery in Inverness and this might in some instances require that they travel there and await the onset of labour. Such an arrangement is currently employed satisfactorily for many patients from other parts of the Highland Region and also for those from Orkney and Shetland who deliver in Aberdeen.

e. Discontinuation of inpatient deliveries in Caithness General Hospital

Such a radical change might be necessitated if neither the local population nor the midwifery staff were prepared to countenance Option d but it is clearly workable and would in a sense bring Caithness more closely into line with the current provisions within several other rural communities across the Highland Region.

These five options were subjected to a numerical scoring assessment conducted by the five panel members independently. This is attached as Appendix 3.

Ultimately the key and difficult decisions concerning the future provision of the maternity services will need to be taken by the new unified NHS Board which comes into existence within the next few months. The Review Group recognise the intense public concern which has been articulated. This is an essential part of the democratic process but health care providers have an unenviable challenge in meeting the expectations of the public while reconciling these with practical realities and the other demands on a finite Health Care Budget. The new Board will have to recognise the wider consequences of decisions they may take in respect of the maternity services and it is incumbent on them to guard against compromise to other services.

The Review Group take the view however that even with unlimited financial resources and goodwill on the part of health care staff and management it will not be possible to sustain the current arrangements for specialist obstetric services at Caithness General Hospital far less an enhanced specialist service there. It would be understandable if the Health Board endeavoured to shore up the existing type of service in order to try to allay local anxieties but it is our view that this would not be a desirable option and would almost certainly be accompanied by a continuing deterioration in the service.

The Review Group reached the inescapable conclusion that the current provision of specialist service is unsustainable. We have, however, also reached the conclusion that it would be quite inappropriate simply to withdraw the Consultant Obstetricians without exploring all the possible alternatives in order to arrive at the most appropriate and acceptable service provision. We are in no doubt that whatever pattern of care is put in place a very great deal of work is required to ensure that the best possible system is implemented. It is not our business to endeavour to achieve financial economies as part of this exercise and indeed we take the view that whatever service is finally provided might be even more expensive than the current one. We also believe, however, that with sufficient imagination and determination the future service provision, far from being inferior to the current one, may well represent a more sustainable and robust service.

The Board may wish to explore in greater depth the type of models which we have superficially examined under Option c. We suspect however that such an arrangement might be at best a temporary expedient. There are cogent arguments for seeing the assistance of the Scottish Executive and the Remote and Rural initiatives in the longer term objective of staffing the service with pluripotential practitioners capable of offering obstetric assistance in specific circumstamces . Such an option could, however, only be implemented in the longer term.

The notion of withdrawal of all inpatient maternity services from Wick as outlined in Option e seems unnecessarily radical and would be highly unpopular with the local population. The Review Group do not consider that it would be necessary to go to such a radical solution.

In the final analysis the Review Group have reached the view that the best configuration for high quality maternity care in Caithness and Sutherland would be for Option d to be enthusiastically embraced and seen as the basis for the development of a high quality obstetric service that would represent the best arrangement for the maternity care of the women of Caithness and Sutherland. This however will require

much more than simply the implementation of the broad model for such an arrangement as has been defined by the Expert Group on the Acute Maternity Services. Rather it requires major initiatives and endeavours on the part of a wide range of medical, midwifery and health service management in order to maximise the skills of the staff concerned, to support them to the highest level and to continue to explore new and better ways of meeting the high expectations of the future generations of offspring in Caithness and Sutherland, their parents and their families.

In attempting to address our "Terms of Reference" the Review Group consider that the balance of risk between the current consultant led service and of not having this in the future is not capable of precise definition. Due largely to geographical considerations these risks are probably finely balanced but our attempt to make that judgement is rendered to some extent academic by our perception that the current service provision is close to collapse and unlikely to be sustainable in the near future.

We believe that the preferred configuration should be the Community Maternity Unit model and that it should be developed under the following stringent conditions:

a. There should be substantial and genuine investment in enhancing the training and confidence of midwives to enable them to undertake the necessary extended role.

b. The midwives should be supported by the regular daytime presence of specialists who would be there to assist with risk assessment and care planning while contributing to antenatal and postnatal care and conducting consultations in obstetrics, gynaecology and family planning and performing appropriate gynaecological surgery.

c. All clinical practices should be guided by custom developed protocols, guidelines and care pathways with the most effective employment possible of communication links and support such as telemedicine.

d. Good quality accommodation should be provided for women and their families when they have to travel to Inverness for maternity care.

e. The best possible system for the transport of pregnant women from Wick to Inverness, particularly those in labour, must be identified and provided.

f. The current schedule of training of midwives in newborn resuscitation and stabilisation should be developed into a more definite programme.

g. The National Newborn Transport Service should take particular cognisance of, and address, the issues in Wick.

It is the firm view of the Review Group that while the Trust might try to continue the pattern of recent years this is likely to perpetuate an unsatisfactory situation which is not in the interest of the population of Caithness and Sutherland. A reconfiguration of services is, we consider, inescapable and can if successfully managed produce a safe pattern of care of at least as high quality as is currently provided.

13. Bibliography

1. Good Medical Practice

General Medical Council, July 1998

2. Maintaining Good Medical Practice

General Medical Council, July 1998

3. Maternity Care Matters

Scottish Programme for Clinical Effectiveness in Reproductive Health, May 1999

4. A Framework for Maternity Service in Scotland

Scottish Executive, February 2001

5. A Review of Highland Maternity Services for Highland Health Board

Maternity Services Advisory Group, August 2001

6. Expert Group on Acute Maternity Services

(EGAMS), Scottish Executive Health Department, 2002

Highland Acute Hospitals NHS Trust

Geographical Location of babies born in Raigmore Hospital

2002 data is from SMR2 coded records
2003 data is from Scottish Birth Record, excluding babies transferred out of Raigmore
All data does not include still births
Multiple births are counted as per the number of live births
Produced by the Department of Planning and Performance

BIRTHS.xls

2.3.04

1. Based on all the evidence available – written and verbal, professional and lay – themes relevant to maternity services in Caithness and Sutherland were developed.

2. Each individual theme was assigned a weight in order of "importance" based on professional opinion. Eg if safety was considered twice as important as "social convenience", "safety" was given a weight twice that of "social convenience". Weights were expressed as percentages of the total model and therefore totalled 100%.

3. Potential models of service were described.

4. The "strength" of each theme was scored (out of 10) against each model. A high score represented a theme that was supported by the given model.

Seven themes were identified:

i. Safety – includes maternal and neonatal aspects

ii. Quality – includes such things as the likely standard of health professionals who would be working, professional supervision/development, professional appraisal, standards of training, up dates etc

iii. Sustainability – ability to recruit and retain staff – midwives, obstetricians, etc

iv. Effect on medical services – "pack of cards" scenario

v. Effect on wider community – does the presence or lack of maternity service impact on the wider community eg ability to attract business, other people to work in area.

vi. Social convenience

vii. Cost/affordability – this must reflect cost to health service. It is not meant to include financial

cost to families as this comes under "social convenience"

Each of the five members of the review team independently attributed weights (out of 10) to each of the

themes. The totals for each of the themes were:

Five models of maternity service provision were identified:

1. Enhanced service – more obstetric consultants, paediatric service, possible neonatal facility.

2. Status quo – 3 or 4 consultant obstetricians based in Wick.

3. Peripatetic consultant services – consultants "visit" Wick at various frequencies and remain for variable time.

4. CMU.

5. No hospital deliveries.

The strength of each theme in any given model was scored (out of 10) independently by each

of the five review group members. Total raw scores (out of 50) were as follows:

The weighted scores and total adjusted scores for each model are given below. Note that three options appraisals have been calculated: one looking at just safety, quality and sustainability which might be regarded as a purely clinical appraisal of maternity services; a second that includes wider issues such as the effect on the community and the other hospital services; and a third which includes all the issues including affordability.