Paper To Be Put Before NHS Highland Board Meeting on 6 April 2004
MATERNITY SERVICES IN CAITHNESS AND SUTHERLAND
Report by Roger Gibbins, Chief Executive
The Board is asked to discuss the document entitled
“Maternity Services in
Caithness and Sutherland” and to decide on the proposals
contained therein:1. That the Board agree with the conclusions of the
report that options A, B and E are not viable option to consult on.2. That
the Board asks the Deputy Chief Executive (Modernisation) to lead work
to:(i) assess the viability of option C as a possible subject for
consultation.(ii) assess how the ‘stringent conditions’ relating to Option
D may be met with a view to consultation(iii) consider other issues raised
at the Board meeting on 16 march 2004(iv) continue to engage proactively
with people and organisations with an interest in the proposals(v) bring a
report on these aspects and a proposal and plan for formal consultation to
the June Board meeting.3. Highland Council be asked to note the stages and
timetable for this work in relation to their commission of the social and
economic impact study.
The Board received the report, from Professor Calder, ‘Maternity Services
in Caithness and Sutherland, An Independent Review Conducted on behalf of
Highland Acute Hospitals Trust’ on 16 March 2004.
At that meeting the Board agreed that the Review Group
had met the terms of reference that had been set for it. Namely to
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
d. What support mechanisms need to be in place to sustain this model?
The report concluded:
· 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.
· 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 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
The purpose of this paper is to summarise the main
points raised and recommendations of the Review Group, to set those in the
context of the Board meeting on the 16 March 2004 and the parliamentary
debate on the 11 March 2004, and to make proposals to the Board with a
view to beginning an official consultation period of 3 months.
The Calder Report
The report highlights 5 possible options for the future of Maternity
Services in Caithness. Three of them:
· Option A (enhancement of existing specialist services)
· Option B (maintenance of the status quo) and
· Option E (Discontinuation of inpatient deliveries in Caithness)
are dismissed by the group as being either unrealistic,
unsustainable or unnecessary.
The two remaining options from the report are Options C
and Option D.
Option C. Alternative models of provision of specialist
This option has several different possible approaches:
C.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.
The challenges to this approach would be:
· 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.
· 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).
· 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.
C.ii. 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.
The challenges to this approach would be
· Although such an arrangement might seem superficially attractive
individuals undertaking this style of working would become rapidly
· 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.
C.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.
The challenges to this approach would be:
· The problems of unfamiliarity, lack of long term commitment, and
variable and unpredictable quality of the individuals that might be
In overall terms, the review group have suggested that
“Option C” would not satisfy the immediate concerns of the service. “There
are cogent arguments for seeking 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 circumstances. Such an option could,
however, only be implemented in the longer term.
Option 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. 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.
Option D 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.
Challenges/conditions to option D
Whilst the Review Group believe that the preferred configuration should be
the Community Maternity Unit model they also stipulate 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
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.
Within the report the report professional concerns of
midwives were highlighted as:
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.
Some of these concerns are left unanswered by the
Calder Report. They are concerns – particularly in relation to transfer,
retrieval and transport, which may be shared by members of the NHS Board
The Review Group also recognise one further issue that
the Board will have to consider. ‘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
NHS Board Meeting - 16 March 2004
The NHS Board met on the 16 March in Wick. Representatives of the public
were invited to participate in the debate about Professor Calder’s report.
A full minute of the meeting is attached and Board members will note the
specific issues raised by the public representatives.
The actions following on from that meeting were:
· Further consideration be given of the necessary linkages between the
issue of Maternity services in Caithness to be seen in relation to
forthcoming Out of Hours consultations.
· That the subject of affordability of the recommendations of the report
· That a meeting be organised between Highland Council and NHS Highland to
discuss the scope and timing of the Council/HIE sponsored 360 degree
· That the accommodation needs of mothers who might travel to Inverness be
· That the NAG and community representatives would be invited to be
involved in the consultation process.
A debate on the subject of Caithness maternity services was held in the
Scottish Parliament on the 11 March 2004.
The debate centred around a number of issues relating to travel, wider
economic factors, pan-highland working by Consultants, as well as the need
to explore all alternative models with maximum input by the community.
The Process for Consultation
Any consultation process will follow that outlined in the new draft
Guidance “Informing, Engaging and Consulting the Public in developing
Health and Community Care Policies and Services”, that was issued on 1
March 2004 in combination with the “Draft Interim Guidance for
Consultation” from 3 May 2002.
The 2004 guidance states that there are 4 stages of a
realistic and proportionate involvement process.
Stage I is about Informing people and organisations affected
Stage II is about Engaging with those people and organisations proactively
to develop potential options
Stage III asks Boards to ‘Consult potentially affected people and
organisations on feasible options for policy or service development
including service change, noting factors to be taken into account in
assessing the merits of options. When you (i.e. Boards) have a preferred
option for the proposal, this should be clearly stated alongside the
reasoning behind its choice.’
Stage IV is about offering Feedback on the outcomes of the above/
A further stage is highlighted which is about seeking
Ministerial approval for major service change. At that stage reports
should include accounts of the involvement process.
Presently the Board is moving from Stage II to Stage
III of the above process.
The Board will need reassurance that the following
factors (as outlined in the 2004 draft guidance) are taken into account:
1. Why people are being involved in the process
2. What will happen to the information gathered
3. What methodologies will be used to gather those views.
1. That the Board agree with the conclusions of the report that options A,
B and E are not viable option to consult on.
2. That the Board asks the Deputy Chief Executive
(Modernisation) to lead work to:
(i) assess the viability of option C as a possible subject for
(ii) assess how the ‘stringent conditions’ relating to Option D may be met
with a view to consultation
(iii) consider other issues raised at the Board meeting on 16 march 2004
(iv) continue to engage proactively with people and organisations with an
interest in the proposals
(v) bring a report on these aspects and a proposal and plan for formal
consultation to the June Board meeting.
3. Highland Council be asked to note the stages and
timetable for this work in relation to their commission of the social and
economic impact study.
Dr Roger Gibbins
26 March 2004