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Response To NHS highland Public consultation On Maternity Services In Caithness By Mr Brian Valentine - Obstetrician Caithness General Hospital

Mr Valentine has written a detailed response to NHS Highland.  We have written a summary to make it easier to what points have been addresses in his response that he has made available to us.  
The full response is also published here.  With an Executive Summary

Synopsis of “Report on Service Provision at Caithness General Hospital of Obstetric & Gynaecology Facilities” by Mr. Brian Valentine

Mr. Valentine’s attempt to address the problem of provision of acute obstetric and gynaecological services to the counties of Caithness and Sutherland outlines the main problems to be addressed in solving this issue, breaking down some of the specific risks involved with working in the area, and providing an opinion as to a solution. Mr Valentine worked in the department for 22 weeks, so has some experience in the area (more than most of the expert consultants proffering opinions for the NHS).

Main points:

  • the use of outside expert consultants was supposed to provide the public with the feeling that the NHS was being unbiased and impartial, however the public view these outsiders with scepticism, fear and distrust.

  • The committee have done a good job of sifting through a lot of facts, however without the benefit of local knowledge they are open to simple errors of judgement that can destroy their credibility

  • Notes that it is a Nation-wide problem, however this does not reduce the local problem

  • A solution that incorporates the local perspective is required as some of the problems here are unique to the area and do not apply to other areas where a mid-wife led community maternity unit has worked

  • The NHS charter states that everybody should received exactly the same standards of care and attention, and that services should be adjacent to their place of abode

Problems encountered during Mr Valentine’s 22 weeks:

  1. Non-availability of an ambulance (can take up to 6 hours)

  2. Additional delays (traffic, bad weather)

  3. Pre-term and precipitate deliveries

  4. Foetal distress (can require emergency caesarean section, which are not in the compass or experience of registered midwives)

  5. Low case numbers (make it difficult to maintain skills and increase experience) and difficulties with respect to training.

  6. Lack of epidural service (forbidden due to lack of Anaesthetists and Midwifery Practice Regulations)

  7. Incomplete anaesthetic cover (unspecialist people can administer an anaesthetic in an emergency, but these leaves them open to litigation)

  8.  Lack of acute resuscitative support for the mother and/or baby

  9.  Need for two obstetricians on site

  10. Transport connections in Caithness (some of the worst in the UK; road journey min. 2 ¼ hours, plus possible ambulance delay, adverse road conditions; train line requires upgrading but unlikely to be completed; air transport non-functional in inclement weather, especially fog, also availability factor)

  11. 11. Lack of junior staff (their presence would enable the consultants to work more efficiently and effectively)

  12. 12. Psychological Effects (distrust, fear and anger)

  13. 13. Changing Decision Parameters

  14. 14. Working Relationships/Openness

  15. 15. Media Statements

  16. 16. Alternative MLU Propaganda

  17. 17. Continuing Medical Education/Continuing Professional Development. GMC Revalidations. (difficulties encountered to update/upgrade training)

  18. 18. Post Partum Hysterectomy Requirement

  19. 19. Severe Perineal Disruption

  20. 20. Retained Placentas

  21. Equipment Standards:
    Laparoscopes
    Colposcope
    Urodynamic Equipment

Requirements

  • Proper and safe facilities

  • Patient acceptability of services and its limitations

  • A genuine consultation process without fear of NHS Highland reassessing the service, but rather showing a desire and willingness to find a way to provide that service (not excuses)

  • Suitable staffing requirements, with long-term planning in place to provide happy and secure working conditions for staff

Proposed Alternatives for consultation
Outlines the 8 possible alternatives for services at Caithness General Hospital proposed by the Board

  1. Consultant led 24/7 service with locum support

  2. Rural Maternity Centre with single handed resident specialist doctor (9-5 Monday to Friday)

  3. Rural Maternity Centre supported by a Consultant Outreach Service (2-3 days per week)

  4. Midwife Led Community Maternity Unit with weekly outpatient consultant support in Wick

  5. 2 Full Time Consultant service working Monday-Friday 9-5 including night time on call

  6. A service run as a satellite of Aberdeen

  7. A service run as a satellite of Aberdeen and Inverness

  8. A service providing ante natal and post natal care only, with all deliveries in Inverness

Opinion

  • Only options 1 and 8 fulfil most of the criteria

  • Option 8 does not remove the real emergency delivery requirement in Wick

  • Status quo is not an option, but a radical re-think of the organisation at Caithness General is required.

  • Cutting service provisions will make the unit less viable eventually to the point of inevitable closure

  • Core facilities to be retained at local level:
    Casualty
    Obstetrics and Gynaecology with similar emergency facilities
    Medicine in all its parameters for both young and mature
    Imaging facilities to complement those specialties
    Physical/nutritional facilities to aid the healing process
    Laboratory facilities (as full as possible)
    Adequate anaesthetics
    Each core discipline to have at least 3 consultant staff
    Expansion of services provided where possible, i.e. local ENT, Orthopaedic, Opthalmological, Chest Endoscopic work and Urological work, will increase skill level and job satisfaction of staff

Conclusions

  • “Only option one fulfils the majority of criteria required for patient and foetal safety but not as the status quo. The problem needs to be looked at from the perspective of all the services at present provided in Wick, especially those that impinge on the Obstetric services directly.

  • There would need to be planned rotation / visiting to Raigmore to ensure there was an upgrading of skills where necessary, together with the ability of the consultant and other staff to liaise and interact in a team building manner.

  • Caithness and Raigmore should be seen as one hospital, but on 2 sites, with similar local services in all the basic core disciplines.

  • There may be a need to provide a ‘Remote Incentive’ as occurs in the outer island jobs, either as a set amount, or in the form of 2 extra sessions premium per week. That would still be cheaper than locums and would sweeten some of the less palatable facets of remote hospital, and non junior staffed appointments.

  • In fact the training available in such outlying units does give a lot of hands on experience to GP type trainees, although they would need to go to Raigmore to be sure of getting experience with forceps assisted deliveries. As happens from the Western Isles.

  • The Medico Legal and Risk management perspectives need to be addressed by one of the 9 panel members of NHS Litigation Defence Board. One of which is Capsticks Solicitors. A contact for that company is; -
    Mr Tom Hayes of :- Capsticks Solicitors,
    77/83, Upper Richmond Road,
    London, SW15 2TT.
    Tele:- 020 8780 2211; Direct 4738
    Fax :- 020 8780 1141; Direct 4728.

  • The opinion of such a risk management knowledgeable company should be sought before any other considerations are entertained. In view of both the inclement weather, the long journey times and the fact that there is only one road south. Unlike the situation in Fort William where there is an alternative road to Glasgow, which might be open when the Inverness Road is closed. But, even there the journey distances & times are medico-legally likely to be ‘too far’.

  • Finally, I must apologise for my amateur presentational and typing skills. We only have one gynae sec/manager and she has more important things to do looking after patients and GP’s needs to waste her time on this paper. Which confirms the point that the Dept needs another secretary if it is to be able to get letters out to GP’s within 24/48 hrs of a clinic or operating session, which should be the default standard in clinical medicine.”

Possible means of staffing continuity solution

  • Appoint staff to dual job planned roles, such as Consultants or Associate Specialists, Staff Grade in
       Obstetrics & Gynae, Paediatrics and Anaesthetics.

  • Junior staff working under more senior consultants

  • Appointing two staff at each level, to rotate within generalised jobs on a 3 monthly basis.

  • Proper accommodation in Wick that staff could utilise without stress or delay