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:
-
Non-availability of an ambulance (can take up to 6
hours)
-
Additional delays (traffic, bad weather)
-
Pre-term and precipitate deliveries
-
Foetal distress (can require emergency caesarean
section, which are not in the compass or experience of registered
midwives)
-
Low case numbers (make it difficult to maintain
skills and increase experience) and difficulties with respect to
training.
-
Lack of epidural service (forbidden due to lack of
Anaesthetists and Midwifery Practice Regulations)
-
Incomplete anaesthetic cover (unspecialist people can
administer an anaesthetic in an emergency, but these leaves them open to
litigation)
-
Lack of acute resuscitative support for the
mother and/or baby
-
Need for two obstetricians on site
-
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. Lack of junior staff (their presence would enable
the consultants to work more efficiently and effectively)
-
12. Psychological Effects (distrust, fear and anger)
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13. Changing Decision Parameters
-
14. Working Relationships/Openness
-
15. Media Statements
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16. Alternative MLU Propaganda
-
17. Continuing Medical Education/Continuing
Professional Development. GMC Revalidations. (difficulties encountered
to update/upgrade training)
-
18. Post Partum Hysterectomy Requirement
-
19. Severe Perineal Disruption
-
20. Retained Placentas
-
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
-
Consultant led 24/7 service with locum support
-
Rural Maternity Centre with single handed resident
specialist doctor (9-5 Monday to Friday)
-
Rural Maternity Centre supported by a Consultant
Outreach Service (2-3 days per week)
-
Midwife Led Community Maternity Unit with weekly
outpatient consultant support in Wick
-
2 Full Time Consultant service working Monday-Friday
9-5 including night time on call
-
A service run as a satellite of Aberdeen
-
A service run as a satellite of Aberdeen and
Inverness
-
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.
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Junior staff working under more senior consultants
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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
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