Eye On Index

Maternity Issue

Executive Summary of Report on Service Provision At
Caithness General Hospital
Of
Obstetric & Gynaecology Facilities.
By
Mr Brian Valentine.
MB,BS; MRCS,LRCP;D(Obst)RCOG;
FRCS(Edin); FRCOG.
Consultant Obstetrician & Gynaecologist

The Full Report Can Be Found Below the Executive summary

This summary needs to be read with the backup facility of the full report in case explanation or clarification of statements should be required.

1.      The NHS Charter states that medical facilities will be provided for all patients reasonably adjacent to their place of abode. Such services providing a safe level of medical provision at all times. That service being free at the point of need within the provisions arranged and provided by the locally administering Health Authority, in this instance NHS Highland. 

2.      Staff should have facilities provided for Continuing Medical Education and Continuing Professional Development. Being assessed & audited annually to fulfil the national requirements of  Clinical & Staff Governance. 

3.      Patient’s reasonable views must be accepted and dealt with in an open and transparent manner. The views of staff should also be respected and dealt with in a similar manner. 

4.      The above statements have not been complied with in this case, over a number of years and managerial changes. The present NHS Highland Board and the Chairman of the North Highland Community Health Partnership [NCHP] have unfortunately lost the confidence and respect of the local hospital staff, most general practitioners and the local population. 

5.      A multitude of events have occurred in the last 6 months which confirm the facilities for effective onward transfer of the acute high risk patient do not always exist immediately. A 7 hours delay being quotable on more than one occasion. These facilities are not likely to suddenly, or possibly ever, become available  

6.      The road, rail and air transport facilities are all controlled by geography and the weather. At times Caithness has to have full and complimentary facilities to provide care at all levels, albeit possibly only on a holding basis for up to 4 days, because of an inability to leave the area by any modality. This state of facilities is patently absent in all specialities at the time of this report. 

7.      The NHS Board and Chairman of the NCHP have stated their preferred option for accepting the Orkney model of care which would remove the local onsite provision of 3 Consultant Obstetricians and Gynaecologists, with anticipated savings of at least £500,000/annum in staff costs when you take all the financial parameters into account.  

8.      The local midwives have made it clear that whilst they would feel comfortable and competent in running a Low Risk Midwifery Led Unit [MLU] in close proximity to an Integrated Maternity Unit involving medical and midwifery staff working as a team, they do not feel that to be the case in the prevailing circumstances of 110 miles distance, poor road connections and occasionally imposed isolation. That situation is not changed by the suggestion of NHS Highland that Surgeons would provide a Caesarean Section facility. A facility that would have to be based on the diagnostic decision of a midwife + or – a distance telephone based opinion from Inverness.  Midwives not being legally trained or licensed to deal with decision making in abnormal obstetrics. 

            With 35 yrs experience I., and my colleague Dr R Van Huyssteen, can confirm that the only             person who is guaranteed to assess the situation adequately is the person in attendance to the              patient and that person should be obstetrically qualified to the level of MRCOG and ideally             have at least 3 yrs post qualification experience. If you are ever asked an opinion on a case             any sensible obstetrician would state that they will be coming in to assess the patient. You             simply cannot make correct decisions that involve an opinion, rather than permission, over              the telephone. That is how mistakes occur and accidents happen. 

9.      The Midwifery capability will not be enhanced by bringing in ‘Consultant’ midwives unless it is medico-legally agreed that they will be expanding their role into abnormal obstetrical care with anticipated surgical intervention. Should that be the case you would require at least 7 such appointments to cover all the nuances of 24 hr cover on a daily basis. Nurses and Midwives working different time scales to Doctors. Such a change would also change the accepted demarcation lines of care and surgical interventive capability. Such methods of safe practice have been developed over 50 or more years and have seen the Royal College of Obstetricians and Gynaecologists split from the Royal College of Surgeons and the Royal College of Midwives split from the Royal College of Nurses because the disciplines were now considered to be so individually distinct for it to be unacceptable for them to be trained and represented under the charter of a single College. 

10.  The local midwives provide a good distinctive, caring and safe service in an Integrated Maternity Unit. But following the years of managerial indecision over the unit’s viability, and on going certified competence training, their numbers and confidence have been progressively diminished. It is easy to destroy something but to regain the original status quo usually takes 2-3 yrs even in personally busy units. If there were no obstetricians actually on site 24 hrs a day I, and my colleague,  think it likely that a lot of the midwives would resign and go to work in an environment acceptable to their professional satisfaction and confidence. 

Before such a statement is misconstrued as weakness on their part it should be remembered that they are the on-site coalface workers who understand the full implications of the work presented to them. They are not desk bound managers, or oracles, pontificating from afar on something they neither understand nor are capable of comprehending correctly because of their working circumstances. 

11.  The lack of paediatric cover is often quoted as a reason for downgrading the unit. But, if surgeons can be considered a safe option to obstetricians then it would seem more than reasonable to consider that physicians, possibly in combination with anaesthetists on occasions, could also cover that service entity. The Royal College of Paediatricians has continuing close examination links with the Royal College of Physicians. But, the local Consultant whilst mentioning this stated he would have to be seconded for at least 6 months to be fit to provide such a service, and what would happen to his work in such circumstances. It is always easy to send junior staff off for training but not easy to dispense with the Consultant lead, especially for a protracted length of time and in a Consultant staffed unit such as Caithness General.  

On a resuscitative note the present consultants and staff have just completed a Neonatal Resuscitation Course and been duly certified. Something that would not be likely in bigger units but confirms the local desire for professional development and certification for the patients benefit. Availability being the biggest problem. 

12.  The generally accepted number of cases required before professional competence is

considered to be 50 in both Obstetrics & Gynaecology and Surgery. To allow a surgeon a certificate of competence below the number of cases would make him an exception to a national standard. That may be perfectly fair but if the lawyers were ever to become involved they would not view it in the same light. Ideally a baby should be delivered within 2 minutes of the original skin incision. That is not as easy as it sounds and the slightest delay for whatever reason will quickly push the skin incision / delivery interval into a progressively dangerous range. Even if you have onsite paediatrics obstetricians find this anxiety provoking because it represents an increased risk for the foetal brain. 

13.  There is often a need to have two pairs of hands covering differing departmental entities. This fits in with the recommendations of the RGOC that a Consultant presence is always available for the Labour suite. 

14.  Of the stated options only 2 have validity. Either: - 

a)      The unit is closed down and all deliveries occur in Inverness, which for the reasons previously stated is a logistical impossibility at times. 

b)     The unit functions with a minimum of 3 suitably Obstetrically Qualified Staff. If 4 were available it would also be possible to provide outreach clinics in Golspie etc which would relieve the pressure on Inverness and most likely increase the use of facilities in Caithness. 

15.  The hospital at Wick has been well described as well appointed and the newest hospital in       the Highlands. Whilst that is true it should also be stated that it has been run down as regards staff. For a multitude of reasons but none of them good enough to survive investigative scrutiny. 

      All departments appear to have recruiting problems, none more so than Anaesthetics.       Without anaesthetists all departments dysfunction and it would not be unreasonable to ensure a constant 3 man anaesthetic presence, even if that requires the appointment of 4 staff intoto. Such staffing would allow an epidural service to be implemented again, whereas at present patients wishing this service have to go to Inverness. 

16.  If  substantive posts were advertised I think it likely there would be applicants. Especially if       such appointments were properly linked and rotated with Inverness. Inverness require more       Consultants and it would not be impossible to link 2 similar posts so that one worked in Wick for an agreed period, the other working the Inverness base. Such job share schemes are not anything new, except in the separation involved in this situation. There is no reason why such posts should not have a sub specialisation role, indeed on would expect it to be the case.

 17.  Rather than closing Caithness General facilities they need to be expanded across the board so that intensive care and paediatric care are available locally. That would mirror the situation in the Western Isles and allow 90+% of mothers to deliver locally, and safely.

 18.  The imaging facilities must also be expanded in both Thurso and Wick. The fact that an MRI scanner funding has not been taken up my management because of the revenue costs is less than acceptable. The wait in Inverness is up to 9 mths and yet a local facility could be run by a radiographer and the images transferred to Inverness for interpretation. My patients not only have to wait for this procedure but have to travel 220 miles round trip to receive it.

 Brian Valentine
12th November 2004

Report on Service Provision
At
Caithness General Hospital
Of
Obstetric & Gynaecology
Facilities.
By
Mr Brian Valentine.
MB,BS; MRCS,LRCP;D(Obst)RCOG; FRCS(Edin); FRCOG.
Consultant Obstetrician & Gynaecologist.

Preliminaries.
This report is based on a total of 22 weeks actual working in the above department. A very short time in the circumstances, but more than most of the Non Medical and Nursing qualified Health Board managers who have been driving the protocol for change.

The period can best be termed ‘difficult’, or challenging, according to your use of phraseology. Due to the constantly changing service circumstances produced managerially. The summation of past expressions by management; coupled with the short term but constantly changing, staffing arrangements, together with an absence of any promise of long term continuity of a 3 Consultant 24/7 day service [The Status Quo], has lead to an exodus of staff at all levels, as well as the anticipated lack of confidence and working place enjoyment.

I have read the following reports: -

1. A Framework for Maternity Services in Scotland. NHS Scotland.
   Scottish Executive. Working together for a healthy, caring Scotland.

2. Implementing A Framework for Maternity Services in Scotland.
   Overview report of the Expert Group on Acute Maternity Services. [EGAMS]
   Scottish Executive. Working together for a healthy, caring Scotland.

3.  Maternity Services in Caithness and Sutherland.
   Known as ‘The Calder Report’.

4.  Maternity Services in Caithness.
   Important Information for Women and their Families.
   Issued 16 April 2004.

5. Dr Valentine paper:- Initial impressions on Service Provision of Obstetrics and
   Gynaecology at Caithness General Hospital. 1 June 2004.

6. Maternity Services in Caithness General Hospital. N Hobson Director of Nursing
   [Operations] & P Martin Deputy Chief Executive [Modernisation]. Draft 3

I have attended: -

1. Review of Maternity Services in Caithness.
   A Workshop Programme on 19th May 2004 at The Portland Hotel, Lybster.

2.  Review of Maternity Services in Caithness. 2.
   A Workshop Program me on 9th June 2004 at The Portland Hotel, Lybster.

I am aware of :-

1. The comprehensively Newspaper reported difficulties of Ambulance provision, especially on an immediate, and as required basis. The problem appearing to be from the aspects of both staffing and vehicle provision.

2. The proposed, but yet to be finalised, provision of new air ambulance facilities.

3. The intended long term improvement of the direct rail, and road, facilities to Wick.
    

I have read and refer to:-

1. Evaluation of an experimental midwife-led unit in Scotland.
   Mahmood T.A. Journal of Obstetrics and Gynaecology(2003)Vol.23, No.2,121-129.
   Forth Park Hospital, Kirkcaldy,Scotland,UK

2. A free-standing low-risk maternity unit in the United Kingdom: does it have a role?
   K.Reddy, P W Reginald, J E spring, L Nunn and N Mishra.
   Journal of Obstetrics And Gynaecology (June 2004) Vol. 24, No. 4, 360-366
   Slough and Ascot Hospitals. Heatherwood & Wrexham Park NHS Trust.

3. HTA abstract20040231. Centre for Reviews and Dissemination.
   Free-standing midwifery-led units.
   FischbacherC. Free-standing midwife-led units.London: Bazian Ltd (Editors), Wessex Institute for Health Research and Development, University of Southampton, 2004;20

Problem being addressed.
Provision of acute obstetric and gynaecological services to the Counties of Caithness & Sutherland. The Northern Community Health Provider [CHP] of the Highland NHS Health Board.

Conditions.

1. Best possible safety for mothers and babies consistent with facilities, their home location and personal wishes. As stipulated in the NHS Charter.

2. Workload adequacy for maintenance of professional confidence and reliability of, both the Medical Obstetrics & Gynaecology Staff, Anaesthetic Staff, Theatre Staff and the Midwifery Staff.

3. The provision of ongoing study leave for the upgrading of the Staff knowledge base, and the provision of locum staff to ensure continuation of a viable service during such absences. The period of conferences and courses being dictated by external sources.

4. The requirement of continuing ‘hands on’ experience by all grades of staff employed in low number remote and rural units.

Discussion
If there was an easy answer to this problem, and some of the leading managers and Health Board Officials give the impression that there is, then none of the above reports and meetings would have been necessary. Therefore, whatever the final decision there are going to be parties at various levels of Medical, Midwifery and lay groups who will feel their views have been ignored, overruled, rejected or a combination of all 3.

Basically, it is simply a ‘no win’ situation because of the attitudes displayed on both sides. These have destroyed trust and confidence &/or hardened resolves. It will therefore be imperative that the final decision is seen to be totally independent and fair. At which stage all the parties must be seen to back the decision wholeheartedly and not continue with a battle that has already been lost. I have greater anxiety of such a negative response from the Health Board staff should they have to forgo their preferred options, than I do from the indigenous population. As long as they know their views have been listened to and acted upon by independent counsel separate from the NHS Highland Health Board. Difficult in the circumstances, but that is where the present conflict produced mentality has taken the problem.

But, the fact that both the GP’s, Hospital Staff and Local Organisations now have been forced to do their arguing through the media shows how much distrust there is of NHS Highland Management and its Board by people who seem to have quite valid reasons for believing that their stated views have neither been listened to properly, and certainly not heard and acted upon. As one would expect to be the case with a government organisation set up to look after the regional and local requirements of the local populations.

I appreciate that the problem is a Scottish Nation wide problem which involves the National Ministerial teams as demonstrated by protests across the country, but that does not reduce the local problem, indeed it makes it even more difficult to resolve calmly, sensibly and satisfactorily for all concerned.

That viewpoint unfortunately comes from experiencing a list of less than helpful expressions on the type of medical staff that can be expected to be found in such a unit, to the verbalisation of statements to the press that are known to be at variance to the facts. If such facts were not known, then they should have been in such experienced senior staff, before they made comment ‘on the record’. For that reason alone malicious constructions have been placed on these statements by the local population. As a public relations exercise in trust and integrity the past few years can only be described as an unmitigated disaster. If the NHS was a private company it is likely a lot of people would have been asked to consider their position due to a loss of client confidence in their veracity, attitude and in depth knowledge of the subject they were reorganising.

The reasoning for the final decision will need to be transparent and openly divulged to the affected population and all levels of staff. Together with the immediate arrangements to be implemented and what extra facility provisions have been made to ensure smooth running of the final decision. [Solution in NHS Highland jargon at public consultation Wick 7-10-04]

The original input of distant experts via the use of consultation documents has, unfortunately, only made matters worse as the public demonstrations have shown. One can understand that the use of external experts was intended to show that there was total impartiality in any decisions being made, or immediately implemented. It was intended to improve the situation but as the experts concerned were visitors for a very short period of time; and to save even more time flew into and out of Wick, the reverse conclusion of a ‘fait accompli’ was not unreasonably assumed. Their Central Scotland work locations were also counter productive. Most people in the area cannot afford to fly in and out of the town and naturally resent others doing so when they might be closing local services on the basis of their findings. Especially if the trip is made in good weather, thus circumventing one of the major anxieties of the local population.

If the committee members had possessed the foresight to travel up to Wick strapped down in the back of ambulances with 10lb medicine balls attached to their abdomens, their opinions might have been better received. Even more so if the journey had been through fog, which is so often present at all times of the year, or even at night in a delayed large lorry convoy procession with its extended travel time.  A thistle head strategically placed might have been used to simulate the discomfort likely in a post delivery lady being transferred to 105 miles because of a badly torn perineum. Beyond the ability of midwives to repair, as well as a 3rd or 4th degree perineal tear involving disruption of the anal sphincter.

Such indifference to people’s anxieties and fears should have been signalled in the minds of the panel as a likely cause of complaint and indeed anger. That it did not seem to occur to them causes anxiety as to their thought processes; as this is exactly what has happened. On such simple errors of judgement, seen only as arrogance by the local population, does a fair minded and credible report destroy its credibility.

Totally unfairly in my opinion as I think the Committee have done as good a job of sifting a lot of facts as one could have expected them to in these difficult, but less than thoroughly investigated circumstances. But, I would have had much more faith in their judgement if they had all actually worked in Caithness for 6 mths or so. A totally impossible thing to have happened of course, but only then do I feel they would have been clearly aware of all the facets of the situation from a local, as against a National perspective. I have only a smattering of knowledge on the subject, but a lot more knowledge of the local perspectives than others with less continuous attachment. My experience has also been ‘hands on’, not desk reported statistics to committee members who, through no fault of their own, could not have any idea of the problems involved with working in a single handed situation in a remote & rural setting.

In this case the problem is local and therefore a local perspective is a lot more important than people from outside the area might either be willing to accept, or for that matter even to understand. Whilst they would genuinely wish to respect that situation, and state their intention so to do with total honesty, when it comes to decision time, with the best will in the world, they would have little ‘gut feeling’ for the ideas and fears they were addressing. That said it is also important to consider the changes and improvements made to medical standards over the years. For this reason it is easy for people from out with an area to consider they are doing the right thing because, to them, it feels sensible and correct. As an outside quorum they will tend to be in agreement if they feel science and their experience supports their corporate views. Hopefully having previously worked in an urban hospital, and improved its facilities to encompass today’s acceptable standards, I hope I can see both sides of the argument and attempt to balance the varying parameters of care.

In the majority of these cases the end result has to be an unusual arrangement designed to fit the local needs. That would appear to be the likely need here in view of location and connection ability to central sites on a 24/7 day basis. Such decisions may not always be ideal for the person who lives in a city, large town or conurbation; but such decisions may well be correct for the people who are requesting their making. Designed especially for the locations in which they have chosen to live, or find themselves living. People in the rural Highlands may similarly be there by desire or because of their work. But, being in that environment their expectations will not necessarily be those of a city dweller or a conurbation dweller. Especially in situations they would consider to be acute, dangerous and life threatening. In fairness only somebody actually living in that situation would be able to fully comprehend such feelings and fears.

The above preamble may seem totally superfluous but whilst I am sure these statements are mentally accepted it does not hurt to refresh people’s memory on things they take for granted as having been accepted by them in their thinking, but not necessarily of such importance to other people from a different life style. The NHS Charter does indeed state that everybody should receive exactly the same standards of care and attention, but that does not, in fact, happen in many spheres of medicine. The Charter also states that the services should be adjacent to their place of abode.

The ladies who live in Caithness, but have been treated in Inverness and transferred back, will be grateful for their care but even more grateful to be back amongst their families; and generally irritated that they were forced to leave in the first place. Because of the threat posed by Inverness every small problem will be remembered and regurgitated to family & friends or as a complaint on the basis of local solidarity. Unfortunately the obverse attitude will be seen from the Inverness perspective, and valid criticisms unintentionally ignored. Thus fuelling the inbuilt antagonism built up over the years by intransigent attitudes and statements. I understand, and was aware from personal discussions with a now retired Inverness Consultant over many years, that the desire to downgrade Caithness and centralise everything in Inverness has been muted for a good 10 plus years.

The comments I made then were little different to the ones I make now, except that my views are now made with a little local knowledge. At the time I said it was important that a team and equality of facilities attitude prevailed on the basis of ‘one hospital on two sites’; but that situation does not appear to have been reached or accepted/considered.

I would make the point that I offered Caithness theatre time to help clear the Raigmore Theatre list backlog, and the problem of finding enough theatre time. The genuinely considered response from Dr’s Lees [Who stated at the Public Consultation that he had written to his patients and audited their response.] and Reid was that their patients would find it an unacceptable distance to travel for operations. Presumably a 200+ mile journey would be too much for a generally healthy lady to travel for day care surgery. The recurring journeys by family to visit major cases would also be unacceptable. One can understand the views of such patients and their families when they have a facility on their doorstep. But it should be realised and accepted that there are a lot of ‘doorsteps’ that could be used for such work in the Highlands, with differently planned staffing arrangements. But most of those appear to be closed at the present moment and would require a lot of expense to re-open them. As is always the case when one has to reopen any service that has been closed down for one reason or another, be it a short or long term closure.

One should, therefore, be able to understand the deep feelings of people who have a service on their doorstep but are seeing it closed by officials who do not live in the area. The same can be said for the ready acceptance of patient transfer in labour, or for other reasons to Raigmore in an ambulance, if one is available, in inclement weather. The dangers being recently demonstrated by an ambulance crashing, in fog, with a cow. Luckily, on return from Raigmore having delivered a physically distressed, prematurely delivered baby in an incubator! Equally luckily no human damage occurred, but the same could not be said for the ambulance which was unserviceable. The cow was less lucky and was killed by the force of the impact. Assistance was not swift in attending due to the logistics and the weather.

Problems encountered over 5 mths.
During the last 5 months the following problems have occurred on at least one occasion:-

1. Non availability of an ambulance
Non availability of an ambulance for 6 hours. The last ambulance to leave Caithness was taking an emergency patient with psoriasis to Raigmore from Casualty. Luckily, the patient was female and did not mind sharing her ambulance. Equally luckily my patient had a skeletal, rather than a foetal problem and was happy to travel with another lady.

If the problem had been foetal I would have had to commandeer the ambulance on a priority of care basis. Similarly, if the other patient had been male. Although I was quite glibly informed that no other ambulance would be available, and in Wick, within 6 hrs! I doubt the other patient would have been happy if delayed for that length of time, and neither would my patient, her husband or I have been in acceptance of such a delay.

This is not the first time an ambulance has not been available, even for an  emergency, for 2 to 3 hrs. Even cases of foetal distress and pre eclampsia with nervous system involvement requiring Magnesium Sulphate administration and possibly intensive care/high dependency care have had to wait for an ambulance to be ready to journey up to Wick [21/2 hrs average], before being able to load up and return to Inverness. Turn round time could take from 30 minutes according to medical and family circumstances.

The Newspapers give out the facts, which are denied by the Ambulance Service hierarchy in Inverness. But, when you speak to the ambulance staff on the ground they confirm the honesty of the media. Anyone who does not toe the party policy of adequacy appears to be fearful of being considered, by higher NHS management, to be suspect and not a reliable witness. That may not be true but it does not change the fact that it is a perceived truth which is very worrying for staff.

But, the public consider that to be a more relevant comment on the veracity of NHS Highland in all its different guises. There is simply no trust in the organisation and its various pronouncements and that is exceptionally unfortunate, and needs to be reversed as soon as possible, if a resolution to these problems is ever to be accepted.

Specifically regarding the ambulance crash in fog, with the writing off of that ambulance for a period of time. I understand there is no substantive supporting facility of old retired ambulances that can be utilised in such circumstances

1. Rather as the Government mothballs ships and planes in case of an emergency requirement either for increased numbers in an extreme emergency, or to allow unexpectedly damaged vehicles to be repaired and returned to a duty role. There is only one spare vehicle which is based in Thurso and serves as the reserve for the whole of Caithness & Sutherland. I believe the service was basically an ambulance short for this unanticipated period of repair, I have been informed by people who are aware of the Services circumstances.
    

2.  Additional delays
   If you add the Berriedale delays into this equation, even with the new calls for a by-pass to overcome this problem, you have yet another negative factor to be considered in the evacuation time assessment.[John O’Groat Journal 17 Sept 2004] I appreciate a lot of money has been spent improving Berriedale this summer, but the basic problem of terrain and location in bad weather has not altered.
    

3. Preterm and precipitate deliveries
   There have been several premature and precipitate deliveries. The baby being delivered within a ½ hr or so of attending the department. In most cases there was a period of transient foetal distress which was adequately dealt with by the Midwives and/or Anaesthetists.
   
   Such a delivery led to the requirement to transfer the crash case baby to Inverness in An incubator. Luckily the Inverness paediatric resuscitation sister was in Wick and arranged for the therapy and transfer of the baby to Inverness. Equally luckily the ambulance crashed on the way back to Wick with the returning staff and not on the journey down to Inverness.
   
   A not inexpensive way of returning staff to their base hospital, but most likely cheaper than a taxi, especially if the vehicle has to return to Wick to go back on station. But, staff can often be held up in Inverness for extensive periods of time before being returned to their base/home. Such delays tax natural goodwill and affect relationships within family units. Often leading to decisions within the family to move in order to have a more stable and managerially supported home life. Or simply to give up Nursing or Midwifery in order to have a more normal, and appreciated life style.
   
   I appreciate such decision making occurs within other government services as well as private organisations. But, the NHS has actually stated that one of its main aims is to improve family life for its staff. When such a transfer is taking place the return of staff to base should be addressed and organised whilst the transfer is occurring. That does not describe the present situation.
    

4. Foetal distress
   Acute foetal distress with meconium staining has occurred on several occasions necessitating a quick caesarean section or an assisted delivery by high ventouse or Forceps. Non of those priority deliveries would be with in the compass of, or experience of, a Registered Midwife. There are some midwives who are capable of, or trained to do, low level assisted delivery by forceps or ventouse/kiwi apparatus, but they do not exist in the Highlands and even if one was appointed you would require 4 WTE’s to allow service continuity through all eventualities.
   Arguably an assisted delivery should never be attempted if you do not have the onsite capability to perform a Caesarean Section if vaginal delivery should prove impossible. I have personally attended ‘flying squad’ services to remote GP units and patients homes, where there has been obstruction to delivery and foetal distress, in the days when it was considered safer to take the doctor to the patient. Often, in arguably sub optimal conditions one achieved success and either left the baby at home with mother and midwife, or took mother and baby back to the safety of the bigger unit.
   But, occasionally the baby would not deliver and all you did was make a bad situation worse, especially if an anaesthetic had been given and a tension pneumothorax produced, as can also happen with pushing in a prolonged obstructed labour. Inserting a urethral catheter as a chest drain bubbling into a jam jar, transferring the patient to the hospital, having arranged a police escort and
   the closure of all road junctions to ensure a smooth journey was all part of the job, but it was both dangerous to the patient and stressful to her family. Hence ‘flying squads’ became a thing of the past, but we should remember their hazards when we contemplate delivering babies without full facilities for all forms of emergency care by Speciality Trained Staff i.e. Not GP’s or General Surgeons trained to perform the ‘odd forceps or Caesarean Section’ as a managerial exercise to suggest acceptable cover. Quite simply neither suggestion is medico legally acceptable in this day and age and the suggestion by NHS Highland managers that it is acceptable suggests either extreme naivety, or a desire to bamboozle the local population whilst in fact insulting their intelligence. At one time all obstetricians were members of a Surgical College but the Royal College of Obstetricians & Gynaecologists was formed 50 yrs ago because the lack of specialist knowledge by General Surgeons was detrimental to mothers and babies care. I would suggest we accept that decision was sensible and not try to re-write history and put the clock back to satisfy politicians and non medically trained managers. I gather it took 40 yrs to get the correct staffing in Caithness, it would be a shame if People ignored the reason for that giant step forward for the obstetric and gynaecological care of ladies in Caithness & Sutherland.
   Everybody is very aware that Mr David Alston, Deputy Board Chairman and Chairman of the Northern Community Health Partnership favours the Orkney methods of practise. But, I understand that Orkney never gets ‘cut off’ due to bad weather because of the Gulf Stream Drift and the high winds; which diminish the risk of fog at Kirkwall Airport. Which is not the case in Caithness.
    

5. Low case numbers
   Whilst the Caithness & Sutherland Midwives are generally very experienced and deliver high standards of midwifery care the lack of delivery numbers has lead to a diminution in some of the Midwives confidence, and also their chances to expand  their experience. The same would occur with any doctor who practiced in Wick for a number of years. The reduction in experience would be improved on both fronts if the facility to treat patients locally, as happens in the Western Isles, was enhanced.
   
   That said the core competencies of midwifery skills laid down by EGAMS are the foundation of all training requirements. Training and skills updating being considered a high priority. Currently Advance Life Support in Obstetrics[ALSO], Advanced Neonatal Resuscitation Programme[NRP] and the basic Intravenous cannulation, Perineal suturingand Drug Administration Courses are pursued.
   
   That said it is likely that the Consultants do as many personal Caesarean Sections, as the Inverness Consultants, as they have no training role for SHO’s and Registrars. They will certainly do more forcep/ventouse assisted deliveries as that is invariably the prerogative of Senior House Officer’s{SHO’s}, Staff Grades and Registrars in larger units.
   
   It is difficult to maintain skills and learn new ones in a small remote and minimally staffed unit, especially with low delivery numbers. For this reason many staff are forced to undertake training in their own time and at their own expense, especially the trainers. They then fit training sessions around the working day which saves the NHS the problem of staff shortages. Going off to a Study Day even to Edinburgh requires at least 2 days travel and the backfill for covering extra shifts at such times.
   
   I found this out for my self recently when I was invited to attend an Inaugural Conference on Delivery Facilities. To attend I had to fly down the previous day and then stay until the 3rd day to catch the next available plane back to Wick. I had to forgo the conference due to clinical requirements, although I will be able to attend an Advanced neonatal Resuscitation Programme as that is being held in Wick for 12 members of Staff.
    

6. The lack of an epidural service
   The lack of epidural facilities has meant that patients who wish to have an epidural, or who are likely to require one in labour, need to be selected out and sent on to Inverness. This problem is produced by both a lack of Anaesthetists, who cover all Specialties, and cannot be expected to ‘top up’ the epidurals, and Midwifery Practice Regulations. However, it is also something most midwives have been taught to do, but are ‘forbidden to do unless there is an anaesthetist resident in the hospital’ by their Midwives Regulations.
   
   Therefore we have a ‘Catch 22’ situation. The only way round this would be a local protocol allowing the use of a continuous epidural pump. Which did happen with a previous anaesthetist who was happy with this degree of written protocol responsibility being given to the trained midwives. But, I gather that if training facilities had been provided at Inverness then there would still be a problem as they do not use this technique. If that situation was altered the problem would not exist, but it would be impossible to train the Midwives ‘on site' in Wick in the present circumstances.
   
   Interestingly I am reliably informed that an epidural service was available in Wick prior to being available in Inverness. It just had to be terminated due to the working conditions imposed on the midwives, but that at least confirms there is no fear of their encompassing advances for their patients care and comfort, as well as the support given to babies in mild intra uterine distress.
   
   The one lady I sent to Raigmore for such a service ended up with a Caesarean section and a flat baby that require the support of the Special Care Baby Unit for a few days. Which makes a point, although on perusing the notes and investigations I think I would have operated earlier and possibly reduced the likelihood of such a need. But, if I had I would most likely have been quoted as a statistic by Mr Alston, the Chairman of the Northern CHP when he suggested we performed more Primiparous Caesarean Sections in Wick in the local newspaper, possible because we did not have a Special Care Baby Unit. It might also be that in Wick the person who sees a case is a consultant rather than a junior member of staff acting on instructions.
    

7. Incomplete anaesthetic cover
   Anaesthetic absence has occurred where by the on call anaesthetist informed me he had to take a medical patient to Raigmore, and there would not be any anaesthetic cover until his return in approximately 5 hrs. Luckily, the ‘balloon’ did not go up in that time, and we had nobody in labour when he left Wick. I accept I can perform an Epidural or Spinal Anaesthetic in an emergency, but if anything untoward happened I would be ‘hung out to dry’ medico-legally and nobody would remember the circumstances that lead to the situation. Quite rightly so in my opinion because such a situation should never be allowed to occur by management. The GMC and the Royal Colleges would give me no support either. This is the Medico-legal world we work in, but it is so designed to ensure the best safety possible for patients.
    

8. Lack of acute resuscitative support for the mother and/or baby
   There is a lack of ability to hold and deliver cases that show signs of Pregnancy Induced Hypertension in case of deteriorating maternal or foetal condition that can ‘go bad’ during delivery or the delivered foetus requires Resuscitative Support or Paediatric intervention. Such cases are deliverable in the Western Isles due to their more enlightened attitude to the needs of Remote and Rural Hospital facilities. They insist on having an onsite paediatrician who can arrange transfer later if required. I gather they deliver 99% of their ladies locally.
   
   Thus ensuring maximum training and hands on experience for the midwifery staff, and to a lesser extent the Doctors. They also have an epidural service. I gather their maternity numbers are 200 cases a year, as against Wick’s 250.
   
   Dr Russell Lees stated at the public meetings that he would happily arrange his planned Caesarean Section list in Wick, because he would bring his paediatric cover with him. But, that would beg the question of what he would do if the baby needed transferring to Raigmore, and what level of paediatric staff the Raigmore Paediatric Dept would send to Wick. In Raigmore it would be an SHO initially, possibly in GP Training, covered by a registrar if required and then a Consultant in extreme circumstances. A perfectly normal arrangement in such a unit.
    

9. Need for two obstetricians on site.
   It has been shown that you need 2 pairs of hands on site if one of the Medical staff is tied to a fixed session in Wick. The tied colleague cannot leave a theatre list or single handed out-patient clinic to attend to problems on the labour suite or Casualty. Whilst such cases do not occur very often you have got to work to the lowest parameter for safety, not an assumption that people will cope when the problems compound and occur concurrently. Whilst I was in the middle of a hysterectomy the labour suite had a foetal heart at 60 bpm at full dilatation and bleeding. Dr Erinle dealt with that, only to be confronted with the need for a second forceps deliver for foetal distress and meconium drainage. Neither of these cases had been signalled, they simply occurred in the 2nd stage of labour, as happens in ANY obstetric department. Luckily we had the pairs of hands to cope without being thrown into chaos and the patient’s babies being put at risk.
   
   If I had been single handed, or he had been in Thurso, or even Golspie I now hear the Inverness Head of Department has requested, there would have been problems not only for that baby but medico-legally for the trust for not having somebody freely available to attend labour suite as and when required. That is the National Standard and must be adhered to if the trust does not wish to expose itself to litigation. It is why the Royal College of Obstetricians and Gynaecologists has insisted on increased numbers of Consultant sessions covering the Delivery suite during the normal working day when junior staff may be committed to more than one task. As we have no junior staff it is imperative a consultant is freely available.
   
   (Example included in the original not included here.)
   
   We can be called to Casualty, as well as the labour suite, and on occasions there is no accredited radiographer for obstetric scanning, so we are expected to fill that gap as well, but without the same degree of specialist training.
   
   Then there are the constant telephone calls from GP’s, and other staff, requesting advise and distant decision making. You cannot answer such calls if you are not freely available, and that means unscrubbed for any planned interventions. Other people also have work to do and cannot be expected to await your availability when they have a patient sitting in front of them.
    

10. Transport connections in Caithness
     Transport connections in Caithness are acknowledged to be some of the worst in the UK. The A9 is a bad coastal road which is being constantly upgraded piecemeal, but still contains adverse cambers in areas that are known to be susceptible to ice for at least 4 months of the year. Berridale has been publicly described as ‘a road more worthy of horse and cart transport than today’s vehicles. (Caithness Courier.6 10 04. MEP for Sutherland.)
    
    The road journey time to Inverness will never be less than 2 hrs 15 minutes, but could be considerably more in adverse conditions, be that traffic, fog, ice or snow. If convoys are running during the winter then the delays can be measured in hours rather than minutes. Add to that the possible delay factor of 6 hrs before an ambulance arrives and the figures speak for themselves regarding the safety of mothers and babies. The paramount concern so often stated by the National Politicians and Ministers, Chairman and Board Members of NHS Highland and Raigmore based Paediatric and Obstetric Consultants.
    
    Whilst I appreciate police cars are now filling in the gaps for the Ambulance Service, or the police are driving the single staffed ambulances because the  ambulance man is required to look after the patient in the back of the vehicle, I do not think it is fair, or reasonable, to expect them to do that with pregnant ladies in the distress of labour and the anxiety of a long and potentially dangerous journey due to problems with their pregnancy or their labour/baby. {The John O’Groat Journal 10 Sept 2004} The train line is being considered for upgrading and a more direct route, but that is not a priority and is unlikely to be completed within the next 10 yrs, if ever. Trains also find it difficult to run when there is snow on the ground, especially when the line is little used, as is the case with the Wick line. Fog also has an effect on speed even on a single line track. Points ice up, as do roads, and the whole journey becomes a nightmare, as well as dangerous to both the patient and the carers.
    
    Unfortunate, but none the less ignorant comments made by the Highlands Health Board Senior staff that accidents can happen at anytime simply ‘beggar belief’. Whilst they can occur ‘de novo’ in the normal act of travel that is generally planned travel that has to take place in the normal course of events. In the case of patients being transferred from Wick to Inverness due to planned reduction of facilities and services the situation is totally different. So, I imagine would be the legal responsibility for intentionally producing that situation.
    
    It would be interesting to know how readily the ‘planners’ of this situation would accept personal legal and financial responsibility for any disaster that should occur to anybody being forced to undertake such a journey in hazardous conditions. The operative word would be ‘personal’ in that they should be responsible personally for any legal charges that might occur, as well as the litigation costs. It is always easy to make and enforce disastrous views on to people when ‘Government’, in the form of the tax payer, will be picking up all the complaints and legal bills. Totally different should you be the person who could be on a charge of corporate manslaughter for your incorrect, and imposed actions.
    
    Especially if imposed against the stated will of the populace you are supposed to be representing and serving. As Mr Gerry Coutts has been quoted in the press as accepting; 90% of the local population are anxious, and scared, of the decisions being imposed on them for ‘their, and their babies benefit and safety’ by people they have not elected and, regrettably, in whom they have little or no trust or confidence.
    
    The use of air transport, whilst seeming to be the ideal answer, is also non functional in inclement weather. There is also the availability factor, once again, and that can be a lengthy period, especially if there is a lack of planes or helicopters as appears to be likely with the new, cheaper, air contract being drawn up. The managers will always seek to reassure people that the service will be better, but they fool nobody, except possibly themselves and their political masters. People know that you only get what you pay for, no more no less, especially if you are dealing with a non governmental organisation that has to breakeven at the very least.
    
    In closing this section it should be remembered that fog can occur in both the summer and the winter, and indeed the ambulance that crashed did so in the summer. Also, I understand that if fog closes in the planes are diverted to Kirkwall, as, I gather, has happened with meetings at Dounreay. People attending those meetings arrived late from the Orkney’s. That may be acceptable for a meeting on Nuclear Energy, but in Obstetrics one is not blessed with such a time scale when someone requires immediate transfer to a secondary, or tertiary unit. That is the crux of this clinical situation and cannot be altered by the wishes of politicians, managers or medical staff whose intentions may be honourable but cannot be fulfilled with the constantly media stated desire of optimum safety for mother’s and babies.
     

11. Lack of junior staff
    With a total lack of junior staff the amount of time that can be involved in providing a composite service cannot be fully appreciated by Consultants who do have junior staff upon whom they can offload some of their basic workload. That does sound very obvious, but until you actually work in that mode you do not realise just how much is entailed by such a working practice. Even the surgeons and physicians working locally would have difficulty understanding as they have junior staff. A single handed GP would have the clearest concept of such a working practice.
    
    If there is a call from a GP, community midwife or patient, then the Consultant will be bleeped, regardless of their location. You can receive 2 to 6 such calls a day. If the consultant has to attend a meeting somewhere then his clinic or list has to be shut down. There is no Registrar to keep the service running under the cover of another onsite consultant.
     

12. Psychological Effects
    The protracted time of Service uncertainty has produced both fear and anger in the
    patients and their families. A situation not improved by the media coverage of the contract termination of the 2 polish doctors. Rightly or wrongly the patients and their relatives are certain the whole situation was contrived by ‘Inverness’. Whatever the truth of the matter that is an opinion they are unlikely to change, whoever assures them otherwise.
     

13. Changing Decision Parameters.
    The constantly stated views of the NHS Highland Board and Raigmore Managers has convinced patients and their relatives that the Consultation document is totally biased and is a statement of impending intent and certainly not a Consultation document in any shape or form. Regardless of what was said at the public meetings to the contrary.
    The comments of Dr Neville Jones, of Mid Clyth, in the John O’Groat Journal on Friday Sept 17th 2004 sums up peoples views both honestly and cogently. But, people ‘know’ that neither the Board nor the Government in the person of Mr Chisholm, the previous Minister, have any intention of listening to what they are saying. Especially as the medical planners and Professors are intent on a centralised service across Scotland. A view confirmed at his first interview by the new Minister, Mr Andy Kerr.
    
    How you get over that problem is difficult to imagine, and it is a problem that is taxing Government in more than one sphere of activity as we all know from the recent demonstrations in Whitehall and ‘invasion’ of the Chamber. But, if somebody does not show a positive listening response in this matter, when the majority is against a politically orientated and financially driven minority, then anything could be possible even with such pleasant and generally ‘laid back’ people as those who reside in Sutherland and Caithness.
    
    You can only take advantage of people’s innate pleasantness and tolerance so far, and only then if you are totally and scrupulously honest, and that has patently not been perceived to be the case here.
    
    If the patients decide to pursue a policy of delivering in Caithness then every delivery will be an emergency and there will be tragedies. Whilst I appreciate the Health Board will place blame on the patients shoulders, both medically and legally, it should be anticipated that in view of the prevailing local wishes a legal defence of the patient’s rights under the stated NHS Governance proposals would be likely to occur. Possibly through the European Court, if unsuccessful in Scotland. The law is never a cheap option and would only waste monies that would be better spent on providing local medical facilities.
     

14. Working Relationships/Openness.
    (Example included in the original not included here)
     

15.  Media Statements
    A similar attitude to the treatment of the Caithness Consultants as second rate, which has also emanated from the Raigmore Management and Consultant Staff in the past, and may indeed be the reason for the Midwifery & Nursing Staffs anxieties, must cease. One appreciates that not all Locum staff are on the Specialist Register of the GMC, but the way that cause has been trumpeted loudly is a little annoying, especially when a patient asks you if you are a ‘proper Consultant, because Mr Nigel Hobson and Dr Russell Lees have stated that the Caithness Consultants are only second rate doctors?’ I am lucky and can say that I held a Consultant post for 19 yrs and took early retirement on mental health grounds as I was ‘Burnt out’.  For which the NHS accepted full managerial responsibility. But not all doctors would be willing to be so open, nor be able to confirm they had held such a post.
     

16. Alternative MLU Propaganda
    The continual statements on the efficacy of Skye, Lochaber and Orkney only give the impression that the Health Board have made up their minds and are not in fact listening.
    That may not be the case, but it certainly appears to be the case for those that have to listen to these less than ideal ‘facts’. It does appear that these units have had most of their patients withdrawn and are seeing few patients over the year, and even less on a personal numbers basis. That can only lead to a deskilling of the staff even if they do feel more professionally responsible due to the lack of direct medical input. Radical Midwifery has been shown to be pleasant for many mothers, but disastrous for others when the change from normal to abnormal obstetrics is not realised, or ignored by the local staff in the hope that in a ‘little while’ all will be well. It seldom turns out to be the case unfortunately, as any competent midwife working in an integrated unit will tell you.
    The only people who suffer medically is the mother and her child, although the midwife seldom recovers from the error she has produced in her ignorance, often gained due to a reduced work load. Recently Midwives have been struck off for such errors of judgement, but all of them have had small case loads, often only private cases delivering less than 12 cases a year.
    Midwives in busy units may moan and groan about workload, but they generally know what they are doing and the sensible ones revel in the team approach with their Consultant and Junior Doctor colleagues. Admitted there is often a reduced hands on role in such units due to student practical teaching, but even that stimulates the brain and increases the confidence as you control and judge each case individually with the student. The staff who invariably lose out are the managers who have too many other duties to perform to get involved in delivery suite care. The same can be said for Consultants, in fairness, most of the acute work being done by Junior staff. Even cold caesarean section lists will be performed by a junior in most instances as part of his/her supervised training.
    We have well documented evidence that for every 100 cases booked to deliver in such units, 30 at least will be transferred to the ‘mother’ unit, which is generally no more than 15 miles away, or 30 minute from decision to arrival time. Such units that are likely to be cut off in snow [Yorkshire etc] are generally advised to close their doors to delivery and attempt to get all cases of early labour to the ‘mother unit’ as soon as possible. So that one does not get ‘stuck’ with and statistically anticipated, but no less unexpected, problem when time is of the essence.
    
    To hear the chairman of the Northern CHP putting such weight behind the safety and acceptability of such units does not give the local population much hope for anything other than a ‘fait accompli’, whether that is the case or not. It is certainly the way that response appears to me, I have to admit. I can also see the reasons for his anxieties for the future stability of the service, but I do feel that a lot of that instability has been built in, and built upon, by management over the years. At all levels I should add, as is being shown across Scotland due to higher level doctrinaire attitudes not build on patient confidence or acceptance.
     

17. Continuing Medical Education/Continuing Professional Development.
    GMC Revalidation.
    This problem is compounded in remote areas, even with the availability of distance learning facilities. The Royal College of Obstetricians & Gynaecologists [RCOG] insists on a mixed bag of points to ensure your 250 points over each 5 yrs. 50 points sounds easy to obtain when each point is for 1 hrs study/meeting attendance/examination attendance etc.
    
    Without obtaining these points your College accreditation is in doubt and without that your re-validation and re-licensing by the GMC at risk. It is obviously easier to attend courses around the UK from a city base. It is less costly in terms of travel and accommodation than from Wick or The Western Isles/Shetland Isles.
    
    There is a need for a guarantee of such freedom to attend meetings, if needs be by the provision of locum cover if the course does not fit in with the Lecrest Week, [Free week of 3 in block working.], or 2 Consultants need to attend the same course. There must also be a guarantee to pay all the extra accommodation costs required because of the distances involved and lack of transport to Wick etc. At present there is no such stipulated agreement. Such an agreement must be available for all levels of staff working in remote locations, not just Consultants & doctors.
     

18. Post Partum Hysterectomy Requirement.
    Before my time Dr Lees was doing a locum job here and had to deliver a lady with an Ante Partum Haemorrhage. The mother was delivered of a live child only to subsequently develop uncontrolled bleeding that required an emergency hysterectomy. She survived because there was a Consultant on site capable of performing an immediate post partum hysterectomy. Not an easy procedure, and certainly anxiety provoking when you do not have a ready supply of blood available as is the case in a bigger unit. But, she would never have got to Raigmore or he would not have operated here, so his presence was imperative and saved that ladies life. The year was 1987, I gather, which is not that long ago in terms of the development of a baby who has lost its mother at birth!
    
    Today one would hope Intervention Radiology would allow embolisation of the uterine arteries, but that requires an on site Radiologist and facilities/ expertise in such procedures which is not the case in Wick. If you remove the gynaecologist then a general surgeon would be called on to perform a very difficult and potentially dangerous operation, of which he would have no experience. Not a pleasant thought for either the surgeon or the patient and her family.
    
    One can only applaud Dr Lees surgical skills, but I am surprised that having had to deal with such a case locally he does not remember the life he undoubtedly saved by being on site in Wick.
    
    The only way to overcome all these problems is too have a properly integrated unit with 24/7 cover for the whole year. How you achieve that ideal, which is said to be the cheapest option by Dr Roger Gibbins, NHS Highlands Chief Executive, is another matter.
     

19. Severe Perineal Disruption.
    On several occasions I have been asked to ‘come and repair an episiotomy’. A call that fills one with dread now a days; as Midwives generally are trained to repair their own surgical incisions. Which is what usually happens in Wick.
    
    On each of the occasions I was summoned the call for assistance was genuine and the correct decision. The degree of perineal disruption in each case was extensive and if not repaired carefully and correctly at the time of original injury would have been a source of comfort &/or continence problems at a later date. I have not seen an anal sphincter tear, but I have seen the sphincter laid bare, but miraculously intact. The Operating Theatre books do record cases of 3rd and 4th degree tears and their local repair.
    
    It takes a competent and confident person to know when they are out of their depth in the work they are doing or contemplating attempting. These patients would have had to wait 3 to 4 hours to have their exceptionally tender & torn post delivery vaginas, perineum and anus’ repaired. After a little matter of a 105 mile journey to Inverness. Dr Russel Lees confirmed at the public meeting that there would be no staff that could came to Wick to deal with such patient’s problems, as they could not leave the Raigmore unit understaffed. A very reasonable and understandable statement but of little help to an acutely discomforted lady who has had her unit intentionally understaffed by the actions of the NHS Health Board, of whom Dr Lees is a member. Confirmed by the Scottish Parliament and Executive, I accept.
     

20. Retained Placentas.
    A similar problem exists in a MLU with retained placentas. This does not happen that often but when it does it is not a situation that an obstetrician views lightly. If the separation is partial then the patient can bled torrentially in the worst scenario. I have been forced to put up 3 drip lines on more than one occasion in such circumstances. Generally in a hospital environment with a fully functional blood bank, but even those circumstances can tax the resources severely.
    
    In a similar situation on a flying squad call I had to get the police involved to bring more blood to the patients address whilst the anaesthetist and I resuscitated the lady to a point whereby she was fit to travel. We won the day but to use a well known quotation ‘it was a closely run thing’.
    
    It is not accepted practice legally for midwives to deal with abnormal obstetrics, nor is it the medico-legal prerogative of general surgeons as far as I know. Removing a placenta that is totally adherent or partially separated is always a relief. There is the risk of rupturing the uterus during the procedure, or having to proceed to a formal hysterectomy for uncontrollable haemorrhage. Small risks, but would anybody honestly wish their wife to be placed at such potential risk 105 miles away from a competent consultant, or his junior staff. If I was asked to make such a decision to produce that set of circumstances I would put my wife and recently born child into the equation and my honest answer would have to be ‘Not on your life will I agree to such a foolhardy decision’.
    
    I accept non medically qualified personnel may be excused for not considering such a situation, but I cannot see how experienced medically qualified staff can overlook the possibility of such a situation and the resultant problems it could bring to the patient and her family, her recently born child and to the Midwives who have to cope with a situation they are not trained for, and could not be trained for. In medicine you never start a procedure unless you can perform the next procedure to get you out of any problems. Unless you are an exceptionally foolhardy practitioner, especially in the present litigious climate. Midwives are not capable of performing major abdominal surgery, especially on the road to Inverness, regardless of the time of day or weather conditions.
     

21. Equipment Standards.
    Laparoscopes.
    Nobody should blame their tools for second rate work, but sub standard equipment can make life very difficult. Generally the facilities in Wick are excellent but when it comes to the Gynaecological Laparoscopic equipment it leaves a bit to be desired. It is old reusable stock of a protracted vintage. The trocars are blunt, or possibly blunted from a false view that so doing would enhance safety. In fact the opposite risk occurs because greater pressure is required to gain abdominal entry, and therefore it will be less easy to control the forward progression of the trocar as it descends into the abdomen with gut and great vessels in the direct track of the instrument.
    
    A very competent general laparoscopic surgeon used the gynae equipment the other day, his being in Raigmore being sterilised. It takes 3 days to turn round such sterilised equipment. After 6 attempts to effect entry he changed the very blunt tri- finned trocar, and was successful.
    
    Ideally in this day and age, with the risks of cross infection and MRSA infections in hospitals all equipment should be disposable if at all possible, at least in a Ist world country. There are good, relatively cheap retractile trocar devices for all sizes of laparoscope. The retractile device allows sharp blade entry against resistance and then pops out again to cover the blade once the resistance has been removed.
    
    Admittedly reusable equipment is still produced and used internationally, but in such a case it is sharp in the extreme and without defects. It also has to be repaired when not up to scratch, and to facilitate that and provide a service you need an adequate supply of equipment.
    
    There are 3 gynae. scopes in Wick and once used on a list they are sent to Inverness for resterilisation.. Therefore if there is an emergency that night requiring laparoscopy it cannot be done and the patient has to have a formal laparotomy.(Opening of the abdomen, which is a major procedure necessitating a longer stay in hospital and operative/survival risk)
    
    Gynae requires 4 scopes to be available for each list, one in reserve for any emergency procedure and a spare to fill the gap if ever a scope requires repair. A total of 6, we have only 3. Ideally one of those scopes should be 10mm, as against 5mm, in diameter for some of the more difficult procedures.
    
    Colposcope
    The adjustable eye pieces are stuck and not adjustable. Therefore it is not possible to obtain a sharp image of the organ you are going to resect. One can cope, but how this equipment was allowed to get into this state of poor repair I do not know.
    
    Urodynamic Equipment
    The equipment is affectionately labelled NIKKI. But, it is old and when I tried to get support it its use and parts replacement I was informed it was obsolete. There is a lot of obsolete equipment in the NHS I accept but I wonder if it is sensible to be in this situation when it is generally accepted, following the pronouncements of Prof Linda Cardoza of Kings College Hospital and an accepted world authority on Uro Gynaecology, that to perform any vaginal repair procedure without a proper Uro-dynamic abdominal pressure retraction procedure is unacceptable medico-legally.
    
    In medicine you can always find opposing opinions in everything, but in this day of Risk Management and Clinical Governance it does seem managerially reprehensible not to have automatically upgraded this equipment to today’s accepted standard.

Requirements

1. Maternal and foetal safety throughout the Ante-Natal, Intra Partum and Post-Natal periods.

2. Safe delivery facilities for both normal and abnormal cases.

3. Neonatal Resuscitation capability with continuing Paediatric neonatal facilities should they be required.

4. Emergency evacuation facilities by road or air. To Inverness, or to Aberdeen and elsewhere if Raigmore are unable to accept the case due to a lack of facilities, in the neonatal unit. [The smallest in the UK, which is chronically short of such beds or the staff to service them.] The hassle involved in confirming that both the labour suite and the neonatal unit are in a position to accept a case is quite considerable on occasions. I have not had to transfer elsewhere, but my colleagues have, and the final locations have included Edinburgh and Glasgow by both road and air. I gather, from the public meeting statements, that cases have had to be transferred from Raigmore to Newcastle and Middlesborough. I pray I never have to go to such extremes to find adequate cover for an ‘At risk baby’.

5. Patient acceptability with any proffered service and acceptance of its limitations.

6. A genuine consultation process where by patients and locally working practitioners are genuinely listened to, without a constant changing of the conditions by which NHS Highland will assess the service whilst stating acceptance of the local populations fears and requirements. Showing a desire and willingness to find a way to provide that service, rather than finding an excuse for not providing it and using that to dictate a preferred option. Which is perceived to be the situation that exists at present.

7. Arrangements whereby there could be a continuity of Medical and Midwifery
   Staffing, rather than the present short term planning and fear provoking scenario whereby nobody can be sure of a continuity of employment, whether they want it or not. Such Human Resource Management leaves a lot to be desired, especially in view of the constant statements from Dr John Reid, Secretary of State for Health and the Chief Medical Officers that they wish to provide happy and secure working conditions.

8. Full arrangements for the provision of skills continuity for all disciplines, be they
   Medical, midwifery, nursing or para-medical. Guaranteed funding for study leave and any locum support that may be required to maintain acceptable working roosters for those left in post. Such that the European Working Times Directive is generally adhered to.

9. As full a gynaecological service as possible, ideally with a degree of local sub specialisation in gynae oncology, uro gynaecology and infertility.

Proposed alternatives for consultation.
The Board has proposed 8 possible alternatives for consultation. They have also stated the status quo is not acceptable, but included it as their first alternative! They have outlined their preference for a Midwifery Led Unit [MLU]. Pre selecting those cases they feel might have a greater potential for problems to Inverness. Such clients being accommodated at Inverness in NHS accommodation from 37 weeks gestation to await normal labour, or a decision to induce labour at term + 10 days medically. [Possibly a 5 week period away from home for the mothers, not all of whom will be in their first pregnancy]

The papers of Mamood, in the Scottish Borders, and Reddy in Berkshire/Surry confirm with other papers that an anticipated 30% of previously selected cases for a MLU end up requiring transfer to a specialist unit for delivery. In both of those papers the main unit was only 15 miles away, but in Epsom there was always a staff grade obstetrician, paediatrician and anaesthetist on site because of the anxiety of transfer in that area being delayed. In this case the cause being the roads, rather than the weather.

Such facts should not be ignored, nor the medico legal responsibilities and costs if one does. I had the opportunity of a face to face conversation with Mr Tom Hayes of Capsticks Solicitors and mentioned the Wick situation. He simply made the comment ‘too far’. Capsticks are one of the 9 panel members who try to defend the NHS when legal complaints are made. They have their own Risk Management Section for just such problems as we are trying to cope with in Wick. I am sure there is a local Scottish Practice that serves the Highlands, but if not Mr Hayes has expressed a willingness to forward any queries for advice to the Capsticks Section. I will send him a copy of this paper, which he is fully aware of being anecdotal and amateur, as against authorative and published evidence based.

The options are:-

1. A Consultant led service with 3 Consultants & locum support running 24 hrs per day, 7 days per week.

2. A Rural Maternity Centre[RMC] with a single handed resident specialist doctor working Monday – Friday, 9am to 5pm.

3. A Rural Maternity Centre supported by a Consultant Outreach Service. [2-3 Days per week]

4. A Midwife Led Community Maternity Unit[MLU] with weekly Out patient Consultant support in Wick.

5. A 2 Full Time Consultant service working Monday to Friday 9am to 5 pm including night time on call. Weekends and annual leave would be covered by a pool of locum doctors.

6. & 7 A service run as a satellite of Aberdeen, or jointly by Aberdeen and Inverness.

7. A service providing ante natal and post natal care only. All deliveries to be in Inverness.
    

NHS Highland favours options 2 or 3 as stated in their discussion document. Option 8 would require the building of a ‘village’ at Raigmore to house the families of ladies transferred to await natures timing after 37 weeks gestation, or for longer in cases which have known complications that will need timely intervention at some time in the pregnancy. It would be highly irresponsible to leave such cases in the 2 Counties, be they Medical, Haematological or Obstetric cases. Such a village would obviously serve all the other Highland Remote Areas like Skye, Fort William and possibly even the Western Isles, as I gather their GP Trainee Obstetric SHO serves 2 weeks of his training in Raigmore.  Such ‘boarding in’ facilities are costly to the patients family both in financial terms and emotional terms, especially if other children are involved.

Opinion
For the reasons previously enumerated I believe that only options 1 & 8 fulfil most of the criteria required. I also agree with NHS Highland that option 8 is the one option nobody wishes to pursue, and it still would not remove the real emergency delivery requirement in Wick. It would require a ‘village’ being built in Inverness rather than the present accommodation. That would be costly and take time to develop. Possible 2-3 yrs with planning permission, as well as construction time taken into consideration.

It has been stated by the health board and the minister, Mr Malcolm Chisholm, that the status quo cannot be considered an option, and I totally agree with that statement. Therefore there needs to be a radical re-think of how Caithness General Hospital is organised from the view point of the services it provides. Cutting any service provision will only make the unit less viable, and the chances of obtaining staff in all disciplines will continue to be reduced to the point that the hospital will cease to be viable. I do not believe that is the underlying agenda of NHS Highland. Mr Paul Fisher, Clinical Director in Wick, has stated his desire to see the Obstetric and Gynaecology services retained in Wick but made the point that medical provision is constantly changing with tertiary specialist units being developed. With such central control of events remote units will constantly be being changed and challenged, even in his speciality.

That said there are some core facilities that should be retained at local level and that should include Casualty and the expertise to deal with any patient that attends on a local or stabilisation and forwarding basis; Obstetrics and Gynaecology with a similar emergency facility in certain levels of work; Medicine in all its parameters for both the young and the mature; Imaging facilities to complement those specialties, Physical/Nutritional facilities to aid the healing process or expand the diagnostic capabilities & as full laboratory facilities as possible. Much easier now so many tests are automated.

All disciplines need to have at least 3 consultant staff. Although working on the basis of a Lecrest system {Block working} of 2 weeks duty, and one week free of fixed duties to allow study leave, audit work, distance learning, office work, catch-up time to provide a rota reasonably consistent with the European Time Directive and annual leave is not perfect. However, it is the best that can be managed in the present circumstances.

The Obstetricians and Anaesthetists are actually employed like the surgical & medical SHO’s being first on call for their cases. In ideal circumstances they would live in hospital site accommodation, but that is not available in Wick. Being sold off I gather from Dr Lees. So they live close to the hospital in private accommodation. But, their call response time is less than 15 minutes, which is no worse than one would find in staff living on site in other UK hospitals, even if actually living in the hospital. Therefore all their duty time is Ist on call which presents more of a problem with the European Time Directive. The Consultant Physicians and Surgeons time on call only being ‘counted’ when they are actually called into the hospital. Unfair for them to say the least, but that is the current situation and medical remuneration has never been fair to everybody. Although in this case it is hours being counted in the NHS Contract which encompasses an ‘on call’ portion. The situation only changes when Agency staff, on an hourly rate, are employed. But they do not receive the sick leave and study leave facilities in their package, not the employer pension funding of substantive staff.

The same situation pertains to the anaesthetists, although at the present time there are only 2 of them so their rosters do not fit the European Time Directive, especially as they alternate daily between being first or second on call! They have, and are, the biggest problem that needs to be addressed urgently. I am not an anaesthetist, only an observer, but perforce of circumstances their work does not appear to be very varied. But, it is onerous in the extreme. Because of their situation they cannot provide an obstetric epidural service as previously stated. Neither, at the present time do they appear to have any respite time from being ‘on call’. A less than healthy situation in the long term. One of them is due to retire in 10 months so urgent consideration needs to be given to their working role and variability of work if one hopes to interest new applicants for the post.

Before Caithness & Sutherland became part of NHS Highland it seems to have provided a viable service but without intensive care facilities. Most patients seem to have been dealt with locally although the service was not composite, in that it also had no locally based paediatric services. That service being provided as in options 3 or 4 for the Obstetric Service. A system also used in Opthalmology, Chest Medicine, Occupational Medicine, ENT, Orthopaedics and Facio maxillary surgery, and possibly others of which I am unaware.

I think the anaesthetic post might be more interesting if there was greater variability of work available, and certainly the hospital would provide a more comprehensive local service if that were the case. There are cases of other disciplines that can be performed in a rural setting, as is shown by the type of work carried out by the Visiting Aberdeen Surgeons to Orkney.

The theatre and day case facilities in Wick are extremely good and would lend themselves to further, and variable, casework. I am not an expert in other domains, and do not wish to appear so, but I would suggest the key to the survival of Caithness General Hospital, & Thurso, is in expansion of the services provided locally. Not the curtailing of services which has happened in the past and is muted in all the options except option one.

You can only chop off so many branches without causing the tree to finally wither and die. That has already happened to a degree with, quite correctly, the setting up of tertiary centres for certain specialities and subspecialties. eg Neurological Surgery, Paediatric surgery, Gynaecological oncology, Infertility, Breast surgery etc.

But, the corollary of such centralisation is that the provision of initial diagnostic facilities and post operative chemotherapy, and continuing surveillance can easily be carried out in the local vicinity as long as you have enough properly team engaged staff. But, for most of those procedures you do need a fully staffed and multidiscipline experienced anaesthetic department.

 believe that with local ENT, Orthopaedic, Opthalmological, Chest Endoscopic work and Urological work the role of the anaesthetist could be made more interesting, especially if a holding Intensive Care facility were introduced. If there was also an arrangement to cover any procedural discrepancies by visits of staff to Raigmore on a regular basis, then the posts should be more desirable. If that recruited the anaesthetists, then not only could patients who might require intensive care be dealt with in Wick, but an epidural service could also be provided. Although the Midwives would initially have to go to Raigmore to be updated and recertified. Every midwife in Caithness has in fact been given initial training, presumably because there used to be an active service here.

Such facilities would allow many cases now transferred to Raigmore to be dealt with in Wick, including the administration of Magnesium Sulphate for Pregnancy Induced Hypertensive Disease with neurological changes. Such cases occasionally requiring intensive care support. But, such cases would also require an onsite neonatal resuscitative capability with a possible holding potential during inclement weather conditions. But, it would be reasonable to argue that such a facility should be available for all paediatric cases that may present at the present time.

Being so close to Dounreay with its possible problems, even in decommissioning, I admit I was surprised to find an Intensive Care Unit was not available already. Only a High Dependency Unit which would do for most cases, but not all. Recently I had to cease an operation, which I could have performed, because of the likely need for intensive care if I had had to open the lady’s abdomen for a complication of a laparoscopic approach. At 75 yrs of age the lady could have done without a second procedure to resolve her problem.

The other problem is Paediatric cover. The Midwives are continually updated and instructed on resuscitative methodology and generally have little problem. If they do then that is another task that falls on the anaesthetists shoulders! Paediatricians are in short supply at all levels, but generally it is a paediatric SHO who takes the Caesarean section cases in most centers, only calling in the registrar if required, and then the Consultant. I know paediatric clinics are run on an out reach basis but that does not mean anyone is available for resuscitation, except when Dr Farquher is rostered to cover. A less than ideal system but a special for the hospital in an attempt to provide some form of service in adverse circumstances.

Whether that cover could be integrated to provide a service by placing sub-consultants in Wick I do not know, but with the outpatients seen in both Wick and Thurso, it would not seem to be unreasonable. As those persons would be Inverness based and rotated into Wick there should not be a professional development problem.

All services require an imaging service, and in obstetrics there should be a scanner in both Wick and Thurso that the Obstetrician may use when required, not when available. Few Obstetricians are capable of foetal anomaly scanning, but they can scan for position and size where required. Therefore the scanners could be old ones that have been replaced by new models being present on both the labour suite and Thurso Hospital. In the same vein it seems silly that patients have to travel to Inverness for a hysterosalpingogram [HSG]. The investigation of tubal patency when the service could be provided locally radiographically, or ultrasonographically using ‘Hycosi’ as a medium. A medium less likely to cause post use tubal problems than the radio opaque mediums used for an HSG.

Summary
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.
The public meetings this week have called for a solution, if anybody has any ideal of how to achieve that. The only thing I can think of over and above direct appointments is to appoint staff to dual job planned roles. Either as Consultants or Associate Specialists, Staff Grades in Obstetrics & Gynae, Paediatrics and Anaesthetics. A substantive consultant could cover more junior, but obstetrically competent staff and would lead the department. Such a designated leader is required anyway, and should be suitably remunerated.

Appointing two staff at each level, to rotate within generalised jobs on a 3 monthly basis. would give service continuity at both ends of the appointment. Such working would preclude mothers, or those likely to be starting a family. Similarly where a father is a single parent. There would have to be proper accommodation in Wick into which people could move without any stress or delay.

Such appointments may seem far fetched but they would over come the problems of updating and CPD locally. No such facilities being feasible in Wick.

Would anybody be interested in such appointments? The answer is that I do not know, but if Wicks services are expanded appropriately that might be a hypothetical question. But, such appointments would not seem totally unacceptable, especially if people were appointed to such a job. Would I have been interested in such a job? The answer would have to be ‘No’ but at the time I was in the fore front of laser surgery and colposcopy; attempting to sub-specialist such work with gynae cancer within the local unit. So, I had to remain within that unit’s environs. But, other people have different ideals and it is now being recognised by the Colleges that generalists have an important role, as the recent advertisements confirm.

I think it feasible that such an option in the 3 specialities could be made interesting enough and well remunerated enough to be of interest to some trained staff, but only if Wick is upgraded in its care potential at the same time.

In the long term it might be feasible, even in this litigious age, to get the Royal Colleges to put the clock back 50 years and provide a combined FRCS/MRCOG qualification that would produce the generalist of old. A ‘man for all seasons’ who could run casualty, surgery and obstetrics & gynaecology, and possibly even anaesthetics, as occurs in Australia and Canada, I understand. A very tall order in this day and age. Especially with the need for constant re-certification and accreditation; but a possible long term solution. Such a person would have had to train for twice as long as today’s young 3 yr Specialist Registrar’s /Consultants. Such a short period of training does make the double certification time scale feasible, but such people would deserve to be rewarded appropriately to their training and accreditation. But, this is not the same as showing a surgeon how to do an easy caesarean section, or even high forceps deliveries, both attitudes being likely to be unacceptable to the legal firms, and today’s legally trained risk assessment managerial officers.

Brian Valentine
15th October 2004.