Agenda item A4(iii)
The Vision for Maternity and Neonatal Services at NuTH
Presentation to Trust Board 22.01.14
Prepared by Chris Wilkinson and Dr Stephen Sturgiss
Directorate of Women’s Services
Royal Victoria Infirmary
Newcastle-on-Tyne
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This document sets out our vision and aspirations for the Neonatal and Maternity services at NuTH. Both
services are facing major capacity-related pressures, but are also characterised by major opportunities for
development and expansion. Our vision is to develop both units in ways that will significantly enhance the
quality of clinical care, at the same time as providing sufficient capacity for the all the local population to
access maternity / neonatal care at NuTH – and create sustainable, future-proofed state-of-the-art services
fit for purpose in the new 24/7 NHS environment.
Executive summary
•
Activity in both neonates and maternity services at NuTH has increased substantially over the last
few years
•
The capacity in both services is now exhausted – and the current levels of activity are frequently in
excess of capacity, leading to significant clinical and organisational difficulties.
•
Large numbers of local mothers and their preterm / sick infants are transferred elsewhere in the
region for delivery and neonatal intensive care and we turn away multiple requests for the transfer
of mothers and infants to NuTH
•
Women needing urgent interventions on the maternity unit – such as emergency Caesarean
sections – are sometimes waiting for several hours before undergoing surgery
•
We are failing to meet nationally agreed standards for Consultant cover. The excess avoidable
mortality in babies born out of daytime hours has led the Royal Colleges to recommend 24/7
Consultant working – as is increasingly the case for all acute specialties
•
The fabric of our estate is in very poor condition – with dated and inadequate facilities, especially
on the postnatal wards
•
Our vision is for a new build and / or redesigned / expanded facility with state of the art
construction standards, 24/7 Consultant cover, an appropriate number of midwives / nurses and
sufficient capacity for all local mothers and babies, as well as the additional women who are likely
to choose such a facility for their place of birth
•
It is entirely plausible to believe that even more mothers would choose to give birth at the RVI if we
were to build such a unit
•
There are significant barriers to the creation of such facilities, not least of which are the
increasingly challenging financial constraints of the current NHS. The additional workload and
income associated with this proposal will, however, make a substantial contribution to the cost
•
We are committed to working with the Trust and Commissioners to achieve widespread alignment
of purpose, and fulfilment of the aspirations set out in this document.
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Background
The maternity and neonatal services at NuTH have both become substantially busier over the last few
years.The activity levels in each service area are as follows.
Neonatal services – increase in activity
The intensive/high dependency (IC/HD) workload undertaken by the Newcastle Neonatal Service has
increased by 63% since 2006 (Figure 1), despite only a 12.5% increase in IC/HD cots in the same period.
Figure 1 RVI Ward 35 2004 - 12: Rolling Annualised HD workload
7000
6000
5000
4000
3000
Jan-04
Jan-05
Jan-06
Jan-07
Jan-08
Jan-09
Jan-10
Jan-11
Jan-12
Date
The increase in workload has come from several sources:
•
Improvements in the survival of babies born at the extremes of prematurity, as well as in babies
with complex congenital malformations (referred via the Fetal Medicine Unit or from elsewhere
within the region – ‘quaternary’ referrals)
•
The surgical referrals of extremely preterm infants (primarily necrotising enterocolitis) from the
region
•
The increase in the number of deliveries at the RVI
Current neonatal service capacity is now completely saturated.
Implications of working at (and beyond) the limits of current capacity for neonatal services
The implications of working to or beyond the limits of our current neonatal capacity are profound – and
include:
•
Median occupancy rates on the neonatal unit exceed 100% despite numerous measures to address
this issue. This means that on most days, there are more babies receiving intensive care on the unit
than there are cots to accommodate them.
•
We continue to turn away and / or transfer out very large numbers of preterm / sick babies of local
mothers. From January to September2013, we refused 57 in-utero and 22 ex-utero transfers, as
well as transferring 9 pregnant women to other maternity services and 33 babies for care in other
regional units – amounting to 121 babies in all. This number of babies would have needed (at least)
630 intensive care days, 600 high dependency days and 1090 special care days. This is a very major
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quality of care issue for those mothers and families having to be dislocated from their support
network at a time of extreme anxiety and stress.
•
Very few babies are transferred out of the region – suggesting that (a) the overall capacity in the 4
North east Neonatal units (NuTH / Sunderland / North Tees / James Cook) is appropriate, but that
(b) there should be a redistribution of resource / cots from other units to NuTH
Maternity Services – increase in activity
The number of women choosing to give birth at NuTH has increased dramatically since 2004 – at which
time there were about 4,800 births pa. In contrast, there were 7565 births in 2013. This increase in activity
has been sustained year-on-year (see Figure 2) since 2004.
Figure 2: Numbers of births at NuTH since 2004
The reasons for this increase are likely to be multifactorial, but include the reputational strength of the
unit. This increase has not been seen in other local units.
Current service capacity is now virtually exhausted. There is the potential for a few additional births of “low
risk” women in the Newcastle Birth Centre (the unit’s Midwife-Led-Unit), but capacity on the Main Delivery
Suite is at critical levels
Implications of working at (and beyond) the limits of current capacity for maternity services
Managing the peaks in maternity activity is now extremely difficult. There are very considerable day-to-day
(and month-to-month) variations in the numbers of women giving birth. During these peaks in activity,
which are becoming more frequent and sustained, we are starting to witness:
•
Women having to wait several hours for emergency procedures such as Caesarean sections - a
consequence of multiple simultaneous urgent situations
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•
Delays in transferring women to the Delivery Suite, with the potential for unattended births
elsewhere on the unit. Women are now waiting many hours for elective interventions such as
induction of labour and / or augmentation for ruptured membranes
•
Increasing use of the escalation policy, with times when we’ve been vey near to closure of the
maternity unit. To date, we have never closed the unit for capacity reasons as this would have
significant safety issues for women throughout the region. This despite the fact that many
maternity units (including those in the local area) manage their capacity on a regular basis in this
way – In 2012 from April - September 28% of maternity units closed for 12 hours or more,
including 8 who closed for at least 2 weeks, either because they lacked physical capacity or
midwives.
168-hour Consultant presence on the maternity and neonatal services
The need for 168-hour senior medical staff presence on maternity and neonatal wards has been recognised
for many years. There is a marked increase in the numbers of babies coming to harm when born out of
usual daytime hours. This has been confirmed in multiple studies, including a recent article in the BMJ
(Pasupathy et al, 2010), which examined the incidence of anoxic neonatal death in babies born throughout
Scotland (see Figure 3). This increase in out of hours mortality is attributed to the lack of senior medical
staff presence throughout the day and night.
Figure 3 Incidence of anoxic neonatal death in 1,039,560 livebirths (Scotland; 1985-2004)
3.5
2.9
3
3.1
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Weekend
All out of hours
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0
Weekday, 09.00- Weekday 17.0117.00
08.59
The maternity unit currently has 98-hour cover, and the neonatal unit plan to provide this level of cover in
the near future, but this remains well short of 24/7 presence, as is recommended for units of our intensity
and workload
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Fabric of the estate
In June 2011 the Newcastle Birthing Centre (NBC)
opened and has been a resounding success. The unit
provides 5 star facilities for low risk women –
leading mothers and their families to report high
levels of satisfaction.
This is in stark contrast to the rest of the maternity
unit. The rooms on the Delivery Suite are highly
medicalised (as shown to the left), and the fabric of
the estate is in a very poor condition. Moreover,
there is a marked lack of basic facilities (outwith
NBC) such as showers on the postnatal ward.
The “state of the estate” is becoming increasingly important – with ever greater numbers of women making
choices about place of birth based on the ambience of the facilities. If the condition of the estate is not
addressed, there is a significant risk of mothers being attracted to other local providers who have (or are
planning to build) more structurally attractive facilities.
Current quality of care in neonatal and maternity services
The staff in both the neonatal and maternity units are working extremely hard to maintain quality of care
despite these difficulties. There is external, objective evidence to confirm that quality of care is being
maintained.
Neonatal services
The quality of care in relation to very preterm / sick babies is monitored nationally with a quality
dashboard, looking at various measures including the percentage of babies undergoing appropriate and
timely retinopthay screening, as well as blood stream infections associated with vascular catheterisation.
The results for NuTH during the Autumn quarter of last year (the latest dates for which we have available
data) are shown in Figure 4
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Figure 4 The Specialised Services Quality Dashboard for NuTH (Autumn 2013-14)
The results for those parameters relating to local (rather than regional) care are all extremely encouraging –
with values that are considerably better than the national average.
Maternity services
The CQC have just published benchmarking scores for women’s responses to questions about their
maternity experiences. The scores were grouped into 3 categories - labour and birth, staff and postnatal
care in hospital. The results for NuTH in comparison to other large service providers in the Shelford group
are displayed in Figure 5
Figure 5 CQC review of maternity services; benchmarking scores for NuTH in relation to other provider units
in the Shelford Group
It can be seen that Newcastle performed better than many of the other units, with the exception of
Cambridge and Oxford, who serve a much less disadvantaged population than ourselves and the others in
the group.
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Long-term strategy for the provision of intrapartum care in the region
The first meeting of the new Maternity, Child Health and Neonates Strategic Clinical Network is due to take
place later this year.
The current clinical lead for the maternity arm of the SCN (Dr Sturgiss) has been visiting various CCG leads
throughout the region over the last few weeks. There is a high level of awareness amongst senior clinicians
and CCG managers that the current configuration of maternity and child health / neonatal services is
unsustainable.
The principle of adopting 168-hour Consultant cover for all maternity units in the region was agreed about
3 years ago, but the implications of doing so are profound – and would probably mean consolidation of
service into 4-5 units regional offering intrapartum care. A final plan has yet to be drawn up and / or
agreed, but it seems likely that in the longer-term, there will be significantly fewer medical units in the
region. Hence, it seems very likely that there will be an ever increasing demand for services at NuTH.
Current and impending financial / staffing constraints throughout the region have led the neonatal network
to conclude that the 4-unit configuration of service (Newcastle, Sunderland, North Tees and James Cook) is
inappropriate and unsustainable. The most recent suggestion from the neonatal network is that there
should only be 2 units – at Newcastle and Teesside; this is currently still being debated.
The vision for neonatal and maternity services at NuTH
We have worked closely with the Trust Executive to create a vision for the future of neonatal and maternity
care in NuTH. Our aspirations include:
•
A newly built and / or redesigned, expanded neonatal unit with state of the art facilities to modern
standards, and with sufficient capacity to provide care for all local sick babies
•
A new build and / or redesigned maternity unit – constructed to modern standards, and with
sufficient expanded capacity to cope with the ever increasing numbers of women choosing to give
birth at NuTH, including those likely to do so when aware that these units will be staffed with:
•
168-hour Consultant presence for both the Neonatal and Maternity services, thereby ameliorating
the recognised increased risk of babies coming to avoidable harm when born out of hours
•
Appropriate staffing levels for neonatal nurses and midwives – in accordance with national
standards
The benefits of service expansion and development
The benefits of such an approach are numerous and include
•
The numbers of preterm / sick babies needing to be transferred out of the unit would be kept to an
absolute minimum, thereby avoiding the distress associated with dislocation of parents from local
support networks
•
We would be able to accommodate all requests for the transfers of sick / preterm babies, and or
mothers at risk of preterm birth from neighbouring service providers – thereby avoiding having to
divert these women elsewhere
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•
The quality of experience for mothers in labour needing intervention would be dramatically
improved by keeping waiting times to an absolute minimum, thereby avoiding unnecessary distress
and the risk of superimposed (and avoidable) complications while waiting
•
The risk of babies coming to harm when born out of hours would be reduced as far as is possible to
do so
•
Senior medical staff presence thoughout the day and night would result in better and more reliable
decision-making, thereby leading to less adverse outcomes and fewer legal claims
•
Appropriate staffing levels will reduce the numbers of complaints, as well as improving sickness
levels and retention rates
Barriers to implementation
There are several barriers to implementation – including estates and financial limitations, as well as the
possible responses of the commissioners
Estates
There are very limited opportunities for expansion within the current footprint of the building. Hence, full
implementation of these proposals would mean either (a) considerable build out from the existing estate,
and / or (b) a complete new build. Both options are very costly
Finance
Full implementation of the proposals described above would be very costly. We have carried out detailed
financial analyses, which have shown that the additional income associated the potential increase in
neonatal and maternity activity would make a very substantial contribution to the cost of these
developments. There are key issues in relation to the financial analysis, including:
•
The anticipated level of increase in neonatal / maternity activity that would be seen following the
expansion. We can be certain that the additional neonatal cots would be used to full capacity – this
is based on the numbers of babies that are currently exported from and / or turned away from the
unit. Moreover, we are aware of work undertaken by the North Tyneside CCG demonstrating that
almost all the women in their area (who were asked; n=1100) would come to NuTH for the birth of
their baby if allowed to do so. The existing reputational strength of the maternity service, as well as
the increased competitive advantage associated with the provision of 168-hour Consultant cover
mean it is highly likely that our birth rate will continue to rise if we have sufficient capacity. This
impression is reinforced by the likely longer-term reconfigurations in maternity care anticipated
regionally and nationally.
•
The level of remuneration associated with the increase in activity. This is currently problematic in
neonates. Activity is purchased as a block – with activity over and above designated levels (80%)
funded at marginal rates. Hence, a large proportion of our current activity isn’t funded
appropriately. However, the forthcoming switch to tariff-based specialist commissioning for
neonatal services – as compared with the current block arrangements – mean that expansion of the
neonatal service to a level where transfers out of the RVI are reduced to a minimum and we can
accept the substantial majority of requests for inwards transfer would be associated with a very
substantial additional income.
•
The local commissioners have never refused to fund maternity payments at full rate, but there is a
widespread acknowledgement that the current maternity tariff is insufficient for purpose. Current
payments are based on reference costs – based on service provision without appropriate
Consultant cover. This will change, but the timing is uncertain.
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The anticipated response of the Commissioners (CCG and Specialist)
It is difficult to predict the response of the CCGs (for maternity services) and specialist commissioners (for
neonates) to this proposal. It is unlikely that the total amount of funding for maternity and / or neonatal
critical care in the region will increase substantially - hence, the funding of more activity in Newcastle
would mean reduced funding for the other units. It is now evident that the present configuration of
maternity / neonatal units in the region is unsustainable, but commissioners have (to date) been reluctant
to force change by proactive imposition of altered funding pathways. More recently, however, there has
been an increasing acceptance that the current service models are unsustainable. Moreover, the
commissioners would only need to lend "passive" support - by agreeing to fund activity wherever it takes
place as compared with manipulation of funding streams to preserve the current systems
Summary
The neonatal and maternity services are facing similar, severe capacity-related pressures, which are
resulting in significant problems for large numbers of preterm / sick newborn babies and pregnant mothers.
The Directorate has worked closely with the Trust Executive to create a vision for the future development
of neonatal and maternity services that will resolve all these difficulties, as well as pioneering the
establishment of state of the art facilities and working practices – thereby providing local mothers and
babies with the highest quality of clinical care whenever it’s needed through day and night.
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