Agenda item

Anna Stewart, Programme Director for Start Well, at North Central London Integrated Care Board, gave a presentation to the Committee on proposals that had been developed as part of the Start Well Programme proposals. This Programme of work had been initiated in 2021 to ensure maternity, neonatal, children and young people’s services were set up to meet population needs and improve outcomes.

Anna Stewart said that she would take notes during the discussion of this item to feed back into the formal consultation. She also encouraged all present to submit their own feedback if they had not already done so.

She noted that Start Well had been operating in north central London for approximately two years.  She described the programme as a “truly integrated piece of work”, across the whole of the ICS, involving colleagues from all of the acute trusts across NCL, as well as GOSH as a key partner and local authority colleagues. A case for change had been initiated approximately 18 months previously and then time was spent with a wide range of clinicians developing best practice care pathways, with a view to developing idealised pathways of care needed for maternity, neonatal and children and young people’s care. From there, three key areas were identified which would potentially need some organisational changes in order for them to be delivered and could not be delivered through the normal systems of working together through the integrated care system. 

The three main areas of the Programme which were the focus of public consultation were:

·       The number of neonatal and maternity units in north central London and the proposal to move from five units to four. The reason for this was changing demographic patterns, the declining birth rate in north central London, the increasing complexity both of women and pregnant people giving birth and the babies they were having who needed additional care. This meant a mismatch between the existing pattern of care available in north central London and the need. There was a lot of pressure on services looking after women with more complex needs  and complex babies, meaning pressure on the level three neonatal intensive care unit at UCLH. Conversely, there was a level one neonatal unit in NCL, which cared for the least unwell babies, which was generally half empty, because it was not able to meet the needs of the babies being born.

The proposals around maternity and neonatal services were not to save money, rather they were driven by a belief that having a smaller number of larger units would better deliver best practice care standards, improve the quality of care and improve the resilience of care in services that were historically pressured in terms of recruitment and retention.

Both options would require a considerable investment in the estate in north central London, in terms of the fabric of the buildings. Under both options, £40m capital had been earmarked to invest in those buildings. 

Two options were being consulted on:

1. To close maternity and neonatal services on the Royal Free Hospital site and retaining services at UCLH, North Middlesex, Barnet and Whittington Hospitals

2. To close maternity and neonatal services at the Whittington Hospital, whilst

retaining services at UCLH, North Middlesex, Barnet and Royal Free Hospitals.

In the interests of transparency, all of the reasons for the preference for option one, closing services at the Royal Free and retaining services at the Whittington Hospital, had been set out by the Board. However, both options were deliverable and affordable and were the subject of consultation.

·       Also the subject of consultation was maternity care at the stand-alone midwifery-led unit at the Edgware community hospital site. Out of 20,000 births in north central London per year, only 34 had been born at this site in the last financial year. Only the birthing suite was the subject of closure, the remaining ante-natal and post-natal services would be retained.  

·       A further part of the consultation related to children’s surgery. No changes were proposed to the paediatric emergency departments within north central London.  This was about the onward care of very young children after they had been seen and assessed in the emergency department. The first proposal was to set up a paediatric surgical assessment unit at GOSH, to see predominantly under threes who needed a surgical opinion and some surgery. It was anticipated that approximately one thousand children would be assessed there and three hundred would have surgery. These were children who were predominantly seen at GOSH or outside NCL at the moment, so bringing their care into one place.  A very small number of under threes would be seen for day surgery at UCLH, where there were a number of paediatric anaesthetists and skills to see children for predominately ENT and dental issues.

Much work had been carried out to involve people in the consultation and to seek their views.  An independent partner would evaluate the outcome of the responses to the consultation. Based on that, decisions would have to be made on whether supplementary work was needed and therefore it was not anticipated that a final business case decision would be made until the end of the calendar year.  It would then take time for any decisions to be implemented, pending the necessary capital works to buildings. Until that time, all current services remained open.

Questions/responses were as follows:

There was a fear that, with Whittington Hospital as the nearest in Islington, there was competition with the Royal Free. Islington Council did not want to see any closures in maternity wards.  If maternity services were closed in the Whittington Hospital, would other services be affected in years to come?  The response was that services had been reviewed, including paediatrics, and there were no plans to close emergency departments.  There were inter-dependencies for some clinical specialties in both options which would need to be worked through and separated eg obstetrics and gynaecology with joint rotas.  The Board had looked at all of the staff groups on all of the sites and the anticipated impact of any  changes and this was just one of the reasons why retaining maternity services at the Whittington Hospital was the preferred option, as it would be less disruptive from a staffing point of view.

Islington councillors were in favour of maintaining services at the Whittington Hospital and had been campaigning to retain services there, as they had to retain A&E services at the Hospital some years ago.  Noting that the final decision was to be made at the end of the year, it was suggested that this was a long time for people to be “in limbo”.

On the proposals for surgery, it was noted that GOSH would provide services for children under five, although it was understood that this was something they were currently providing?  If, for example, a four year old required an appendectomy, where would that be removed?  Were UCLH carrying out much day care surgery at the current time?  A response was given that some children who, for example, required an appendectomy, would be treated at GOSH and some were going outside north central London to the Royal London and Chelsea and Westminster Hospitals.  Clinical colleagues who had been consulted on this, particularly those involved with paediatric emergency services, had said that there was no completely established pathway for very young children who, although not medically complex, were anaesthetically complex and would require a paediatric anaesthetist for opinion and intubation.  It sometimes took hours for clinicians to ring around other hospitals to identify a suitable hospital to take a particular child.  Setting up a four-bed paediatric unit at GOSH would assist in caring for those children at that Hospital. Much day care surgery was carried out at UCLH. However, UCLH had a growing service, particularly around radiotherapy, where a large number of children were anaesthetised, and had a large anaesthetic department and were well set up to manage that and to build it into their existing caseload.  On dentistry and ENT, much work was carried out at Barnet Hospital and community dental services at the Whittington.  GOSH dealt with young children requiring anaesthetics.

Although it would be difficult for staff to have to wait until the end of the year for a final decision on which services were to close/continue, much work had to be carried out between now and then, especially on all the observations to the consultation. It was thought that staff understood this and staff at the Whittington and Royal Free both wanted their points to be considered thoroughly.  It was thought best to take time over this.

A comment was made about page 35, which referred to the Royal Free being underused and the Whittington not meeting standards, though no reference had been made to the Whittington being well used. The point was made that maternity services at the Whittington were well used.  It was important that people responded to the consultation.  However, digital exclusion had been referred to earlier in the meeting and that was an issue here. A person had to be digitally literate to respond to the consultation and it was not that easy. How was the ICB dealing with people who were not able to respond online?

The response was made that many staff on multiple sites had been consulted. In terms of the reach of the consultation, the ICB was using a multiplicity of methods to gain feedback. There was an online questionnaire which was fairly intuitive, but it was acknowledged that one required a level of digital knowledge to be able to complete the form. Written questionnaires were also  available and it had also been translated into community languages, with all the summary documents translated into eighteen languages, in an attempt to be as inclusive as possible.  It was pointed out that the written questionnaire was only one way of responding to the consultation. Many targeted sessions had been arranged with voluntary and community sector groups, identified through the integrated impact assessment, and commissioned highly targeted engagement through a specialist organisation to work with traditionally hard to reach groups, such as asylum seekers and traveller and gipsy roma communities. All of this feedback would be collated.  There was an email address, postal address for a letter and a telephone number.   It was pointed out that this was not a vote. Engagement and feedback in the round would help to guide the next steps.

It was good that the ICB was reaching out to community groups.  How could Bangladeshi and Somali groups be reached?  The response was that many engagement events had been held with the Somali community, working through VCS partners in Haringey. The Elfrida Society had assisted with some specialist work with particular groups too.  If there were other groups that might not have been reached, members were asked to contact the ICB to let them know.  There were between 3-4 hundred groups on the ICB’s mailing list, who had been updated throughout the course of the consultation.  It was pointed out that the Bangladeshi community was the largest ethnic community group in Islington and the second largest in Camden and that it would be good to have a system to reach out to them.

A question was asked about the impact of this on home births, noting that there were home birth services at all of the Hospitals and sites under consideration. What were the numbers for home births, which was a good option for some people?  Had the impact of the home birth service being sited at Whittington or Royal Free been factored in to the proposals?   In response, it was noted that  there were not large numbers of home births. However, under both options, ICB wanted to enable the range of choice for birth, in an alongside unit, home birth, or an obstetrics led unit.  One of the issues was that there were recruitment and retention challenges and, if there were pressures currently on the service, it was likely that home births and the alongside units were shut temporarily to support the obstetrics led units. The new proposition was that if there were a smaller number of resilient services, women and pregnant people would be better supported in their choices.  There was no difference between the Whittington and the Royal Free options in this case. In the event that a decision was taken to move to a four site model, the  boundaries of the home birth units would need to equalised, given the sizes of the units.

It was noted that approximately £40m of capital would need to be invested under both options.  The funding would be used not only on the buildings, but also in upgrading services, dependent on the option chosen. The proposals were quality driven, rather than financially driven.

If Whittington Hospital lost its maternity unit, would it also lose its neonatal unit? It was confirmed that both would close.  Clinicians were clear that there should be no level one neonatal units, as these were rare in London.

On behalf of the Committee, the Chair re-iterated the wish for maternity services to remain at Whittington Hospital.  He thanked Anna Stewart for attending and for her presentation.