Category: Uncategorized

Liverpool Women’s Hospital working with the large Acute Hospital trust

This is the fourth of a series of blog posts intended to share the current issues facing Liverpool Women’s Hospital.The posts are based on a report to the Board meeting held in public on 7th November 2019. The earlier posts are about Maternity, Gynaecological Oncology, and the age profile of the medical staff at LWH. This post is about LWH working in partnership with the large acute hospital, Liverpool University Hospitals NHS Foundation Trust, which includes the Royal, Broadgreen and Aintree. The proposals are for ways LWH can work with the Liverpool University Hospitals NHS Foundation Trust

As with the earlier posts, the purpose of publicising these papers is to make these important discussions accessible to the concerned lay woman and to medical, midwifery and nursing staff who do not have easy access to the main papers, which can be found here. Publishing them does not imply support, nor is this a critique. Such a critique will follow when our supporters have had the opportunity to discuss the options. We are all too aware that the NHS is monstrously underfunded and overworked and that policy changes since 2010 have done great harm.We are aware that life expectancy for women in poor areas is slipping and that many people have died from the impact of Austerity. Our campaign to Save liverpool Wiomen’s hospital goes on. Our petition is here.

Partnership Board

Following discussions between the respective CEOs of LWH and LUH, an MoU (Memorandum of Understanding) has been created for the formation of a Partnership Board between the two trusts. This group will be accountable to the respective Boards of Directors via the executive bodies and will have operational, medical and nursing/midwifery representation. It will further develop and formalise the ‘virtual bridge’ linking the two organisations with respect to the provision of clinical care.

In addition to details given above around the provision of gynaecological oncology, the Partnership Board will examine the following:

 · Partnership working for HDU provision at LWH which may include joint nursing and anaesthetic appointments, rotation across sites and support at LWH from LUH intensivists

· Consideration of the pattern of critical care outreach services that could feasibly be provided on the LWH site

 · Formalisation of the working arrangements that allow for the provision of urgently needed specialist care from non-women’s specialists on the LWH site · Formalisation of the working arrangements that allow for the provision of urgently needed care from women’s specialists on the LUH sites

 · Review of the present pattern of delivery of maternal medicine services in the light of national drivers for change

· Establishment of a gynaecological nursing and midwifery presence on the LUH sites

· Formalisation of pathways for access to imaging and diagnostics on a seven day basis, with consideration of providing CT and extending other imaging facilities at the LWH site; including image generation and timely reporting

 · Partnership working to provide staffing for a proposed new blood bank and extended lab facilities at LWH with 24/7 delivery of urgent services

 · Formalisation of pathways surrounding access to seven day service requirements with respect to therapies, dietetics, pain management and tissue viability services

Consideration of the potential for the use of the LWH site for LUH clinical activity where clinically appropriate, if this is needed to enable gynaecological activity on the LWH to be moved onto LUH sites

· Exploration of the use of digital technologies for the sharing of clinical information across sites to advance patient safety

· Formalisation of the process of safe repatriation of patients from LUH to LWH sites, taking into account the available services and facilities available at the LWH site

· Provision of oversight wrt (with regard to) the transfer of sick patients from LWH to LUH, reducing delayed transfer and minimising the risks associated with the transfer itself.

 LWH has also suggested that NHSE/I and Liverpool CCG join that Partnership Board, which would then also report into (a) the One Liverpool place based care leadership group and (2) the Acute Sustainability Board for C&M. This would provide all parts of the system with continued sight until such time as the trust’s clinical problems have been fully resolved.

 Recruitment and Retention The Trust is finding it difficult to recruit and retain consultants with the skills to maintain and develop its adult services. The problem has been highlighted above with respect to gynaecological oncologists but there have also been difficulties recruiting consultant anaesthetists and consultant gynaecologists with advanced skills in complex benign laparoscopic surgery.

 In future, obstetricians trained in maternal medicine may also prefer to work elsewhere as LWH is unable to meet the essential MMC criteria. This will have a negative impact upon the trust’s prestige.

 In principle, there are two ways in which the trust can maximise its potential for recruitment and retention and these are now being considered as a separate workstream by the Director of Workforce and Communication’s team:

 Optimise the professional offer

 · Increased access to facilities off site (eg) multidisciplinary teams, robotic surgery

· Improved facilities on-site (eg) imaging, blood bank, digital

· Bespoke job plans to prioritise each consultant’s professional preferences

· Attractive terms for study leave

 · Overseas recruitment

· Promote the LWH brand.

Optimise the personal offer

· Part time working and job shares

· Annualised working hours

 · Off site delivery of non clinical duties

· Leeway in holiday provision

· Attractive remuneration with respect to recruitment

 · Attractive remuneration with respect to retention.

The establishment of a Partnership Board with LUH and the forging of closer working relationships may help with some of the ‘professional offer’ issues as it will provide LWH clinicians with access to a greater range of facilities and multidisciplinary expertise. Similarly, an expansion has been seen in the number of joint consultant anaesthetist posts with LUH and this is likely to continue but the services provided by LWH are otherwise highly specialised and the same opportunity is unlikely to be found in the trust’s other clinical services.

 Without relocation, the recruitment and retention of consultants is likely to be problematic for the foreseeable future

The Age Profile of Consultant Medical Staff at Liverpool Women’s Hospital

This is the third of four blog posts about the current issues facing Liverpool Women’s Hospital. The two ealier posts were about the Maternity Services and Gynaecological Oncology The fourth post is about partnership working with Liverpool Univesity Hospitals NHS Foundation Trust

The issues discussed here affect Doctors’ training nationally and need consideration in that way too. Women’s health care matters and requires specialist input. Specialist hospitals exist in the NHS alongside the large acute hospitals. The acute hospital model is not the only option.

The Age Profile of Consultant Medical Staff. Full document here

Doctors pursuing a career as a specialist in the UK must follow nationally recognised training pathways to gain relevant clinical experience and to obtain their advanced professional qualifications. These pathways have evolved over the years. The Calman reforms in the 1990s and Modernising Medical Careers in 2005, for example, funneled doctors into their chosen specialty at an early stage in their careers while the European Working Time Directive in 1998 reduced the year-on-year volume of clinical work that doctors were exposed to while working towards consultant status.

These changes may have improved consultants’ specialised knowledge and skills but they have also made them more reliant upon cross-specialty working when dealing with patients with multiple medical or surgical co-morbidities.

Put simply, consultants who were born before 1970 could be described as being ‘multi-skilled’ whereas consultants who were born in 1970 or later could be described as being ‘hyper-specialised.’

In obstetric, gynaecological and anaesthetic practice, an increasing number of women with significant medical and surgical co-morbidities are now presenting for care who would not previously have done so. In a medical environment populated by hyper-specialised rather than multi-skilled consultants, patient care must therefore be delivered by a range of specalists in a co-ordinated manner, yet this cannot be provided on LWH’s Crown Street site.

This In 2018, 24/47 consultants in the trust’s three acute adult specialties (just over 50%) could have been described as multi-skilled rather than hyper-specialised. In a simplistic model of recruitment and retention, if we accept that one hyper-specialised Consultant will be recruited each time a multi-skilled Consultant retires in coming years, then: · By 2023 around 40% of our consultants will be multi-skilled · By 2028 around 20% of our consultants will be multi-skilled · By 2033 none of our consultants will be multi-skilled. The data show that in the absence of relocation onto an adult acute site, the shift towards a hyper-specialised consultant workforce will add to the clinical risk associated with the trust’s physical isolation in an incremental manner in coming years.

In the absence of relocation, a partial solution to the conundrum of a changing skill set amongst the trust’s consultant workforce would be to increase the opportunities for the trust’s clinical activities to take place in a multidisciplinary environment: (a) Switching work that we presently do at Crown Street onto an adult acute site (b) Bringing specialists from other disciplines onto the Crown Street site. The CEOs of LWH and LUH have agreed to form a Partnership Board in order to address the trust’s accumulating clinicial risk, including the element of risk posed by its changing consultant profile. Details about the proposed Partnership Board model have been provided below, with elements of (a) and (b) above included. Similarly germane, the trust’s ability to recruit new consultants and to retain its present consultants has also been considered later in this paper.

Gynaecological Oncology at Liverpool Women’s Hospital

This is the second of four blog posts about plans currently being made by the management of the Liverpool Women’s Hospital for the future of the hospital.This hospital is much valued by the people of the area and by all women who want to see a more women centred future for the NHS, a future that would hopefully see women live lives without chronic illnesses, for many more years than they do now. The expertise of the hospital in terms of women’s health should not be underestimated nor undervalued. The blog posts are split into these sections so lay camapigners can more easily access the reports.

This post is about the significant challenges facing LWH in delivering Gynaecological Oncology (cancer treatment).

LWH has, since 2015, been involved in attempts to fundamentally change the hospital. This, coupled with misleading press comments about the safety of the Hospital, made in support of the CCG plans, has probably made recruitment more difficult. This for example in the Liverpool Echo “Health chiefs say women and babies would be safer in a new building as they would no longer have to be taken across the city to be treated for medical complications.” The number of women moved out of LWH is very small and in none of the plans published would babies have stopped moving to Alder Hey Children’s Hospital but such misleading statements abound. LWH has had difficulties recruiting Gynacological oncologists, for many different reasons

Whilst the flawed plans to move the LWH to the Liverpool Royal Site have gone on for so long, some key necessary modernisations have been missed. Our campaign has called for imaging, diagnostics and blood services to be improved. We have also expressed concern at the staff satisfaction scores recorded at the hospital. LWH could clearly be made a better place to work. National issues too impact of the nature of the Gynaecological work force and this too is of interest to all concerned with women’s health.

What follows is the report to the board on November 7th 2019. The full paper work for the board is here

Gynaecological Oncology The gynaecological oncology service at the LWH is under significant pressure at the present time, with a high level of activity required yet a low number of consultants with subspecialist skills available to deliver the clinical work. Of the 6.0 WTE budgeted subspecialist consultant posts, the trust currently has 4.0 WTE in post and of these, one is currently on long term sick leave and one will be leaving the trust for Manchester within the next month.

In recent years, recruitment to these posts has proven to be extremely challenging. This has in part been due to the fact that there are more posts available across the UK than there are subspecialist trainees to fill them. LWH does not present itself as an attractive prospect to candidates, however, because of its isolated position on Crown Street. Modern gynaecological oncologists expect to work in a facility with full access to multidisciplinary care, access to robotic surgery and access to an ITU since these services are necessary for the best clinical outcomes to be achieved

 Partly as a consequence of senior staffing shortages, the trust is not currently meeting its 31 and 62 day referral to treatment cancer targets and activity is underperforming against plan. In mitigation, the job plans of the trust’s remaining gynaecological oncologists have been re-written with all benign gynaecological commitments now removed. In addition, a (non-subspecialist) consultant gynaecologist with an interest in oncology has been appointed, who is providing clinical support and who is helping to co-ordinate clinical activity. The drive to recruit subspecialists, however, continues.

 In order to make these senior posts more attractive to potential candidates and simultaneously to improve our clinical services, an increased level of access to operating lists at LUH has been achieved. These consist of one all day list at Aintree University Hospital each week and one extended (10 hour) all day list at The Royal Hospital each fortnight, each with colorectal support and access to the respective ITUs. Discussions about the future provision of surgery at LUH are on-going but the present aim is to achieve:

 · One all day list for open surgery at either The Royal or Aintree each week

· One all day list for robotic surgery at The Royal each week

· Each with access to critical care and ward accommodation for LWH patients · Protected multidisciplinary team working from all relevant specialties

· Formal pathways to be established around access to specialist pre-operative testing

 · Establishment of gynaecological nursing support on the LUH sites for LWH patients

 · Improved access to imaging and diagnostic services

· Improved access to therapies and support services

These matters are being pursued individually by the MD at LWH and DMD at LUH but they will also be formalised as part of the Partnership Board’s workstream once it has been established, described in more detail below.

Repatriating Gynaecological Oncology The option of repatriating the gynae oncology workload has been considered. There are three options. The first option would be to discontinue the service at LWH and recommission it at either Preston or Manchester, both of which are presently active in the field. This option has been excluded to date in part because of geographical constraints – the patients using the service live across the Cheshire and Mersey footprint but most live in Liverpool.

 Equally pertinent is the fact that it is highly unlikely that either Preston or Manchester would have the physical or operational capacity to deal with the increased volume of work that would accompany the change. The option remains under consideration but is presently seen as impractical.

 The second option would be to discontinue the service at LWH and recommission it at the newly formed Liverpool University Hospitals trust, either at the Royal or the Aintree site. In this scenario, all relevant staff would transfer to LUH and out-patient, ward and theatre activity would follow suit. The work would be commissioned with LUH and LWH would simply refer patients with newly diagnosed gynaecological cancers into that service. This option has been excluded to date because an on-site presence would be required 24/7 from suitably skilled O&G trainees for the safe care of the patients.

 This would not be possible at present because a 20% rota gap rate is the norm for O&G trainees across Cheshire and Mersey. This would be negatively impacted by the introduction of an additional clinically active site.

The subspecialist Consultant Gynae Oncologists do not believe that either ANPs or trainees from a non-O&G specialty would have the knowledge and expertise required to provide safe care to the gynae cancer in-patient population, in place of cover from O&G trainees, on either the Royal or Aintree sites.

In both of the above options, the loss of Consultant Gynaecological Oncologists from the LWH workforce would have a significant detrimental effect upon the rest of the service. Specifically, massive postpartum haemorrhage is a key risk in the obstetric services and life-saving surgical rescue in the most extreme cases is provided primarily by the gynae oncology team.

 Caesarean hysterectomy is performed around six times per year at LWH in response to rapid, massive blood loss and the deterioration in on-site surgical expertise accompanying the repatriation of gynae oncology services would clearly increase the risk of exsanguination in these patients.

 The third option is for LWH to retain its gynaecological oncology services but to perform an increasing volume of work at neighbouring adult acute sites as describe above, both for women with advanced disease and for women with multiple medical or surgical co-morbidities.

 Of note, this third option could have a positive impact upon recruitment and retention although this remains to be tested.

None of the above options provides the same impact against safety as the relocation of LWH in its entirety onto an adult a

Gynaecological Oncology The gynaecological oncology service at the LWH is under significant pressure at the present time, with a high level of activity required yet a low number of consultants with subspecialist skills available to deliver the clinical work. Of the 6.0 WTE budgeted subspecialist consultant posts, the trust currently has 4.0 WTE in post and of these, one is currently on long term sick leave and one will be leaving the trust for Manchester within the next month.

In recent years, recruitment to these posts has proven to be extremely challenging. This has in part been due to the fact that there are more posts available across the UK than there are subspecialist trainees to fill them. LWH does not present itself as an attractive prospect to candidates, however, because of its isolated position on Crown Street. Modern gynaecological oncologists expect to work in a facility with full access to multidisciplinary care, access to robotic surgery and access to an ITU since these services are necessary for the best clinical outcomes to be achieved

 Partly as a consequence of senior staffing shortages, the trust is not currently meeting its 31 and 62 day referral to treatment cancer targets and activity is underperforming against plan. In mitigation, the job plans of the trust’s remaining gynaecological oncologists have been re-written with all benign gynaecological commitments now removed. In addition, a (non-subspecialist) consultant gynaecologist with an interest in oncology has been appointed, who is providing clinical support and who is helping to co-ordinate clinical activity. The drive to recruit subspecialists, however, continues.

 In order to make these senior posts more attractive to potential candidates and simultaneously to improve our clinical services, an increased level of access to operating lists at LUH has been achieved. These consist of one all day list at Aintree University Hospital each week and one extended (10 hour) all day list at The Royal Hospital each fortnight, each with colorectal support and access to the respective ITUs. Discussions about the future provision of surgery at LUH are on-going but the present aim is to achieve:

 · One all day list for open surgery at either The Royal or Aintree each week

· One all day list for robotic surgery at The Royal each week

· Each with access to critical care and ward accommodation for LWH patients · Protected multidisciplinary team working from all relevant specialties

· Formal pathways to be established around access to specialist pre-operative testing

 · Establishment of gynaecological nursing support on the LUH sites for LWH patients

 · Improved access to imaging and diagnostic services

· Improved access to therapies and support services

These matters are being pursued individually by the MD at LWH and DMD at LUH but they will also be formalised as part of the Partnership Board’s workstream once it has been established, described in more detail below.

Repatriating Gynaecological Oncology The option of repatriating the gynae oncology workload has been considered. There are three options. The first option would be to discontinue the service at LWH and recommission it at either Preston or Manchester, both of which are presently active in the field. This option has been excluded to date in part because of geographical constraints – the patients using the service live across the Cheshire and Mersey footprint but most live in Liverpool.

 Equally pertinent is the fact that it is highly unlikely that either Preston or Manchester would have the physical or operational capacity to deal with the increased volume of work that would accompany the change. The option remains under consideration but is presently seen as impractical.

 The second option would be to discontinue the service at LWH and recommission it at the newly formed Liverpool University Hospitals trust, either at the Royal or the Aintree site. In this scenario, all relevant staff would transfer to LUH and out-patient, ward and theatre activity would follow suit. The work would be commissioned with LUH and LWH would simply refer patients with newly diagnosed gynaecological cancers into that service. This option has been excluded to date because an on-site presence would be required 24/7 from suitably skilled O&G trainees for the safe care of the patients.

 This would not be possible at present because a 20% rota gap rate is the norm for O&G trainees across Cheshire and Mersey. This would be negatively impacted by the introduction of an additional clinically active site.

The subspecialist Consultant Gynae Oncologists do not believe that either ANPs or trainees from a non-O&G specialty would have the knowledge and expertise required to provide safe care to the gynae cancer in-patient population, in place of cover from O&G trainees, on either the Royal or Aintree sites.

In both of the above options, the loss of Consultant Gynaecological Oncologists from the LWH workforce would have a significant detrimental effect upon the rest of the service. Specifically, massive postpartum haemorrhage is a key risk in the obstetric services and life-saving surgical rescue in the most extreme cases is provided primarily by the gynae oncology team.

 Caesarean hysterectomy is performed around six times per year at LWH in response to rapid, massive blood loss and the deterioration in on-site surgical expertise accompanying the repatriation of gynae oncology services would clearly increase the risk of exsanguination in these patients.

 The third option is for LWH to retain its gynaecological oncology services but to perform an increasing volume of work at neighbouring adult acute sites as describe above, both for women with advanced disease and for women with multiple medical or surgical co-morbidities.

 Of note, this third option could have a positive impact upon recruitment and retention although this remains to be tested.

None of the above options provides the same impact against safety as the relocation of LWH in its entirety onto an adult acute site.

cute site.

Please read this inconjuction with the other linked posts. Your comments are very welcome.

Building a secure future for the Liverpool Women’s Hospital

Our campaign has worked since 2015 to secure a future for Liverpool Women’s Hospital. We want no loss of services, no loss of beds, no privatisation. We want a continued and enhanced focus on the health of women and babies. We do not want relocation to the crowded, crisis ridden site of the Royal Liverpool Hospital. We want to preserve the site at Crown Street. We want no part in PFI. Tens of thousand have signed our petitions, in the streets and on line.

We have roundly condemned the plans previously put forward by the CCG and the Trust. We dismiss the description of the Crown Street site as “isolated”, it is far closer to the Royal than either the Aintree or Broadgreen sites of the new combined trust. With the demise of the PFI system and the huge scandal at the Liverpool Royal Carillion site, these initial plans have fizzled out, at least for now.

Some interesting new discussions have now begun. We are sharing these discussiosns from the hospital board meetings here for our supporters to read and consider. We will hold a meeting to discuss them in more detail when people have had a chance to consider them. We are posting key sections from the report for our supporters to read, not to endorse it.

The discussions from the board are in four sections;

Networked Maternal Medicine Services (which is the subject of this blog post). This means Liverpool Women’s hospital will be working with the Manchester Hospitals, with one of the Manchester hospitals being the lead on maternity, with LWH as a subsidiary hub. Some Liverpool women with the most complex needs, will have to travel to Manchester for their care. Often these women are the least able to travel longer distances.

Sections on Gynaecological Oncology, The Age Profile of Consultant at LWH, and Working in partnership with other hospitals in Liverpool, will be posted in other blog posts.

We are posting these papers as four blog posts so the lay person can more easily understand them. Anyone who wants them in their original form can find them here, these are public documents.

Introduction from the Board

“Liverpool Women’s NHS FT (LWH) has previously set out the challenges it faces in delivering the highest quality of healthcare on its isolated Crown Street site. Clinicians at LWH have concluded that to sustain the services of the trust into the future, relocation onto an adult acute site would be required. These conclusions have been articulated in the trust’s Future Generations strategy, confirmed through a rigorous options appraisal process run by Liverpool CCG and supported in a Clinical Senate report from independent experts under the umbrella of NHSE.

To date, the DHSC has not given the trust permission to raise the capital required for the construction of a new hospital. Even if this was now achieved, services will continue to be run from the Crown Street site for several years to come. Given these facts, it is important that the trust revisits its clinical position periodically so that relevant and up to date information firstly can be used internally to counteract the clinical threat and secondly can be shared externally so that the need for relocation remains a visible priority for the system. To this end, a Clinical Summit was held in the Trust on 11th June 2019, to which all key stakeholders were invited and at which, a set of key clinical questions was asked.

Networked Maternal Medicine Services (My link)

NHSE/I have committed to ensure that all women in England have access to a level of expert clinical care before, during and after pregnancy that is commensurate with their clinical condition, if a significant medical problem isencountered. The national plan is to achieve this by establishing new Networked Maternal Medicine Services (NMMS), each with a Maternal Medicine Centre (MMC) at its heart.

Each MMC will be staffed by an experienced multidisciplinary team including an obstetrician with sub-specialty training in maternal medicine (or equivalent) and an obstetric physician (or equivalent) along with input from all relevant other medical specialists and support from specialist midwives. For the delivery of maternal medicine services within a given footprint, the MMCs will:

  Provide a leadership role

  Liaise with the other providers of maternity care in its footprint

  Agree pathways of care and patterns of referral

 Ensure that women are cared for by clinicians with an appropriate level of expertise.

Peripheral units will provide much of the maternal medical care required for women of low to medium complexity. The referral of some high risk or complex cases from across any given NMMS footprint into its MMC for the delivery of care is, however, inevitable.

To become an MMC, a trust must comply with a nationally determined service specification with its range of associated standards.

An assessment against that service specification has been carried out by the Clinical Director for Maternity at LWH and this has been included as an Appendix to this paper. The trust can demonstrate compliance against most of required elements but it is not co-located with other adult acute specialties, so full compliance has not been achieved.

In view of these constraints, earlier this year, the trust submitted a joint bid with other partners across the North West, outlining a proposal to develop an NMMS which will cover three LMS areas; Greater Manchester and Eastern Cheshire, Cheshire and Mersey and Lancashire and South Cumbria. In this proposal:

 · An MMC will be established at Saint Mary’s Hospital at Manchester University NHS Foundation Trust (MFT). This centre can comply in full with the service specification as its women’s services are co-located with other adult acute services

 · Two sub-centres will be developed including one at LWH, allowing most but not all women to be treated closer to home. Referral from Cheshire and Merseyside into MFT will be required for some women with severe medical problems: around ten per year will receive most of their care at MFT and a higher number will attend MFT for one or more outpatient reviews.

 Establishing LWH as a sub-centre for maternal medicine will require the appointment of an obstetric physician in Liverpool. The Clinical Director for Maternity is presently working with partners at LUH to identify an appropriate clinician for this role. He is also writing to colleagues across Cheshire and Merseyside in order to formalise existing referral pathways for patients.

These are serious issues for Liverpool women. It would be better to have a self contained Merseyside and Cheshire service. Your comments are welcome.

The following posts will discuss the other issues raised.

Who was on Duty? Who is responsible for the state of the NHS?

 

The state of the NHS in November is utterly unacceptable. Responsibility for this state of affairs rests entirely on the shoulders of the governments who have been in charge since 2010.  People should hold them to account.its their NHS we fight for

The BMA said “Under this government’s watch, patients and staff working in the NHS have endured winter after winter of overcrowded emergency departments, long delays, and pitifully low staffing levels. It should not take an election to take stock of just how bad the situation has become”.

The Governments introduced the policies. They held the purse strings, they oversaw appalling practice and plans. They had the motives. Please hold them to account. Don’t let them wriggle out of responsibilities. It’s not all politicians, or “the cuts”, or “the economy”.

NHS staff are providing good services by their own efforts, at a real cost to their own wellbeing. Despite their working conditions, they still take responsibility for their own actions and for any mistakes. Indeed there are rigorous processes to hold staff to account. If they make mistakes or are negligent, they are called to account. So must the government be called to account.

From 2010 it was a Conservative-Lib-Dem coalition, from 2015 it was a Conservative Government and from 2017 to the present, it was Conservatives, supported by the Northern Ireland DUP. The dreadful state of the national NHS is the responsibility of the Conservative Party and from 2010 to 2015, the Lib-Dems too.

The responsibility for the state of public health and wellbeing rests on the shoulders of the government of the day. The poor have been hardest hit by public health spending cuts. The poor get ill more often and die earlier. The state of the Hospitals, GP services, the ambulance service and more, is the fault of the government.

The voters have to call this Government and its party to account in this general election.

Hospitals in England are struggling to cope safely with high but quite predictable numbers of patients, and with predictable levels of illness. There is no element of surprise about the number of older people in the country. These people were born some time ago.

Staff shortages were also predictable.  The number of staff in training has been known to be inadequate for some time. The Hostile environment for migrants makes the NHS  less attractive to migrant doctors. Cutting training bursaries for nurses and midwives was bound to cause problems

The Royal College of Nurses claims that the shortage of nurses is the greatest threat facing the NHS

Racism in the population is a  problem, and this has been fuelled by the toxic debate around Brexit and the Governments hostile environment. Smaller numbers of staff from the EU have been joining the NHS since the EU referendum (and make up a smaller percentage of joiners) The toxicity of the Brexit debate lies squarely on the shoulders of the government.

There is a serious shortage of beds in the NHS. “However, the UK currently has fewer acute beds relative to its population than almost any other comparable health system.” This reduction in the number of beds flows from decisions to reduce the number of beds, not from any accident or change in population. The shortage of beds results from appalling decisions.

Additional calls on the NHS because of poverty are also well known and are sadly predictable. Cuts in benefits for housing has seen more people forced to sleep rough on the streets. The life expectancy of the street sleeper is 47 years old.

Seriously ill people can be discharged from hospital with nowhere to go once their treatment ends. NHS data confirms that some homeless people are discharged to the streets

Hospitals are critically short of funds, equipment and staff.  Public money has been given to for profit-making companies providing services for the NHS and advising the NHS on how to spend its money. Privatisation is rife.

my-chhoice-image-2Care is being rationed. We look at just one of these rationed treatments in an earlier blog post.  Charging has been introduced for some patients, and for some treatments. The Warrington My Choice experiment was “paused” after a public outcry but we know similar situations are happening elsewhere. The charging issues for migrants are well explained here

The responsibility for all this all rests squarely on the heads of Government and their ‘ninja privatisers’.

“£20 Billion per YEAR to be made out of Outsourced contracts in NHS”

Votes can change things. In the United Kingdom, the people making the laws and the major decisions are the government. The party with the largest number of seats in Parliament chooses the Government.

There must be no attempt to blame the  NHS workforce. Jeremy Hunt tried to blame doctors for waiting lists. Do you remember his 7 days a week NHS and his fight with the Junior doctors? Even now Government tax issues which could easily be solved, are directly damaging the NHS. Doctors should pay tax like anyone else but this case is solvable by negotiation. The Government negotiates quickly with big business. This pension issues too should be solved. The NHS needs many more doctors and doctors should not be expected to keep the system running by working over long hours.

“It (the election) comes as staff vacancies continue to put the health service under strain, with the NHS reporting last year it was short of 100,000 staff, including, 10,000 doctors and 35,000 nurses.” (BMA).

There is a lot of money spent on the NHS, but not enough of that money goes on beds, staff and frontline services.

Financial consultants have done well, out of the NHS.

midwives cleaners etcBig corporations have made money from paying poor wages to provide cost-cutting services that have led to their own crisis. Money has been squandered on privatisation, the internal market, additional administrators, and fatally incompetent decisions about cleaning.

Audits of wards hit by a major outbreak found mattresses contaminated with bodily fluids as well as poor cleaning practises” (Liverpool Echo about Arrowe Park’s infection crisis).

only-a-pound-pay-upWorkers, including those at Liverpool Women’s Hospital, are fighting back against poverty wages in outsourced companies.  In London, another set of workers are fighting back.

The Health Service Journal claims that repairing the new build  The  Liverpool Royal Carillion will cost £300million.

This is yet another example of money-making being allowed to run riot in the NHS

 

The responsibility for the state of the NHS rests squarely on the shoulders of the Government. We are not uncritical of Labour’s record on some aspects of the NHS. Save Liverpool Women’s Hospital Campaign and other NHS campaign groups have been highly critical of local Labour decisions to use PFI to build the new Royal, the failure to adequately supervise the build, of local decisions to cut the numbers of beds and to implement uncritically Government policies on the NHS. But the government made the decisions and had motives for their actionsnoam-chomsky

Governments since 2010 have failed the NHS, have allowed its exploitation for-profit and placed staff and above all patient safety at risk, whilst employing silver-tongued PR exercises to cover up the problems.

An election gives a welcome opportunity to hold the government to account.

Votes_For_Womenits their NHS we fight for Voting works. The old folks who are now accused of “Bed Blocking” voted in 1945 to start the NHS. Our whole NHS grew from their votes.  Votes can change the situation

 Don’t just vote, we need still more campaigners to join us.

Hi Labour! Thanks for asking. This is what we want for maternity in your manifesto please!

High-quality maternity care for all, free at the point of need, funded to Western European standards and above. Get rid of the internal market and focus funds on frontline staff.

 Immediate removal of the charge to migrant mums

The restoration of the Bursary for midwives and nurses and related professions.

Increased funding and support for the university courses training midwives, initially and throughout their working lives.

Increased neo natal beds.

Significantly improve support for women postnatally: physically emotionally and in terms of mental health

Reinstate breastfeeding support to allow women to choose to breastfeed

Provide good quality mental health support

No women to give birth in prison.

No private companies bidding for midwifery work.

End the  personal budgets  routine.

Respect for women in all aspects of childbirth.

Major research to reduce inductions.

Not one more closure of a maternity unit, nor one bed lost.

Make the UK the safest place on earth to give birth. Its not even in the top ten at present. In 2017 in the UK, 1,267 babies who were born after 24 weeks’ gestation died in their first 28 days of life. ( Bliss) Cuba has better outcomes than the UK https://edition.cnn.com/2018/02/20/health/unicef-newborn-deaths-by-country-study/index.html

Ask all the EU midwives to please, please stay.

Birth close to home is best for mother baby and the family. No more nonsense about it being ok to travel for four hours in labour

Improve ambulance services for maternity

Support home births, understanding that this is not a cheap option and will always need obstetric backup

Research and action to stop the greater risk of maternal death  to BAME mums and to significantly the numbers of BAME babies dying at birth

Reverse the terrible trend where more babies are dying under one

Focus on women’s health and reduce the number of years women live with ill health

Tackle endometriosis. Tackle extreme period pain. Tackle painful menopause Tackle infertility.

Make the NHS focus on women’s health, research into drug effects on women, and make sure the differences in women’s symptoms are well understood

Improve abortion rights

Reverse all cuts in health vistor services and reinstae a full national service for all

Fund IVF

Improve the NHS insurance system for maternity

Protect the genome projects from private companies

End the mother penalty on pay. Stop discrimination against pregnant women.

Fund our whole NHS to Western European standards, and free it from the plague of privatisation and rationing

Save Liverpool Women’s hospital, on-site. Fund Liverpool Women’s Hospital so it can thrive, to serve women and babies locally and nationally and to continue to be a centre of world expertise

Defend NHS Maternity Services Report 2

Jessica Ormerod speaks for maternity services as a public good.

Thank you for inviting me to speak to you today. My name is Jessica Ormerod. I run a research and policy analysis organisation called Public Matters with my lovely friend and colleague Deborah Harrington. We write mainly about the NHS but we are interested in all public services and keeping those service publicly owned and accountable. We also run an All Party Parliamentary Group for Health in All Policies. At the moment we are completing an inquiry into the Work and Welfare Reform Act. We see parallels across all public services in a systematic transformation (a word we hear all too often these days) to a corporate structure, a reduction in NHS provision and an ever widening landscape for private companies to move in and ‘fill in the gaps’.

I know I have spoken to some of you before but I think it’s really important for us to understand the picture of what has happened to our NHS as a whole. Because every closed maternity ward, service or reduction in staff is the direct result of changes to the NHS that have been happening since the 2012 Health and Social Care Act. These changes are having a devastating impact on access to care. It is no exaggeration to say that we are witnessing the reversal of 70 years of universal, comprehensive and equitable care.

The 2012 Health and Social Care Act put into place all the major elements for a step change in the privatisation of the NHS.

A QUANGO called NHS England was formed as the Commissioner-in-Chief of the service, with over 200 subordinate local commissioning units. These commissioning units broke with the tradition of planning services, replacing it with buying in from public, private and voluntary sector providers. Areas of work are subdivided into contractable units and NHS public providers are obliged to compete. The loss of a contract means loss of income, which has a knock-on effect on the viability of the public sector, which is left with high cost acute care and a reduced income.  

In 2014 a new CEO was appointed to run the NHS in England. He created a new plan for the NHS, the Five Year Forward View and this was greeted by the establishment as a welcome antidote to what was seen as the fragmented mess left by the 2012 Act (this was only a mere 18 months on from it being enacted). But it’s important to recognize that far from being an accident, the Act achieved the fragmentation necessary for privatisation to be embedded at an organisational level, including many major health industry players taking key roles in the commissioning and policy-making process.  

At the heart of NHS England’s Five Year Forward View is the idea that the NHS in England will never again be funded to a level that maintains its services in the way they are run now. It puts together a series of proposals for change which are not just cuts but are about a fundamental reshaping of how services are provided. Expensive specialist and emergency care are relocated to centralised hubs and more care is to be delivered in the community via partnerships with local authorities. There is an aspiration for fewer emergency admissions with an improvement to overall health which it argues will lead to less dependency on NHS services. 

We could say the scope of this aspiration is far reaching or we could say it is pie in the sky. It not only assumes the NHS can cope with a growing population without corresponding growth in services but that it will do so with a reduced service with much of the change becoming the responsibility of local authorities. 

The process of transforming the NHS in England, is based on close co-operation between successive politicians and Department of Health managers over many years with the US Health Maintenance Organisation or Accountable Care Organization principles of managed care. This process is continuing without any checks and balances of substance within the formal organisational structures of government. Politicians go to great lengths to deny both privatisation and US influence on the current changes. 

There is, however, a groundswell of resistance to the damage being done to the NHS and there is a lot of knowledge surrounding individual service contractions and closures, but little in the public domain about the overall programme of change. And that is what I am here to talk about today.

The National Maternity Review, aka Better Births – A Five Year Forward View for Maternity Care, is one of the Five Year Forward View’s New Models of Care. It emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets. Personal Care Budgets commoditise and monetise the system. They add layers of unnecessary complication, increase expense, fragment accountability and lead to an accounting nightmare.

44 Local Maternity Systems have been established. The systems have been introduced without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated Care Systems. Unlike the Integrated Care Organisations which are now under consultation, they have been put into place with very little fanfare or institutional opposition.

As with all the changes to the NHS currently taking place, there is a real problem that rhetoric about better care closer to home is not matched by real resources or access to physical structures like hospitals. NHS England consistently refers to services being more important than organisations but fail to fill in the blanks about how this works. They also insist that travelling in order to receive excellent care is not a concern to patients. There is no acknowledgment that time, expense and severity of health condition all very much effect the distance people are able to travel regardless of the excellence of the service at the end of the journey.

In the case of maternity, these questions of distance and the emphasis on community care run two different risks. The first being the potential for increase of emergencies outside hospital setting. The second is that mothers might be taken in to hospital for assisted birth or caesarean in order to pre-empt risk arising.

But what makes maternity different from other services?

Most people use health services most at the beginning and end of their lives. Pregnant women are the exception to this. During pregnancy women come into more contact with the NHS than they probably have ever done in their lives. This is particularly the case if they have a complicated pregnancy or birth. Healthy women can become profoundly unwell during pregnancy and they can be vulnerable to life-threatening complications during birth. That’s why it is so important that women have all levels of care within easy access.

Until now maternity services have been provided in the most part by the NHS. Women have always been free to employ a private midwife. But the NHS has a duty to provide a midwife at every birth even if a private midwife is also in attendance.

Maternity services are woven through the traditional structure of the NHS. Women see their midwife at home or at their local GP. They receive a minimum of two scans to check the baby’s progress and health at the local hospital. If they have a pre-existing condition or they develop a pregnancy-related illness then their specialist will work alongside the maternity team to ensure that the woman and baby are safe and as healthy as possible throughout the pregnancy.

Currently women – depending on where they live – can give birth at home, in a ‘stand-alone’ facility run by midwives, ‘co-located midwifery unit’ – that’s a midwife-run facility on hospital grounds, or in an obstetric unit which includes doctors and surgical theatre. Obstetric units can only be sited in hospitals with A&E because they require acute services which is blood, air and surgeons. A woman can become dangerously ill very quickly during birth so timely access to acute care is essential.

Put this into the context that since 2010 maternity services have been starved of funds and there has been a staff recruitment and retention crisis. Many maternity units have already been downgraded or closed, hundreds of GP practices have also closed so women already travel further to receive care. This means it costs more and takes more time to see a midwife, GP or hospital doctor. It also means longer emergency transfer times. The risk is this will only get worse once the STPs restructuring of the NHS is complete.

Who is driving the changes to maternity? 

Surprise, surprise, Better Births panel includes private health providers and those private companies are working with government to re-write policy.

Although most current providers are NHS hospitals, private providers are now being strongly encouraged. Local Maternity Systems set their own payment systems. This means that they can choose whether they pay via their geographical population or they can pay per activity or service. However, they do not follow established budget areas; they do not share boundaries with CCGs or Local Authorities even though they rely on budgets from both. Across the country there is now a mish-mash of payment systems. The risk is that women will fall through the gaps.

NHS Trusts have been ‘incentivised’ to adopt Better Births by offering a chance to win ‘pioneer funding’ to speed up the transition to the New Models of Care. In November 2016, Seven ‘early adopter’ sites started to implement the recommendations – I don’t need tell you about this because you’re part of it! The sites were told to be bold and radical. Another incentive is ‘the maternity challenge fund’ which instructs successful trusts ‘to explore innovative ways to use women’s and their partners’ feedback to improve maternity services’. A pioneer site is not the same as a pilot test site.

LMSs are encouraged to work alongside private providers in order to offer women a wider choice. As most women have previously been cared for by the NHS this simply means opening the door to the private sector. In a climate of serious staff shortages, it is possible that some midwives may see the benefit of setting up an independent midwifery practice rather than staying in the NHS. Despite protestations to the contrary, this does actually reduce the ‘NHS offer’ and opens an income stream for public money to be handed over to the private sector.

Better Births tells us it is working on a new accreditation scheme for maternity providers. But in a publicly provided NHS service, this is unnecessary because the NHS trains staff to a professional standard.

Private providers are required to have a contract with the NHS in order to receive payment via a Personal Care Budget. It is claimed that the budgets (which are described as ‘notional’) will demonstrate to CCGs the kinds of choices women make during pregnancy, birth and postnatally. This will apparently encourage CCGs to respond to women by increasing their offer. The claim is that this will also empower women. But it is decidedly unclear about how this can be achieved. The guidance talks about using Personal Care Budgets for birth pools, place of birth settings or breastfeeding support but all of this should be available to every woman regardless of a personal care budget. In fact, all of these used to be available to women as part of the normal care given by the NHS.

Moreover, it precludes the notion that women become ill in pregnancy. No one chooses to get gestational diabetes, pre-eclampsia, HELLP or any other life-threatening condition. What happens when your health needs change but you’ve used up your £3000 on hypno-birthing? There should be real concern about the potential lack of access to obstetric care when women have serious complications of pregnancy. Or to return to the issue of financial balance, if £3000 is a notional budget for a normal birth which can be used up in a number of ways then the acute hospital will potentially have to pick up the cost of the emergency care without a matching budget.

What does this all mean?

Scale and pace have taken precedence over caution and evidence. Academic research will take years to catch up to establish the public health consequences of this new policy.

This is a top-down reorganisation of a national service with little to no consultation, pilot schemes, peer review, oversight or risk assessment. A Health Select Committee inquiry into the maternity transformation plan was not completed because of the 2017 election. It has not been re-opened.

The Vice-Chair of the maternity transformation programme finishes his report with the following advice to LMSs: Be Bold! Don’t wait for instruction! Clearly long gone are the years of epidemiological study, of public health planning, of consultation with experts.

However, there is one area that is getting a lot of investment and that’s technology. In 2018 all 44 local maternity systems were asked to supply data to NHS England on the level of their digital capacity. There is a drive across the NHS towards increasing the amount of technology. This can mean more efficient record keeping in hospitals and GP surgeries, it can mean improved tools to cancer care all of which are good and to be applauded. But we are also seeing technology replacing face to face care; already women see a midwife far less regularly than she would have done even five years ago. One area of major concern is in the changeover from paper records to e records. We already know that there are serious barriers to access for many people when they are forced to use technology. The claim is that women will be able to take better ‘ownership’ of their ‘personalised care’ but in reality a paper booklet kept by a woman in her own handbag is far easier to access than erecords locked in a computer that she may not have or may not know how to use.

Better Births is based on consumer choice issues around personalised maternity care. There is a serious lack of evidence that this restructuring will give women the vital services they need. There are fewer services, obstetric departments are being stretched even further and technology is replacing face-to-face clinical care.

On the other hand, it embeds private care and fee-for-service. And, most importantly of all this is not how a national public service works.