‘Consultation now closed’

Quality and Safety

Why would change be safer?

Services are currently unstable across North Wales. We are over-reliant on temporary short term doctors to staff rotas.

Teams are doing all they can to keep services running with daily risk assessments at all three sites. But this is not sustainable. We must avoid any catastrophe that might happen if we allow this situation to continue.

Our clinical leaders with the knowledge and expertise in this area are warning that we must address this. One outlines her concerns about teams becoming ‘desensitised to risk’.

Women that are identified as being at greater risk of experiencing complications during pregnancy will be advised to go to a Consultant-led Unit as described in the options.

Some women may need to travel further in order to access this specialist care, but we believe they will receive a better, safer, more consistent service. We think patients have a right to expect a solid, reliable service and we are not offering that at the moment.

Why is there a dearth of doctors? What are you doing to recruit the right staff?

The Royal College of Obstetricians and Gynaecologists (RCOG) has stated that there is a UK wide shortage of these middle grade doctors. Some 25 per cent of middle grade posts across the UK are unfilled. And this gets worse in rural areas, such as ours. In North Wales, this shortage is between 40 and 60 per cent.

We have been making substantial efforts to recruit full time doctors as well as locums. We are having extreme difficulty with both, despite going out to advert 14 times in the last 12 months. Adverts have been placed on the NHS Jobs website, the British Medical Journal and we have used a specialist international medical recruitment agency. We have tried in India, Sri Lanka, Egypt, Spain and Croatia.

We are also linking with the Royal College of Obstetrician and Gynaecologists (RCOG) to try to recruit overseas doctors.

We are even employing Consultants to work as middle-grade doctors who are resident on call at night (i.e. they stay in the hospital all night) but recognise that this is not a sustainable solution. The Royal College of Obstetricians and Gynaecologists shares this view.

If we increase the number of consultants, the number of cases that each consultant deals with would decrease below a critical level, which is required to maintain their skills.

Also, it is not an attractive career option to be a resident consultant long-term. Consultants are likely to move to another specialty where there is no expectation to do on-call work.

In addition, if consultants are working on-call, this has to have an impact on elective work and clinics, as they are not available to do those following a night shift.

This approach also means that there is a risk that when consultants retire, there are fewer appropriately experienced and qualified medical staff to fill their roles.

We have seen ads for temporary consultant obstetrician posts at Ysbyty Gwynedd very recently. Why not permanent posts?

The posts are for 12 months in the first instance, while we work through the long-term service configuration plan.

We have struggled to appoint to the traditional middle grade posts. Having tried on at least four occasions to recruit middle grades in 2015, we are now trying to appoint more senior members of staff who can plug the rota gaps out of hours whilst also getting onto the consultant ladder in their own career progression – an arrangement that helps both them and us.

A number of our existing consultants will be retiring in the next five to 10 years, and these more junior consultants are gaining valuable experience within our service. Also, appointing NHS locum consultants also means that we are paying considerably less than we would for an agency middle grade doctor.

Why are you against the use of locums? They are qualified doctors.

Excessive use of temporary staff, who can be an unknown quantity in that they do not know the unit or clinical colleagues, can have a destabilising effect on teams.

The middle grade rota gap rate across North Wales this year has frequently been between 45 per cent and 65 per cent.

Temporary agency and locum medical staff play a vital role in covering short term absences due to sickness or annual leave. But if there is a longer term, persistent or increasing need to employ them, it is a warning sign that the service is unstable and unsustainable, both clinically and financially.

Even temporary agency and locum posts can be difficult to recruit to in rural areas like North Wales.

Clinical leaders are concerned that they are held in the position of trying to backfill the service, rather than develop and improve it.

Your consultation document says that you only had two suitable candidates out of 21 applicants. There must be an issue with your criteria.

We have looked at this and do not believe we are asking for too much from candidates. An example, Dr Kumar has explained how on a recent recruitment exercise, over half of the candidates could not meet communication standards adequately.

What if the Deanery decide to put the medical trainees back into Glan Clwyd Hospital. (The Deanery decided to remove trainees from the site earlier this year due to concerns about the learning environment).

It would make no difference. The number of trainees we have is the same. Those that would have been training in Glan Clwyd Hospital have moved to Ysbyty Gwynedd or Wrexham Maelor.

Why do the Wales Deanery insist on 1 in 11 rotas? This makes it difficult to fill rotas.

We work very closely with the Deanery, who are the body responsible for doctors’ training in Wales. We are all aware of the attractions of the bright lights and big units in the big cities to doctors.

We are competing with that so want to make a better offer than is available over the border in England. A 1 in 11 rota means fewer night shifts and more time for training and development for doctors. It is a selling point for us.

Is there a problem with midwife staffing?

No. There will always be churn in nursing and midwifery in that people leave posts for promotions or other opportunities elsewhere. We have appointed 27 midwives in the past two months and have filled all vacancies.

How are we going to retain current and recruit new staff during and after the consultation period?

Our staff are our most valuable asset and we want to support them during this period of uncertainly. We are being open and honest and are doing our best to communicate effectively to ensure that information reaches you as soon as possible.

We will endeavour to recruit new staff on a permanent basis to avoid the uncertainty of temporary contracts. If we need staff to move base on a temporary basis we will take into account personal circumstances and provide relocation support such as travel time, additional childcare and travel costs.

If the Board’s preferred option is agreed upon, is this a downgrade of services at Glan Clwyd Hospital?

We are proposing a temporary change in the interest of the safety of our mothers and babies. The changes we are considering are not permanent and would be for a limited time whilst we stabilise the Obstetric Service.

We have an immediate problem. Today. Now.

The preferred temporary solution is deemed most likely to minimise disruption to women and their families. It maintains the easiest access to services to the greatest percentage of the North Wales population.

Temporary arrangements would allow time to recruit and stabilise the expert medical teams needed to run the service on the Glan Clwyd site.

There are challenges with recruiting obstetric and gynaecology doctors at all levels across North Wales, and indeed nationally, but recruitment has historically been worse at Glan Clwyd Hospital.

This consultation is about ensuring that we can run services robustly at two sites, rather than spreading our resources too thinly at three. Consolidating medical expertise across two sites will provide a more robust service with suitably qualified and experienced doctors.

This has been a problem for years. You have managed this far, so why disrupt everything now?

We have managed with difficulty. The risks are now pressing and services are becoming increasingly unstable. Just because the problem hasn’t been dealt with previously, it doesn’t mean we shouldn’t deal with it now.

Why should Wrexham and Bangor units be under threat when the problems you have are with the team at Glan Clwyd Hospital?

There are difficulties in maintaining the service across the three hospitals – this is a North Wales problem, not solely a problem at a single hospital.

We acknowledge that there have been problems at Glan Clwyd Hospital. A number of independent reports by external clinical experts Royal College of Obstetricians and Gynaecologists (RCOG) have raised concerns about the service at Glan Clwyd Hospital. These are available online.

These reports highlighted a number of problems including communication problems between consultants and a lack of team working; undermining the clinical lead and management team and a lack of ownership of problems in the team.

We continue to work with the team to address these. The team are making progress.

Rhyl has some very deprived communities – you are proposing to take a vital service away. There are low levels of car ownership.

You are right. There are some areas of great deprivation and low levels of car ownership in the Rhyl area. However there are areas of deprivation and pockets of low car ownership across North Wales. We have worked with Public Health Wales to understand the health needs and social factors. What is important is that the Board has good information about needs, and considers the potential impact and whether there are any actions that can help reduce that impact.

Why take away a service to put it back with the Sub Regional Neonatal Intensive Care Centre (SuRNICC)?

The consultation document makes clear our view that the least disruptive option would be a temporary change to the service at Glan Clwyd Hospital. It would have the least significant overall impact on:

  • travel (98.7 per cent of the North Wales population would still be within 60 minutes drive of a consultant-led unit);
  • other services (changes to impatient gynaecology and breast surgery services can be accommodated within the existing bed and theatre capacity); and
  • can be put in place more quickly.

As explained above, the Royal College of Obstetricians and Gynaecologists are advising us and will be describing what is needed in terms of the knowledge, skills and expertise to staff the SuRNICC. We will be recruiting a team for this new service based on this.

It’s all very well you saying this, but what do external experts say?

We have asked the Royal College of Obstetricians and Gynaecologists to come in and take a detailed look at our service and advise us on developing a longer term plan for North Wales. This work will begin early next month.

The Welsh National Clinical Forum – representing the clinical professionals who examine and give advice on services across Wales – have stated in 2012 and 2013 that we cannot sustain the current model of service. They expressed “serious concern about the deliverability and sustainability” of maternity services at three hospitals and that North Wales does not have enough births to justify more than two centres for training.

The Wales Deanery have said that in their view, obstetric training can only be sustained on two sites.

Would mothers and babies be put at risk as a result of temporary changes?

Of course, the Board will need to consider and weigh up any risk from making temporary changes against the risks of trying to continue services as they are now.

We have been holding this risk for months and our staff are working flat out to manage the risks, shift by shift. But this is not sustainable.

We cannot wait for a disaster to happen.

We know there are many concerns and we are sorry that parents and parents-to-be are going through this time of uncertainty.

We want to assure people that we will do everything we can to minimise risks and to be able to respond quickly if an emergency response is needed.

We are using the best evidence to help inform our work.

Birth is a normal process and outcomes depend on so much more than doctors. National Institute of Clinical Excellence (NICE) say that birth should be ‘normalised’ and that healthy women undergoing a straightforward pregnancy should be encouraged to have their babies at midwifery-led units, as outcomes are better. Intervention and surgery is not always necessary.

We must challenge the argument that it is only safe to give birth if there is an operating theatre and a team of surgeons next door.

The Birthplace Study (2011) undertaken in England looking at the experiences of 64,000 healthy women experiencing a normal pregnancy found there was no difference in birth outcomes between Midwifery-led Units and Consultant-led Units.

In December 2014, the National Institute of Clinical Excellence (NICE) said that healthy women experiencing a normal pregnancy should be advised to give birth in Midwifery-led Units.

We must use perspective here. The evidence suggests that for women giving birth in a midwifery-led unit, around one per cent might need transferring in an emergency situation. This would mean about five women a year in a unit of the size we are considering. We would make arrangements to make these transfers as safe as possible (see below.)

How are you going to ensure that any changes do not increase risks?

There is no conclusive evidence either way to show that transfer times impact on outcomes. We have asked Public Health Wales to review the evidence and their independent review will be published soon.

What is important is what happens when you arrive at the unit. We think that it is better to travel a little further for a stable service that is well staffed with people with the right expertise and experience.

We would of course closely monitor services should any change to the current model be agreed by the Board following this consultation.

How is this possibly safer than keeping the currently perfectly safe unit open? No-one has died – it’s not that unsafe, is it?

The reason we are consulting with the public is because we can’t be as confident as we would wish about the quality of care currently provided to mothers and babies. We are struggling to maintain safe services. We cannot allow a tragedy to happen.

Temporary changes often turn into permanent ones. How long is ‘temporary’? When would the service be restored?

If the Board were to decide to take forward the preferred option, this would be for as short a time as possible and we would need to work hard to tackle the current problems in order to stabilise the services.

We would know the service was ready to be restored when clinical leaders with the required knowledge and expertise were confident that a stable, robust service can be provided across the three North Wales sites.

The priority now is how to manage obstetric services in the short term to make sure mothers and babies have the best and safest care possible.

How can I trust the Health Board to keep an Obstetric Unit and build the Sub Regional Neonatal Intensive Care Centre (SuRNICC) on the Glan Glwyd Hospital site?

The consultation is about dealing with the risks we are carrying now, rather than about the long term future. We are trying to sustain the service in its current form but are finding that we can’t.

The First Minister has made a direct commitment to establish a SuRNICC unit at Glan Clwyd Hospital. Plans are well underway for this and are continuing.

If the Board were to decide to take forward the preferred option, this would be for as short a time as possible and we would need to work hard to tackle the current problems in order to stabilise the services.

The priority now is how to manage obstetric services in the short term to make sure mothers and babies have the best and safest care possible.