Agenda item

1.1.        The Committee considered a report which provided an update on the work undertaken to develop maternity services as part of East Sussex Healthcare NHS Trust’s (ESHT) Quality Improvement Plan (QIP) and the current performance of the services.

1.2.        The report was introduced by Dr Adrian Bull, Chief Executive, and Catherine O’Callaghan, Service Manager for Maternity, ESHT.

1.3.        Dr Adrian Bull apologised for some incorrect figures supplied in the Births Before Arrival (BBA) statistics and agreed to provide the amended figures.

Number of transfers

1.4.        HOSC asked whether 40% of patients having to be transferred from the  Midwifery Led Unit (MLU) at Eastbourne District General Hospital (EDGH) to the obstetric unit at the Conquest Hospital was too high.

1.5.        Dr Adrian Bull clarified that the 40% referred to those women transferred from the MLU who are having their first baby. Of the 320 women who started their birth at the MLU 62 were transferred, which is closer to 20%, and less than 10% of women having a second or third baby needed to be transferred. Of those 62 who did transfer, 52 transferred before they had gone into full labour, and the other 10 transferred in second stage labour after having been individually reviewed. These 10 women then spent considerable time at the Conquest Hospital before delivery or caesarean section.

1.6.        Dr Bull said transferring patients is a managed and controlled process and the likelihood of transfer to the obstetric unit is part of the discussion clinicians have with women during the antenatal period. They will also be aware that when choosing to have their first baby at the MLU there is a reasonable chance they may be transferred to the obstetric unit.

Configuration of services

1.7.        HOSC asked how many additional births would be necessary to support two viable consultant –led services in East Sussex; and whether a minimal consultant-led service could be returned to EDGH.

1.8.        Dr Adrian Bull said the total number of births across both sites is 3,300 per year and the recommended minimum number for a single sustainable obstetrics unit is 2,500. Dr Bull said ESHT has agreed that it will continue to look at whether circumstances are changing and whether this means that there is a case for service reconfiguration.

1.9.        Dr Adrian Bull disagreed that a minimal consultant-led service could be provided safely at EDGH as the low number of births would only support a part-time consultant service. One of the biggest risks to patients is to blur the lines between a MLU and an obstetric unit by having a part time consultant presence. This is because a MLU monitors emerging risks more closely than in an obstetric unit.

1.10.      Dr Bull said that under the current maternity configuration, if an emergency transfer for a caesarean had to be made then it would indicate that the risk management protocols put in place at the MLU had gone badly wrong, and this has not happened over the past three years. He said that the MLU is an excellent option for women and those who go there have less need for intervention.

1.11.      Amanda Philpott, Chief Officer, Eastbourne, Hailsham and Seaford Clinical Commissioning Group (EHS CCG) and Hastings and Rother Clinical Commissioning Group (HR CCG), said that the Better Beginnings maternity and paediatric reconfiguration was undertaken on the grounds of the quality and safety of services. The population projections carried out at the time went forward 20 years and estimated a 5% increase in the number of births; there would need to be a 40% increase to make two consultant-led sites viable. The current number of births, the current advice around safety, and difficulty in recruitment and retention of staff remain the same as they were at the time of the decision, and it would not be reversed whilst these circumstances persist.

1.12.      Amanda Philpott added that the CCGs’ remit is to keep services safe, high quality and, where possible, locally accessible. Consequently, the CCGs will always keep the number of births under review, as well as the advice and guidance about best practice for obstetric units.

Criteria for transfer

1.13.      HOSC asked whether ESHT should review its criteria for transferring first time mothers to the obstetrics unit during the second stage of labour. 

1.14.      Dr Adrian Bull agreed about the need to review the criteria for the transfer of first time mothers and said that HOSC’s comments would be fed in to that process.

1.15.      Catherine O’Callaghan disagreed that second stage transfer decisions were bad midwifery practice. She said that the midwives at the MLU were highly trained and experienced; they make decisions throughout the labour process about whether a transfer is necessary using their clinical knowledge and judgement, including when issues arise during the second stage of labour.

1.16.      Dr Adrian Bull clarified that transfers from the MLU to the obstetrics unit are managed transfers made in a controlled way for women who have been assessed as having a requirement for consultant input or the administration of additional pain relief; they were not emergency, last minute transfers.

Number of births at MLU

1.17.      HOSC questioned whether the MLU was fully operational if only just over 300 births were taking place and the capital funding for improvements was not yet in place; and what was being done to improve the number of births.

1.18.      Dr Adrian Bull agreed that there is potential to increase the number of births and suggested that the low birth rate was due to a perception in Eastbourne that all maternity services transferred to the Conquest Hospital following the Better Beginnings consultation; as well as a lack of the same level of local support and promotion of the MLU as the Crowborough Birthing Unit enjoys. He added that it was generally not understood that there was still a full obstetric led postnatal unit at EDGH and that women who delivered at Conquest Hospital could transfer back here for postnatal care if it is more local for them.

1.19.      Dr Bull said that there are more than enough women who are eligible to give birth at the MLU to sustain the unit. ESHT is determined to change the perceptions which are discouraging women to use the service. He agreed that the number of births at the MLU should be included as one of the ‘indicators of success’ for the service.

1.20.      Catherine O’Callaghan said that there is a working party from the MLU that is working with the Maternity Services Liaison Committee, patients, and staff to promote the MLU generally, which will help to increase the number of births.

Classification of BBAs

1.21.      HOSC asked for clarification about the difference between an avoidable and unavoidable BBA.

1.22.      Catherine O’Callaghan said that an avoidable BBA is where incorrect clinical triage advice is given over the phone to a woman, for example, being inappropriately told not to come to the MLU or obstetric unit. Most BBAs are classed as unavoidable and sometimes relate to women who had not attended antenatal care or booked with the Trust to deliver their baby. The 61 BBAs in 2015/16 will be reviewed to discover the reasons for them and whether there are any lessons to be learned, for example, asking community midwives to encourage women during their antenatal period to book their delivery, or provide them with advice on accessing services sooner. Dr Bull said that ESHT was not a national outlier in terms of BBAs.

1.23.      The Committee RESOLVED to:

1)    Request revised BBA and ‘transfer of women in labour’ statistics taking into consideration the difference in transfer rates for mothers giving birth for the first time, comparative figure to the national rate, and if possible the percentage of BBAs that took place during transport;

2)    Request further information about the impact of the reconfiguration – specific questions to be agreed by the Committee outside of the meeting.