Recently, we’ve been asked a lot of questions about the changes to Solihull maternity. Below are a list of the frequently asked questions for February 2010, which should hopefully answer some questions you may have about the changes.
If there are any questions you have which still have not been answered, please contact solihull.maternity@heartofengland.nhs.uk and we will do our best to get an answer for you.
Frequently Asked Questions – February 2010
THE HISTORY
Q1. What maternity services does the Trust currently have?
Since 1995 babies have been delivered through an obstetrician led service at Solihull without on-site paediatric/neonatal support. This was because of the withdrawal of the paediatric service when the Deanery judged the paediatric throughput at the hospital was too low to meet the needs of trainees. The Solihull obstetric-led maternity service without on-site paediatric cover is believed to be a unique model of care.
The current models of obstetric provision across the three sites vary with Solihull being a low-risk obstetric unit with no onsite 24/7 paediatric cover and no special care baby unit facility. On booking, all mothers are risk-assessed and only those presenting as routine are booked for delivery at Solihull. Good Hope has a Level 1 (special care facilities) neonatal unit with 40-hour labour ward cover and Heartlands is a Level 3 unit (neonatal intensive care), again with 40-hour obstetric cover.
Q2. How many births happen at the different Hospitals?
Just over 11,000 births took place within the Trust in 2008. of these, there were 4,921 births at Heartlands, 3,601;at Good Hope, and 2,792.at Solihull
Q3. What has been done to increase maternity staffing and support at Solihull Hospital?
In 2008 the Trust had 26 midwives with the additional voluntary qualification of Advanced Resuscitation of the New Borns (ARNBs) in Solihull. They were concerned about maintaining their advanced practical skills as very few babies born in Solihull need this level of support (roughly 1in 1,600 babies require this, which is about one baby every six months at Solihull).
The Trust explored a number of ways of supporting this service, including additional specialist nursing and medical staffing, approaching the Royal College of Paediatricians to see if it would be acceptable for training if trainees could rotate through Solihull to be available to support neonatal resuscitation. Despite Three attempts to recruit additional paediatricians, no suitable applications were received and the adverts for additional nurses only generated eight applicants for more than 17 vacancies. The College remained unable to accept Solihull as a training location because of the very low volume of paediatric clinical throughput.
At the same time, a national workforce survey suggested a shortfall of some 3,000 specialist paediatricians.
Q4. What changes have been made to meet these new safety requirements?
In 1995 following an accreditation inspection by the British Paediatric Association (fore-runner of RCPCH) the volume of in-patient activity at Solihull Hospital was found to be below required levels for training and accreditation was withdrawn. This meant that the Hospital could no-longer employ paediatric doctors in training or attract paediatric specialists.
In order to continue obstetric services in Solihull, some midwives in 1996 agreed voluntarily to supplement their skills to be able to undertake immediate advanced newborn resuscitation and maintain this for up to 40 minutes while specialist help came from Heartlands Hospital.
This role is unique within the UK and although it has been in place now for many years, has not been taken up by other units faced with similar issues.
A policy of accepting only low risk bookings at Solihull was put in place, with all other bookings being referred to Heartlands Hospital.
In 2005, new resuscitation standards were introduced by Resuscitation Council. This included the expectation that adrenaline should be given by intravenous or intraosseous route as the endotracheal route was thought to be less effective. This gave rise to a new skill requirement in umbilical vein catheterisation.
In 2007 minimum standards were agreed by the joint colleges of obstetricians, midwives, anaesthetists and paediatricians. These stated that there must be 24-hour availability in obstetric units of senior paediatric colleagues who have advanced skills for immediate advice and urgent attendance, who will attend within 10 minutes.
There must also be 24-hour availability in obstetric units within 30 minutes of a consultant paediatrician (or equivalent SAS grade) trained and assessed as competent in neonatal advanced life support. All of these requirements are for medical attendance; where advanced neonatal nurse practitionners are involved, this is only envisaged within Level 2 and Level 3 units.
An audit undertaken in 2007 showed no difference in neonatal outcomes between Heartlands and Solihull. The audit concluded “current booking, in utero transfers, neonatal resuscitation and retrieval transfer practices at Solihull appear overall to give the same outcome as if the baby had been born at Heartlands. On the basis of this audit … there is no difference in the effectiveness of neonatal support and outcomes between births in Heartlands and Solihull maternity units”.
Heartlands neonatologists expressed concerns particularly about the maintenance of midwives’ advanced resuscitation competences given the infrequent use of their intubation and advanced support skills. An estimated 1;1,600 babies require advanced skills such as umbilical catheterisation = 1 baby every 6 months at Solihull leading to an infrequent use of skills.
Repeated efforts have been made by the Trust to provide appropriate clinical support for this service (see Q3 above)
A great deal of work has been carried out by the Trust to make the service as safe as possible but despite this, the full requirements still cannot be met all the time and those ‘fixes’ that are in place are not sustainable. They include:
January 2009 – A revised protocol for the ‘fast car’ service was agreed. This does not guarantee medical assistance for an emergency call in under 40 minutes (from call to arrival at Solihull) and could at certain times be longer.
February 2009 ongoing – To enable us to meet changed European resuscitation guidelines, midwives offering Advanced Resuscitation of the New Borns (ARNBs) were offered additional training to insert umbilical vein catheters for the administration of emergency resuscitation drugs. As midwives successfully went through the training we were able to offer improved care in an emergency.
April 2009 – The Trust started to allocate a Neonatal Intensive Care Nurse (ENB 405) each shift to Solihull to assist ARNBs with resuscitation, keep the specialised equipment checked and to further assist when an emergency team arrives from Heartlands Hospital. They also act as transport nurse if necessary. While recruitment continued, these nurses were initially on-site from 07:30 – 21:00 daily.
June 2009 ongoing – Consultant paediatrians and advanced neonatal nurse practitioner (ANNP)s, agreed to do resident shifts at Solihull to provide second level resuscitation support in an emergency. In the first two months of the rota it was possible to cover around half of nights.
July 2009 – ENB 405 Nurse cover becomes 24/7.
August 2009 – Paediatric cover improved to 80% coverage of nights.
THE CURRENT POSITION
Q1. Why can’t we continue as we are?
Over the last few years, the Department of Health and medical Royal Colleges have produced a series of policy documents seeking to improve both safety of mothers and children and mothers’ experience of maternity care.
There are two specific standards where Solihull Hospital’s current maternity service does not consistently meet best practice:
• Access to advanced paediatric resuscitation within 10 minutes
• Paediatric Medical consultation available to baby within 30 minutes
Q2. When will the consultation process take place?
The consultation will be led by the commissioners of the service (Solihull Care Trust and NHS Birmingham East and North PCT ). The Commissioners will confirm the exact timeline once the date of the election is known. It is likely to take place after the election to ensure that a full and open dialogue can take place with the residents of Solihull and Birmingham. HEFT will support this consultation to the fullest extent.
Q3. Why is this not sustainable until the outcome of the consultation is known?
A lot of work is necessary to prepare for the full public consultation, which is led by the PCTs. This is currently in progress, and the date when this will commence is not yet known. As the Trust cannot sustain the present safety levels beyond April 2010 some safe solution must be put in place in the meanwhile to prevent the service closing completely.
Q4. Why are we making these changes if there have been no issues or incidents with regards to the safety of the service?
The current safety support mechanisms cannot be sustained beyond April, so from that date, the service will have to change.
Q5. Is this a cost-saving measure by the Trust?
No. This is all about safety. A series of independent, professional reviews have raised concerns about the sustainability of the present service and the Trust would not undertake a change unless it was absolutely unable to meet the necessary standards.
WHAT HAPPENS NEXT?
Q1. Will we be closing the maternity service at Solihull Hospital?
A table top planning has enabled clinical staff to review the overall model, consider potential risks and mitigations and ensure as far as possible that all implications of the proposal have been considered.
It is anticipated that the necessary changes should be in place to accommodate additional births at Heartlands and Good Hope Hospitals by April. Once these are operational, all deliveries would temporarily cease at Solihull for a short period of some weeks (possibly up to twelve weeks) to ensure that the new model can be fully tested and all staff fully orientated to the new model. This includes providing staff with additional experience in an established birthing unit. Once this has been completed and the clinical teams are confident that the service is as safe as possible Solihull Hospital will open a midwifery-led unit and this will stay in place until the outcome of the consultation is known.
Q2. What are the temporary changes?
Solihull Hospital will continue to provide midwifery services for low risk births as a midwifery-led birthing unit. While Solihull has had criteria to select appropriate, lower risk deliveries for many years, suitable deliveries for the birthing unit will be similar to those suitable for home delivery. More complicated births will be transferred to Heartlands Hospital, Good Hope Hospital or another nearby Hospital.
Women will have the following choices Solihull – Low risk birthing unit; Full obstetric outpatients
• Good Hope – Low, medium and high risk births; Full obstetric outpatients and ambulatory care unit; Access to Level 1 neonatal unit
• Heartlands – Low, medium and high risk births; Full obstetric outpatients and ambulatory care unit; Access to Level 3 neonatal unit
In order to ensure there is adequate space for additional deliveries in Heartlands, the present gynaecology ward is being made available. Most elective gynaecology cases will be done using the ward vacated by obstetric patients in Solihull with a small number of appropriately chosen, higher risk elective cases being undertaken at Good Hope.
This model offers the following benefits
• Safety
• Risk Reduction
• Cost-effectiveness, particularly mindful of the contingency nature of this proposal
• Use of available specialised resources
Q3. What maternity services will still be available in Solihull?
From the spring antenatal and postnatal clinics will continue as normal. There will be a short period when no deliveries at all can be dealt with at Solihull, but once the birthing unit is open, women whose pregnancy and maternity history would qualify for a home-birth will be able to choose to deliver in Solihull if they prefer.
These arrangements will continue until the people of Solihull have had the opportunity to discuss the various longer-term choices for the service, through a formal consultation process that will start in a few months’ time.
Q4. Why will the maternity unit at Solihull have to close to births for a short period of time?
we need to be confident that the new model has been fully tested and all staff fully orientated to the new practices. This includes providing staff with additional experience in an established birthing unit. Once this has been completed and the clinical teams are confident that the service is as safe as possible, Solihull Hospital will open the new unit and this will stay in place until the outcome of the consultation is known.
Q5. What is a midwife-led unit?
A birthing unit is a small, maternity unit that is staffed and run by midwives. They offer a comfortable, low-tech environment, where birth is treated as a normal event, in a personal, unhurried and informal environment.
Q6. How will the other two hospitals, Heartlands and Good Hope accommodate the additional deliveries?
The temporary changes include:
• Developing a midwife-led unit at Heartlands immediately beside the obstetric-led unit.
• Using the ward vacated at Solihull by the obstetric service to refocus most elective gynaecology at Solihull, except for more complex cases requiring higher levels of care that would fit well within the capabilities and capacity at Good Hope
• Exchanging operating theatres between ophthalmology and gynaecology at Solihull, offering advantages to both patients and the services
• Centring emergency gynaecology at Heartlands, to include the assessment and management of the small number of cases normally dealt with in Solihull (less than one patient a day)
Q7. When will these temporary changes be made?
We are currently in the planning phase and the aim is to have the plans complete and have some of the changes in place in the spring of 2010. The exact dates of all of the changes will be available as soon as possible
Q8. What building works will be carried out to support these temporary changes?
• These include On the Heartlands site work to accommodate additional births, including additional induction and delivery facilities, patient assessment area and creation of a midwife-led unit
• Internal changes at Solihull ward 12 to accommodate gynaecology elective changes
• Solihull theatre changes necessary to accommodate the gynae elective patients (entails swapping ophthalmology and obstetric theatres)
• Internal changes at Good Hope necessitating the conversion of two doctor on-call rooms to delivery rooms to accommodate additional deliveries
• Creation of birthing unit at Solihull including changes to the birthing pool arrangements (with the provision of an additional birthing pool), alterations to existing rooms to provide en-suite facilities and a new patient assessment area
OUR STAFF
Q1. Will any staff be made redundant or lose their jobs as part of these temporary changes?
No staff will lose their jobs or be made redundant as part of these changes.
MOTHERS TO BE
Q1. When the maternity service opens as a birthing unit how many local women will be able to choose to have their baby at Solihull Hospital?
Providing the criteria are met, the unit will be able to accommodate approximately 300 births a year.
Q2. What will happen to those women who have already booked in to have their baby when the Solihull maternity unit is scheduled to be closed briefly?
All of these women are being contacted by midwives from the community and/or hospital to explain the options available. All women will automatically be offered the choice of either Heartlands or Good Hope Hospital. They may also choose another unit.
Q3. Will women still be able to have their antenatal care at Solihull Hospital?
There will be no changes to antenatal care. All women choosing to have their antenatal care at Solihull Hospital will be able to have this.
Q4. What choices do women have if they are not able to have their baby at Solihull Hospital?
Ante-natal care is still being offered at Solihull Hospital. If a woman is not able to have her baby at Solihull Hospital she will be offered a number of choices including Heartlands and Good Hope Hospitals. Some women may choose to look at alternative hospitals and all options will be discussed in full with the mother by community based midwives.
Q5. What is being done for those women who choose to be transferred to Heartlands or Solihull Hospital?
All women and partners will be offered the opportunity to visit the hospitals while they are thinking about their choices.
Q6. What happens to a woman turning up at Solihull Hospital in labour during the time the maternity unit is closed to births?
As with any other emergency that cannot be dealt with by the team and facilities at Solihull, the woman would be transferred directly to Heartlands Hospital.
Q7. What happens to a woman who has complications during labour who is in the Solihull birthing unit?
If there is a concern at any time with mother and/or baby arrangements will be made to transfer the patient to the appropriate maternity unit. The ambulance service will treat any requests of this sort by Solihull hospital as true, blue light, emergencies.
Q8. How fast will an ambulance get to a woman in labour at Solihull Hospital?
The ambulance service will treat any request by the Hospital to transfer a woman in labour or a woman and her newly born baby as an emergency, within eight minutes of the call. This will mean that an ambulance will arrive and will transfer the women under blue light ensuring this is as fast as possible.
Q9. What are the main factors which will mean a woman cannot choose Solihull Hospital to deliver her baby?
The unit, once reopened, will only be able to take low risk women similar to those women who are able to have a home birth. Any women with a medical condition or complications will not be able to chose Solihull Hospital to deliver their baby.
THE FUTURE
Q1. What will happen if the consultation outcome says that Solihull Hospital should have something different?
The Trust is keen to support the consultation process and will honour the outcome.
