Information request from Gail Ross
Responses confirmed by:; Dr Helen Bryers, Head of Midwifery, Mary Burnside, Lead Midwife, Caithness and Sutherland Dr Lucy Caird, Consultant in Gynaecology and Obstetrics, Steven Gorman Area Service Manager (Scottish Ambulance Service), Dr Emma Watson Director of Medical Education, Professor Ronald MacVicar
Postgraduate Dean (NHS Education for Scotland), , Maggie Melrose, Accommodation Manager Staff and Patient Accommodation and Peter MacPhee, Emergency Planning Officer
What collaborative working is taking place to ensure safe transfers take place and that the rest of the community in Caithness are not disadvantaged?
Close working is ongoing across key providers to ensure appropriate, timely and safe transfers. This involves direct communications with expectant mothers, local staff, Raigmore staff and emergency services. In the recent cases there was direct contact with Police and we followed their advice at all times.
However we have agreed that we will look further at the protocol around transfers in adverse weather conditions and consider all current options or creating additional options.
This does need to be considered in the context of other transfers and needs. We have been reviewing all ambulance transfers to ensure these resources are being deployed to best effect. It is important that all requirements are assessed to ensure that provision is appropriate. Work is ongoing to look at actions to reduce transfer where at all possible, as appropriate.
Can NSHH or SAS access a 4x4 vehicle and driver that could be used specifically for women in labour being taken to Inverness to avoid them using their own cars or in the instance where no transport is available to them and can they be given some other form of communication as the mobile phone signal is patchy in some places on the A9.
Yes we are further looking into this because we do have at our disposal 4x4 vehicles and drivers which hitherto have not been specifically used in this way but perhaps could be. Currently where mums are travelling due to a planned birth or where there is no medical requirement for ambulance support ambulance would not routinely be provided with ambulance transport as these vehicles are emergency ambulances and require to be kept for emergency work.
In the event of a patient requiring an ambulance on medical grounds the SAS has access to a number of options of which include 4x4 capability. It would however be balanced against the risks associated with travelling in such adverse weather with whether it would be safer for mum to attend the CGH or delay.It really depends on the individual circumstances.
Where mums are high risk and require to attend Raigmore Hospital for delivery but are unable to drive due to adverse weather then we ensure that there are robust systems to support a timely transfer.
Where is the fixed wing plane based that would be used if needed?
The Scottish Ambulance Service has two fixed wing aircraft based at Aberdeen and Glasgow Airports and helicopters based at Inverness and Glasgow Airports. A charity helicopter which is staffed by SAS Paramedics is based in Perth.
Coastguard helicopters are based at Inverness, Stornoway, Sumburgh & Prestwick Airports.
The most appropriate resource would be dispatched based on its ability and location at time of tasking
Given that the one question still waiting to be answered is that of emergency surgical intervention, should the need arise, can you please answer the following –
Can general surgeons perform an emergency caesarean section?
Our services are not set up with the provision of general surgeons performing emergency caesarean sections and Caithness is no exception.
It is not within the routine and expected skillset of a general surgeon to undertake gynaecological surgery, including c-sections. However there are transferrable skills that would prepare a general surgeon to undertake emergency gynaecological surgery when no other option was available. Such an event would be extremely challenging to both the surgeon, the theatre staff and the recovery facilities post-surgery and therefore should only be undertaken in an extremis situation to “save a life” that would be otherwise be lost.
As a board we are required to develop safe systems and thereforeare required to avoid such situations by planning to access care for “at risk” women in a location that has the expertise, equipment and support services to assure the best possible outcome.
CGH does not have this ability and the presence or absence of obstetrician does not fully make up this gap. Moreover the presence or absence of general surgeons does not make up this gap. If a general surgeon chooses to operate “to save a life” it is in the knowledge that their surgical expertise, support services and aftercare are not to a standard that a larger, dedicated centre/team could provide.
Why can’t the current consultants obstetricians remain in Caithness, based in CGH, continuing day to day gynaecology work but be there as an emergency backup and rotate to Raigmore? The CMU would work as proposed but it would give many people in the county peace of mind.
There will be Consultant in Obstetrics and Gynaecology presence in CGH who will either be based locally or part of a rotation from Raigmore. They will carry out gynaecology clinics, procedures and other work as required.
The critical change around the new arrangements is that all Obstetrics and Gynaecology advice (along with paediatric advice) will all be provided from Raigmore. The consultants will then decide what resources to deploy. Over the past two months this has been tested and is working as planned.
What would happen if a mother had a post haemorrhage at home and there was no time to transfer? The above point would guarantee that her life could be saved.
Anyone with Ante Partum (APH) or Post Partum haemorrhage at home or in CGH will be stabilised by the emergency teams at Caithness with Vc / telephone support from Raigmore and transfer if necessary by adult retrieval team. These types of patients may need theatre and all the special facilities provided in an obstetric unit including sufficient blood/ blood products All midwives and emergency response team are trained in the management of obstetric emergencies and this has historically always been the case, this is because obstetricians even when on call may take 20 – 30 mins to be on site and in attendance.
Could registrars that are completing their final year of training be rotated to CGH for the last three months before they qualify either in their registrar capacity or as acting consultants? They would bolster the current team and they could get experience in a rural setting. This would provide them with an invaluable opportunity. This would ensure more people being seen locally and decrease the need for people travelling to Inverness.
No. Caithness General Hospital is not an approved site for higher medical training and this is unlikely to change in the near future. It is approved for GP Specialty Training but we have had little success in attracting doctors to undertake GP Specialty Training in Caithness.
It is worth pointing out that there are also no senior trainees at Raigmore in Obstetrics and Gynaecology.
Are we reinstating the junior doctor scheme this year and how will this help locally?
Yes- foundation doctors are returning in April 2017. Working alongside clinical development fellows and other non training junior doctors they will be part of the team supporting high quality sustainable services in CGH.
Will there be a midwife in the hospital overnight or will they all be on call if the ward is empty?
They will only be in hospital overnight if they are called in to see a patient. As from 30th January we will move to two midwives being on-call. This will be in common with our other on-call arrangements. It will allow midwives to optimise their contribution during the day when it is busy instead of being at in the hospital with very little or no patient contact.
This was not proposed as part of the CMU model as such, however, work took place last year to monitor overnight calls and activity. We moved from having two on shift to test with one on shift and one on-call. This trial showed that there is not enough work and the midwives themselves asked to make the change as soon as possible.
Who would a mother to be contact if she started labour early, the hospital, the ward or the midwife directly?
If it was out of hours under the new arrangements they would contact Raigmore Labour Suite and speak to the midwife on duty. They will provide advice or arrange for the local on-call midwife to meet the mother to be at Caithness General for assessment. Information has been sent to all women on the caseload explaining the arrangements and all the contact details
Are the midwives currently explaining to women why they need to go to Raigmore?
Yes they are and we will continue to renforce the importance of this. In addition , as above all women have been sent letters and information including who to contact under different circumstances, in hours and out of hours. The midwives themselves want to do more to support the engagement process and have come up with a number of ideas which are being planned.
Do the staff understand fully why the change has to be made?
Yes but as with all change we recognise this may be challenging for some. However they have effectively been working as a CMU since October 2015.. We have built- in support and advice from senior midwives who work in CMUs, elsewhere in Highland. . We have also appointed a Dr Lucy Caird, Consultant in Obstetrics and Gynaecology as Clinical Lead overseeing the Hub and Spoke arrangements. This will support greater consistency and enhance communications and joint working.
Local midwives will be part of the Task and Finish Group we have agreed to set This should build trust and confidence in the new arrangements for patients, staff and public.
Can this message be built in to the ante-natal classes?
Yes – we are developing a programme of work which will ensure that at every opportunity the reasons for the change are explained, the new arrangements are understood and that there are systems in place to ensure feed-back to learn lessons and continue to make improvements.
Can a leaflet be produced to explain?
Yes a leaflet has been produced and is being sent to everyone on the caseload and will be circulated via CHAT and others including via social media and local websites. Going forward we will use our local Task and Finish Group to review leaflets and other requirements.
What communication has there been locally with community councils, charitable organisations, private businesses, trade unions or social enterprises?
Wee have been pro-active with our communications but the more we do the more it is obvious we have to do, and we will. We had a constructive meeting with the Association of Community Councils and we have followed this up with information circulated to all Community Councils including how they can get involved. We are in almost daily dialogue with CHAT and other people who attended the public meeting. We are developing a comprehensive data base including local groups, toddler groups and charitable organisations. We link in via Caithness & North Sutherland Regeneration Partnership. We are a member of the Partnership Advisory Board, and also includes Trades Unions, Community Councils, Caithness Voluntary Group, CVS North, Highland Council etc). This continues to be a good mechanism to get messages across, however they don’t have a meeting until March. We also link in with Dounreay Stakeholder Group and the Board of Caithness Chamber of Commerce.
In the past we have done mail drops to all homes and business and could consider doing that if you felt that would be helpful, however, during this period of transition it is clear as much face to face the better
Why are women in Raigmore not being discharged in the morning if they have a long journey ahead of them? Some are having to travel home in the dark.
The key thing about discharging patients home is that it should be planned and meet individual requirements as far as possible. It is not just about the travel but making sure the home environment is ready too. Admission and discharge pathways are being discussed as part of the wider Hub and Spoke working group, chaired by Lucy Caird and will also be considered by the Local Task and Finish Group
What public engagement (of which there has been very little so far) has been planned?
As you know we did not consult on the considerations around whether to move to a CMU because we were considering a decision on grounds of safety. Since then we have ongoing efforts to engage and communicate about the changes. Last week alone we had four separate meetings in Thurso and Wick: CHAT, Caithness Redesign Programme Board, Caithness Community Planning Partnership and meeting with Councillors, CHAT and Margaret Davidson. A programme of work is being agreed as part of an engagement exercise to consider the wider requirements for redesign but we would welcome any further suggestions
We have implemented a number of changes and will further explore any further changes in line with local feed-back and the National Review.
Accommodation will generally be provided at Kyle Court, or the Ronald MacDonald Women and Family Centre in Raigmore. If there are no rooms available, alternative accommodation close to Raigmore Hospital will be organised in a nearby hotel and where we have arrangements in place to be invoiced.
We have also clarified the offer of staying on Raigmore site to await labour even if no clinical indication. While not ideal it offers choice which might suit some people’s circumstance.
Accommodation for partners or the person accompanying will also be organised if needed. Under the Highlands and Islands Travel Scheme usually two free nights of accommodation is provided by NHS Highland. However, in special circumstances additional nights can be organised. We are also in the process of reviewing this Policy, but there are wider considerations to ensure that we have fair and equitable system for all patients, and in all parts of the Highland, that we can manage and is affordable.
In addition we will be refurbishing a number of flats in the Raigmore site that will be child friendly i.e. socket covered, door locks , stair gates etc so that families can be accommodated. All these moves are in response to the feed-back we have received and we will continue to refine and develop.
We recognise that circumstances vary and we will try and be as flexible as possible to offer you support required.
The key is making sure that the mothers and midwives plan what is required with contingency arrangements in place and that Raigmore staff also understand and follow the arrangements. Clearly further communication and awareness is required because it appears that while we have clear arrangements in place not everyone is aware or following them.