1. society
2. welfare
3. healthcare
4. hospital

North West London Collaboration of Clinical Commissioning Groups
UPDATE ON THE TRANSITION
OF MATERNITY AND
INTERRELATED SERVICES
FROM THE EALING HOSPITAL
SITE
Ealing CCG Governing Body
18th March 2015
Version no:
0.998
CONTENTS
1
BACKGROUND AND DECISIONS TAKEN TO DATE
3
1.1
Decisions taken to date for the transition of maternity and neonatology services
3
1.2
Improving the model of care for residents in North West London
5
1.3
Ealing CCG’s Role in the decision making process
6
2
OVERVIEW OF SYSTEM WIDE ASSURANCE UNDERTAKEN TO DATE
6
2.1
NHS England Led Assurance
7
2.2
North West London CCG Led assurance
7
3
RESOLUTIONS FOR AGREEMENT
9
3.1
Resolutions for agreement on 18th March 2015
9
A
DIRECTORY OF APPENDIX MATERIALS
10
1
PURPOSE OF THIS PAPER
The purpose of this paper is to:
– Summarise the decisions taken to date in relation to the proposed timing of the transition of
maternity and interrelated services from Ealing Hospital
– Outline the role of Ealing CCG in this ongoing process
– Provide an overview of the assurance work undertaken to date in relation to the planning of the
transition
– Set out for Ealing CCG the initial outputs of the assurance reviews undertaken by NHS England
Attached to this paper are a number of Appendices for the consideration of Ealing CCG Governing
Body members.
2
1
BACKGROUND AND DECISIONS TAKEN
TO DATE
1.1
Decisions taken to date for the transition of maternity and
neonatology services
1.1.1
Background to the decision to transition maternity and neonatal
services from Ealing hospital
The SaHF programme, through its work with hospital doctors, midwives, nurse leaders, providers of
community care, volunteer groups and charities, commissioners in North West London developed a
set of proposals in 2012 to transform the way healthcare is delivered for local people. Clinical leaders
from across NW London proposed changes to create fewer, more comprehensive and better staffed
hospitals, able to provide the best quality care throughout the whole week, whilst developing out of
hospital services to allow co-ordinated integrated care for people with less severe acute illness and
those with chronic conditions.
The proposals are aimed at helping NW London meet the challenge of the NHS mandate, save lives
and improve clinical outcomes. The NHS in NW London is facing a range of pressures and
challenges. From a clinical view, there is increased demand caused by the ageing population and
increased prevalence of long term conditions and co-morbidities. There are also unacceptable
variations in the quality of care provided, evidenced by higher mortality rates for patients who are
treated in hospital at night or during the weekend. Alongside this, there are financial pressures which
require the NHS to deliver efficiency savings for reinvestment. As such, doing nothing is not an option.
The SaHF Case for Change was developed with clinicians, who looked at the current and future
demands on the NHS in NW London, and showed that a new configuration of services was necessary
to deliver high quality care within the financial constraints on the system
In order to significantly improve the maternity, neonatal and paediatric services provided to women,
children and families in NW London, these proposals include the intention to close the maternity,
neonatal and paediatrics services currently delivered on the Ealing Hospital site. The full set of
proposals were presented to the Joint Committee of Primary Care Trusts (JCPT) in February 2013
with the full recommendations set out in the accompanying Decision Making Business Case. The
JCPCT met and agreed as a statutory decision making body to accept the proposals included within
the DMBC
1.1.2
IRP Review and Secretary of State Statement to Parliament
The agreed changes were referred to the Independent Reconfiguration Panel in 2013 for review.
In October 2013, the Secretary of State for Health accepted the Independent Reconfiguration Panel
(IRP) recommendations to implement all of the SaHF proposals due to the compelling evidence for
how services will be improved. For maternity and neonatal services this included the consolidation of
maternity (delivery) and neonatal services from seven sites to six sites (Chelsea and Westminster,
Hillingdon, Northwick Park, Queen Charlotte’s, St Mary’s and West Middlesex). For paediatric
services, this included the consolidation of paediatric inpatient services from six sites to five sites
(Chelsea and Westminster, Hillingdon, Northwick Park, St Mary’s and West Middlesex). While no
implementation timeframe was set, there was a clear recommendation that:
3
“Commissioners and providers of acute hospital services across North West London must
ensure that changes required to secure safety and quality for patients are made without delay”
In his letter to the London Borough of Ealing Health and Adult Social Services Standing Scrutiny
Panel, the Secretary of State for Health wrote:
“I support the panel’s recommendation that maternity and paediatric inpatient services should
be concentrated on the sites identified by Shaping a Healthier Future”
1.1.3
Ealing CCG decision to commence contingency planning
In March 2014, Ealing CCG Governing Body made a decision to invest in contingency plans to allow
the potential acceleration of transition of maternity services from the Ealing Hospital site. This was in
response to concerns raised by Ealing Hospital to the Medical Director of NHS England (London
region) highlighting the issue of a reduction in deliveries and the subsequent challenges to
sustainability and quality. Ealing CCG Governing Body agreed to meet again to discuss the issue in
autumn 2014.
It was agreed that a number of factors would need to be considered in detail before a decision on the
timing of the maternity transition can be made. These included:
Maintenance of clinical quality and access to care – all women and their families have access to a
comprehensive range of maternity services which are equitably and appropriately resourced and
comply with safeguarding policies and procedures
Impact on staff – disruption for Ealing Hospital staff must be kept to a minimum, including impact
on training rotas.
Alignment with Out of Hospital (OOH) commitments - sufficient capacity should exist in the
community to provide care as close to home as possible, where this is clinically appropriate and
GPs must be engaged and informed in the development and implementation of any models of care
that have an impact on their patients.
Financial and operational viability – the transition must be managed as cost effectively as possible,
although there will be some double running necessary to ensure a smooth transition.
1.1.4
Ealing CCG Governing Body Decision of 8th October 2014
On 8th October 2014, Ealing CCG Governing Body met in public to discuss the possible next steps in
the implementation of these changes. The Governing Body agreed:
That there is a need to plan for the transition of maternity and any other necessary, clinically
interdependent services from Ealing Hospital as soon as possible, noting that the earliest that any
service transition could take place is March 2015 when additional system capacity will be available.
To seek the views of the Maternity and Neonatal and Paediatric Project Delivery Boards on the
optimum approach to this planning exercise and timing of any change, including those changes
which may be required to associated or interdependent clinical services both at Ealing and other
hospitals
To Seek ‘Delegated Authority’ from any other CCG with a material interest in this change in order
to ensure Ealing CCG can progress this work and, whilst addressing their concerns, take any
decisions on their behalf as required.
4
1.2
Improving the model of care for residents in North West
London
1.2.1
Current model of care and deficiencies arising
For the majority of women living in Ealing, the current model of care does not provide continuity of
care across the maternity pathway
The majority of women who live in Ealing borough choose not to deliver at Ealing Hospital (~60% in
2013/14). These women receive fragmented maternity care, with different parts of the maternity
pathway delivered by different providers.
There are different acceptance criteria between maternity providers in NWL - most prioritise women
from their own ‘host’ CCG boroughs. In addition, there is currently no sector wide Management
Information (MI) which results in:
Lack of understanding of the proportion of women from NWL that receive their first choice which
makes it difficult for the sector to manage capacity appropriately
Women book at more than one site in NWL; this makes it difficult for trusts to accurately and
effectively plan their services and workload
1.2.2
Proposed model of care and benefits
Work has continued on the development of new models of care, such as the proposed approach to
delivering services in community settings and the benefits to our local population. For the first time,
there will be a consistent sector wide community model with all providers in NWL that aims to improve
access, choice and continuity of care for women in NWL. The sector will have a standardised service
across the whole area with a common approach to manage the system and common acceptance
criteria at each site.
This, alongside the development of both midwifery and consultant led community care aims to provide
greater access to, choice and continuity of care
A summary of the further work on models of care to date is attached to this paper as Appendix
A.
1.2.3
Review of the forecast demand and activity flows
The modelling document shows that there is sufficient capacity across NWL to meet demand in births
across the system and at individual sites. Each trust has confirmed that it is confident that the planned
bed and staffing capacity will meet the predicted activity that will transfer from Ealing Hospital. Further,
most trusts forecast that they could take further deliveries if needed.
A summary of this report is attached to this paper as Appendix B.
1.2.4
Communications and Engagement activities
As a part of this work, further consideration will be given to the communications and engagement
approach required. More detail on this is included in Appendix D which is attached to this paper.
5
1.3
Ealing CCG’s Role in the decision making process
The Joint Committee of Primary Care Trusts which met in February 2013 contained representation
from the eight Primary Care Trusts (PCTs) which comprised ‘North West London’ as well as Camden,
Richmond and Wandsworth PCTs.
Following the implementation of the Health and Social Care Act (2012) the successor Clinical
Commissioning Groups (CCGs) covering the same geographical area took responsibility for the
implementation of the Shaping a Healthier Future programme.
Ealing CCG, as the commissioner with the closest proximity to, and largest volume of patients using,
the Ealing Hospital service met on 8th October and requested delegated authority from the other
CCGs with a material interest in the proposed transition of services to take all necessary decisions on
their behalf to determine the timing of the agreed service changes. All of those CCGs in turn agreed
this request and the following table shows the dates on which they made their decisions to delegate.
CCG Governing Body
Date Agreed
Central London CCG
12th November 2014
West London CCG
4th November 2014
Hammersmith & Fulham CCG
11th November 2014
Hounslow CCG
11th November 2014
Brent CCG
26th November 2014
Harrow CCG
24th February 2015
Hillingdon CCG
24th October 2014
Table 1: Delegations received from CCGs in North West London
Camden, Wandsworth and Richmond CCGs each reviewed the documentation which was presented
to the Ealing CCG Governing Body on 8th October. Following this review, each of them wrote to the
Senior Responsible Officer (SRO) of the Shaping a Healthier Future programme to acknowledge the
decisions which would be required to effect the proposed transition of services, and in doing so each
confirmed that it did not believe it had a material interest in that decision making process. As a result
of these letters, no delegations for decision making were requested or required from these CCGs.
Ealing Hospital also currently provides a Special Care Unit (SCU) as part of its neonatal service.
Following the implementation of the Health and Social Care Act (2012), responsibility for the
commissioning of Specialised Services such as this was transferred to NHS England. For the SCU
service at Ealing Hospital, NHS England in its role as commissioner for Specialised Services will take
its own decision regarding the future of this service at a later date.
6
OVERVIEW OF SYSTEM WIDE
ASSURANCE UNDERTAKEN TO DATE
2
To inform the Ealing CCG Governing Body, an extensive array of assurance has been undertaken by
NHS organisations.
2.1
NHS England Led Assurance
NHS England have undertaken a three stage assurance process.
Stage 1: areas for assurance before a decision is made by Ealing Governing Body on the timing of the
transition
Stage 2: areas for assurance prior to the transition of services
Stage 3: areas for assurance in the year following transition of maternity services
This process is currently in Stage 1 and the outcome of Stage 1 assurance is summarised in a letter
received from NHS England.
This letter is attached to this paper as Appendix C.
2.1.1
Further work arising from NHS England led assurance
Before a decision can be made on the timing of the transition of maternity services, NHS England
seeks further assurance on the following:
Confirmation that number of midwives, consultants, sonographers, as set out in the SaHF
workforce plan place at each receiving site by the time of transition
Director of Operations and Trust Liaison posts filled
Estates work at Queen’s Charlotte will be completed in advance of transition
Testing of maternity booking system for monitoring booking at Trusts
Details of gynaecology emergency model at Ealing Hospital
2.2
North West London CCG Led assurance
Following the decision by the NWL CCGs to delegate decision making authority to Ealing CCG
Governing Body for the timing of the transition of Ealing maternity services, provider focused
assurance reviews have been arranged through December 2014, January 2015 and February 2015.
The objective of these reviews has been to provide assurances to CCGs on the clinical and
operational planning and preparations Trusts are leading on to support the transition of maternity and
neonatal services from Ealing Hospital. The outputs and recommendations from these sessions are
expected to be actioned in preparation for decision making and to support the final decision by Ealing
CCG around the timing and implementation of the transition of maternity services.
The provider focused assurance reviews have been led by the lead commissioner for each Trust in
NWL and have comprised of two parts:
Part one: An CCG led assurance review session at a private meeting of the CCG Governing Body
Part two: A CCG led clinical site visit
7
The reviews commenced in December 2014 and focused on assuring the provider implementation
plans for receiving maternity and neonatal activity from Ealing Hospital, rather than assurance on
provider readiness to handle the additional activity at that point.
All of the provider assurance review sessions have now been completed and the findings are broadly
consistent with the work undertaken by NHS England and the TDA. Assurance will continue and a full
suite of materials presented to Ealing CCG Governing Body at a future meeting.
2.2.1
Further work arising from CCG led assurance
Before a decision can be made on the timing of the transition of maternity services, CCGs seek further
assurance on the following:
Workforce readiness and recruitment plans
Confirmation that the required physical capacity to handle additional maternity and neonatal
activity from Ealing will be in place at the point of transition
Plans for providing community maternity care within the new geographic boundaries
Clinical governance and quality metrics to ensure quality of service is maintained during and after
transition
8
3
3.1
RESOLUTIONS FOR AGREEMENT
Resolutions for agreement on 18th March 2015
Ealing CCG Governing Body is asked to:
(1) NOTE that it has received Delegated Authority from the statutory bodies referenced in Table 1 and
is therefore vested with the authority to take decisions on timing with regard to the agreed maternity,
paediatric and gynaecology service changes at Ealing Hospital on their behalf.
(2) NOTE Appendix B, the document titled "Update on the maternity activity and capacity modelling"
(3) NOTE Appendix C, the letter received from NHS England dated 11th March 2015 "Re: NHS
England assurance on changes to Ealing maternity services" and the recommendations contained
within this letter.
(4) NOTE the further assurance work which is recommended to be undertaken as detailed in sections
2.1.1 and 2.2.1 and AGREE this work should be progressed.
9
A DIRECTORY OF APPENDIX MATERIALS
Appendix A: Model of care for maternity and neonatal services in NWL
Appendix B: Update on the maternity activity and capacity modelling
Appendix C: Letter from NHS England Re: NHS England assurance on proposed changes to Ealing
maternity services
Appendix D: Communications and engagement – update for Ealing CCG: 18th March 2015
10
APPENDIX A
Model of care for maternity and
neonatal services in NWL
18th March 2015
Background and context
Maternity, neonatal and paediatrics will be consolidated across fewer
sites in NWL
The SaHF programme, led by local clinicians, proposed changes to services in NWL that would provide high quality
care through better services for the local population. This included:
1.
Consolidation of maternity and neonatal services from seven to six sites to provide comprehensive obstetric
and midwife-led delivery care and neonatal care.
2.
Consolidation of paediatric inpatient services from six sites to five sites to incorporate paediatric emergency
care, inpatients and short stay /ambulatory facilities.
The key hospital sites for these services would be Chelsea and Westminster, Hillingdon, Northwick Park, Quuen
Charlotte’s and St Mary’s Hospiatls and West Middlesex which will become major hospitals with better services.
The Joint Committee of Primary Care Trusts decision was reviewed by the Independent Reconfiguration Panel (IRP)
on 13 September 2013, who made the following recommendations relevant to the transition of maternity services:
“Commissioners and providers of acute hospital services across north west London must ensure that
changes required to secure safety and quality for patients are made without delay.”
“Maternity and paediatric inpatient services should be concentrated on the sites identified by Shaping a
Healthier Future.”
“The NHS’s implementation programme must demonstrate that, before each substantial change, the capacity
required will be available and safe transition will be assured.”
The Secretary of State accepted the recommendations of the IRP in his statement to Parliament in October 2013.
4
Clinicians and commissioners in NWL are committed to improving the quality and
delivery of maternity and neonatal services in NWL through reconfiguration of
existing services
•
The new service configuration for maternity and neonatal care will see
birthing units and labour ward activity concentrated across six sites in
upgraded facilities, with expectant mothers able to choose between
midwife-led or obstetric-led units.
•
Antenatal and postnatal care will still be provided on the Ealing
hospital site as well as in children’s centres, Health centres and GP
surgeries in Ealing
•
•
•
•
Northwick Park
The new service configuration will enable choice of the environment in
which expectant mothers give birth with all units able to provide
higher quality and safer maternity care and improved access to home
delivery.
The case for consolidating the number of maternity units remains strong
as it will enable all Trusts in NWL to provide significantly more
consultant-led care than currently, working closer towards the London
quality standard for obstetric units to provide 168 hour consultant
presence every week.
250
Imperial
1000
800
Ealing
Hillingdon
In addition, it will enable Trusts to provide more individualised
midwifery care through making it easier for maternity units to work
towards the standard for 1:30 midwife to birth ratio.
600
350
Chelsea and
Westminster
Neonatal services will expand on all six sites in NWL. This will
West Middlesex
provide for a greater number of cots across NWL. At Hillingdon and West
Middlesex Hospital seperate consultant rota for paediatrics and neonatal
Figure 1: Summary of agreed additional maternity activity
services will be implemented providing dedicated cover for neonatal
receiving Trusts can handle upon closure of Ealing Hospital
services.
maternity unit
5
The Secretary of State approved the proposals for reconfiguration of maternity and
neonatal services, the SAHF programme are now planning for implementation
• The outcome of the Independent Reconfiguration Panel (IRP) in September 2013 supported the proposals for
maternity and neonatal services and emphasised that ‘any changes required to secure safety and quality for patients
are made without delay’.
• The announcement of the Secretary of State on 30 October 2013 committed the programme to proceeding with the
changes to maternity services at Ealing Hospital.
• On 19th March 2014, Ealing CCG Governing Body made a decision to invest in early implementation of the transition
of maternity and neonatal services from Ealing hospital. This was in response to a letter from the medical director of
Ealing Hospital to the Medical Director of NHS England outlining the risks associated with the declining birth activity
and maintaining safe services. The clinical risks associated with a precipitate unplanned closure prompted this
decision.
• A Maternity and Neonatal Transition Project was launched in April 2014 to develop plans for each of the receiving
trusts in NWL. Planning for implementation is underway and all of the receiving Trusts are implementing plans to
accommodate the re-provision of activity from Ealing hospital both in terms of physical and workforce capacity.
• The critical path for the implementation plan is based on: ensuring physical and workforce capacity exists at the other
receiving Trusts; implementing a revised clinical model to reflect the changes to pathways while protecting
antenatal/postnatal care for the women of Ealing; delivering clear and targeted communications with stakeholders
and the public and ensuring staff at Ealing transition effectively to receiving Trusts.
• The recent decline in bookings and deliveries at Ealing and increased attrition of their maternity staff, make
implementation of this plan more urgent.
6
Model of care for maternity
and neonatal services in NWL
Model of care for maternity services in NWL – key principles
In line with recommendations from the Shaping a Healthier Future (SaHF) Maternity and Neonatal Project Delivery
Board and national standards and guidance, the core philosophy behind maternity and newborn care in NWL is a
localised and normalised pathway. Pregnancy is a normal physiological event and maternity services should be nonmedicalised where possible. Care should be delivered in the community where appropriate, in partnership with
GPs and embedded within wider community provision of healthcare, social and emotional support services.
Women with more complex medical and/or social or obstetric needs and babies who require neonatal services will have
access to specialist services. The clinical assessment criteria for care will be consistent across all maternity services in
the sector.
Key principles for the maternity services in NWL include:
•
More choice must be offered to woman over antenatal care, birth setting and postnatal care
•
More women should be supported to give birth at home or in midwife-led birthing units.
•
There should be a midwife-led unit alongside every obstetric-led unit. These units are described as ‘alongside
midwifery units’ (AMUs).
•
Women require active 1:1 support from a midwife during active labour, regardless of their chosen place of birth.
•
The most senior medical staff must be available on site to support high-risk births and women who develop
complications during labour with the aim of ultimately achieving cover 24 hours a day, 7 days a week.
8
Model of care for maternity services in NWL - objectives and
expected outcomes
Objectives
To introduce a consistent model of care for maternity and newborn services in NWL to:
•
improve equity of access
•
provide care closer to home e.g antenatal care will be provided in the community supported by structured GP
involvement (via an agreed shared care arrangement)
•
offer a choice in ante-natal care, delivery setting and post-natal care.
•
Improve continuity of care for women throughout their antenatal and postnatal pathway.
Expected Outcomes
•
Women have increased choice of where they receive their antenatal and postnatal care and choice of birth setting.
•
90% of pregnant women who are referred by 10 +6 will receive a full medical and social needs assessment with a
healthcare professional before the 12th completed week of pregnancy.
•
Enhanced patient safety and clinical outcomes by ensuring that patients have access to the most skilled and
specialist staff when needed 24/7
•
Help avoid unnecessary referrals and admissions to hospital or specialist services through offering 24/7 day
assessment and triage facilities.
•
Reduction in inappropriate intervention through development of Alongside Midwifery Led Units
•
Improve patient experience and satisfaction
•
Modernise services in line with new and developing technologies and evidence.
9
Implementation of SaHF maternity proposals will enable the
following clinical and quality benefits can be expected
Workforce
• Overall improvement in midwifery to birth ratios across all five Trusts in
NWL, following transition, with improvement as a sector reaching the
target of 1:30 overall (from 1:32 in 2014/15) and an additional 105
midwives being recruited across the sector.
• Overall improvement in consultant hours on labour ward across all five
trusts in NWL from an average of 101 hours in 2014/15 to 126 hours in
2015/16 (an additional 12 WTE consultants) and on a trajectory towards
168hrs by 2017/18.
• Better alignment between numbers of medical trainees and overall
delivery activity to address historical misalignment
Collaborative working across NWL
Model of care
• Improved community model of care for women – for the first time a
consistent model of care will be implemented across NWL. This will
also enable standardised development of the which creates greater
resilience to build and develop the home birth service across offer in
NWL
• More women will have a named midwife that provides their antenatal
and postnatal care across NWL
• Improved continuity of care across the whole pathway as providers
extend their community midwifery boundaries and offer to women
• Increase in midwifery led services, with all six maternity units
providing alongside midwifery led births options
• Increased awareness of choice across NWL and improved
compliance for 12+6 week bookings target
• Facilitates the creation of sector wide posts for perinatal mental health,
domestic violence and safeguarding
Physical estates and infrastructure
• Facilitates sector approach to community breastfeeding support. NWL
aims to be one of the first sectors to achieve sector wide accreditation in • Improved maternity and neonatal estates for women in NWL as a
Breastfeeding Initiative.
result of the reconfiguration. All units in NWL now have Midwifery
• Development of sector wide model for transitional care, with a sector
Led Unit and Transitional Care beds.
approach to multi-disciplinary education, aiming to reduce the number of
babies separated from mothers
• Facilitates a sector wide review of community obstetric provision
supported by consultants and providers – Northwick park and Hillingdon
already have plans to run this model out of the Ealing hospital site
following transition and following an evaluation of the success this may be
extended to all providers in the future
• Partnership working with GPs and CCGs to improve maternity referral
patterns across NWL
10
Model of care for maternity services in NWL – summary of pathway
Choice
Access
Early pregnancy
Continuity of care
Antenatal
Delivery
Postnatal
Choice from six maternity
providers, supported via
advice from GPs, providers
and a maternity booking
service in NWL
Choice of setting with
more care close to home
(children’s centres, health
centre's, GP surgeries,
community hubs)
Choice of birth setting –
home, midwifery led or
obstetric led
Choice of setting - care
either in home or close
to home in community
settings
Early access to maternity
services by 12+6 weeks
Shared care between
GP/Midwives/Obstetrician
as appropriate
Access to translation,
interpreting and advocacy
services based on an
assessment of need
Access to advice and
support on lifestyle,
breastfeeding, diet,
diagnostics etc
Triage, treat and transfer
protocols to avoid
unnecessary admissions
Access to 24/7 Day
Assessment, early
pregnancy and
emergency gynaecology
services for women should
problems occur
1:1 Midwifery care in
established labour
Increase in midwife to
birth ratios in line with
Birthrate Plus
recommendations (target 1
Midwife to 30 births)
Increase consultant
obstetric presence on the
delivery ward (target for
168hrs presence)
A model of Transitional
Care for babies
Clear handover
protocols and
communication with
identified healthcare
professional for the
transition to parenthood
Enhanced children's
safeguarding through
development of
provider:borough
protocols
Neonatal
All babies needing
on-going neonatal care
have rapid access to the
appropriate level of care
as close to
home as possible. Key
elements include:
• A specialist neonatal
transport service
• Established care
pathways that allow
mothers and babies to
access rapidly a unit
offering the appropriate
level of neonatal care
• Adequate assessment
of need and provision
of appropriate
capacity
11
The proposed model of care for promotes access, choice and
continuity of care for Ealing women
Women
Receiving Trusts
• Can choose their delivery unit from six maternity
providers in NWL
• Will extend their current community boundaries to ensure the
majority of maternity care can be provided locally
• Can choose the location for their antenatal and
postnatal care - either at Ealing Hospital, one of
the children's centres, health centre’s, their local
GP clinic for GP appointments or their host
provider site in NWL
• Will offer women a choice of where to receive their antenatal
and postnatal care depending on ongoing assessment of their
clinical/social risk and needs.
• Will work out of the Ealing Hospital site and Ealing Children's
Centres/health centres to deliver:
• will need to travel to their host provider site for
scanning appointments for their two scans (the
first scan will be combined with their first visit to
the unit)
• Antenatal care (including booking appointment & phlebotomy)
• requiring specialist antenatal care may need to
travel to their host provider or will receive care
locally at the Ealing hospital site
• Breastfeeding clinics
• Hillingdon and London North West Healthcare Trust will offer
consultant led antenatal clinics from the Ealing Hospital site.
• will still be able to access the Early Pregnancy
Assessment Unit at Ealing Hospital Trust
• Will offer scanning services at the host provider site (the first
scan to be combined with first visit).
• Will be able to stay with their babies if they
require transitional care
• Will continue effective local services where appropriate e.g.
diabetes clinic
• Postnatal care
• Parent education classes
12
Proposed changes to
community maternity services
in NWL
Context and executive summary
The purpose of this paper is for Ealing CCG to review and agree
the plans for community maternity services in NWL.
Proposed antenatal and postnatal catchment areas in and around
Ealing borough
This paper outlines:
•
The current and proposed model
•
The benefits of the proposed model
•
Examples of patient stories
The proposed changes to community maternity services were codeveloped by the SaHF Maternity & Neonatal Project Delivery Board
and NWL commissioners. They have been endorsed by SaHF Clinical
Board and SaHF Programme Board.
Northwick
Park
Hillingdon
Hospital
St Mary’s
It should be noted that the proposed NWL community model is highly
flexible and can be adapted and enhanced over time as patterns of
activity for women in NWL emerge. This will be regularly monitored via
data received by the Maternity Booking Service and feedback from
patients and individual Trusts on demand for community services.
Chelsea &
Westminster
West
Middlesex
Alongside this, there will be a detailed review undertaken within three
months of the transfer of Ealing Hospital’s maternity services to develop
an enhanced community model
The proposed changes aim to benefit most Ealing women, by
increasing women's awareness of the choices they have for maternity
provider and where they receive their care., It also aims to improve
continuity of care along their maternity pathway
Queen
Charlotte’s
Ealing
Hospital
London North West
Chelsea & Westminster
Imperial
Hillingdon
London North West/Imperial
West Middlesex
The new community model of care will be implemented in phases:
•
Phase 1 – Testing community model for operational readiness
•
Phase 2 - Implement transitional community model ( transfer existing Ealing community model of care to receiving units)
•
Phase 3 - Review transition model
•
Phase 4 – Ongoing performance improvement
14
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The current model
Current postnatal catchment areas in and around Ealing borough
For the majority of women living in Ealing, the current model of
care does not provide continuity of care across the maternity
pathway
Northwick
Park
The majority of women who live in Ealing borough choose not to deliver
at Ealing Hospital (~60% in 2013/14). These women receive
fragmented maternity care, with different parts of the maternity pathway
delivered by different providers. For example:
• For example, both Hillingdon and Imperial offer ante-natal and
delivery services to Ealing women, but post-natal treatment for
these women is always delivered by Ealing Hospital.
Hillingdon
Hospital
• For women choosing other sites, such as West Middlesex,,
Northwick Park and Chelsea & Westminster ,their ante-natal care
and delivery care is delivered at the host provider site and there is
no option for care delivered locally
St Mary’s
Queen
Charlotte’s
Ealing
Hospital
• Women in Ealing who currently choose another NWL maternity
provider, may not get into their chosen units due to preferential
treatment for women from their host CCG boroughs (this is currently
the case for Ealing women choosing QCCH)
Chelsea &
Westminster
West
Middlesex
• The majority of women in the Kilburn area of Brent currently choose
Imperial and therefore receive their antenatal and delivery care from
Imperial but their postnatal care from London North West Healthcare
London North West
Hillingdon
Imperial
West Middlesex
There are different acceptance criteria between maternity providers in
NWL - most prioritise women from their own ‘host’ CCG boroughs
London North West/Imperial
Ealing
Chelsea & Westminster
Ealing borough
There is currently no sector wide Management Information (MI) which
results in:
• Lack of understanding of the proportion of women from NWL that
receive their first choice which makes it difficult for the sector to
manage capacity appropriately
• Women book at more than one site in NWL; this makes it difficult for
trusts to accurately and effectively plan their services and workload
Women’s stories – what currently happens…
•
Currently, a women booking at Ealing Hospital receives all her care from Ealing
Hospital, either at the hospital or at one of the children’s centres/health centres in the
community
•
If a women from Ealing chooses West Middlesex for delivery, she will have all of her
antenatal and delivery care at the West Middlesex hospital and her postnatal care will
be delivered by Ealing. There is limited choice over where women access their care.
15
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The future model
For the first time, there will be a consistent sector wide community
model with all providers in NWL that aims to improve access, choice
and continuity of care for women in NWL
NWL’s providers, through the Maternity Network and Maternity & Neonatal
Project Delivery Board have collaborated on the development of a new
community transitional model
There are two key aspects of the model of care which will change:
1. Expansion of catchment areas for all trusts delivering maternity
services
• Receiving trusts’ midwifery teams will offer care in the new
community as per the catchment areas map on the right
• Receiving Trusts will utilise the Ealing Hospital site, Children
Centres (CC) and Health Centres (HC) in Ealing to provide routine
antenatal and postnatal care.
• Hillingdon will also provide obstetric appointments at the Ealing site
• Chelsea and Westminster will offer routine antenatal and postnatal
care in Chiswick (currently an Imperial catchment area) enabling
Imperial to expand further into Ealing. If demand requires, then
Chelsea & Westminster can expand further into Ealing in the future
2. Common framework across all trusts in NWL
• The Maternity Booking Service in NWL will give sector wide MI,
enabling joint decisions across the system on demand, capacity and
service improvement
• Acceptance criteria will be the same for all women (prioritised as
below)
1) Women from the Trusts local community area (as defined in
figure in the previous slide)
2) Women with medical or social need
3) Women that have previously given birth at the hospital
4) Women in NW London
5) All other women
Proposed antenatal and postnatal catchment areas in and around
Ealing borough
Northwick
Park
Hillingdon
Hospital
St Mary’s
Queen
Charlotte’s
Ealing
Hospital
Chelsea &
Westminster
West
Middlesex
London North West
Chelsea & Westminster
Imperial
Hillingdon
London North West/Imperial
West Middlesex
Women’s stories – what will happen in the future…
•
If a woman living in the blue (West Midd) area of Ealing chooses Queen
Charlotte's, she has the option to have her antenatal care at Ealing Hospital, a
children's centre in the red Imperial area or Queen Charlotte's site if she requires
specialist input or a scan. She can receive her post natal care from either Queen
Charlotte's (at Ealing Hospital or a children's centre) or from West Middlesex
(either in her home or a local children's centre in the blue area.)
•
If she chooses West Middlesex, she will receive the full pathway from West
Middlesex, choosing between at home, locally at a children's centre or at Ealing
hospital or at West Middlesex Hospital itself.
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Detailed description of the changes in Ealing borough
Services to be provided at HC and CC will mirror (or
be enhanced from ) existing service provision
(session/days)
Overview of service changes by Trust and site:
Proposed antenatal and postnatal catchment areas in and around
Ealing borough
Northwick
Park
Petts Hill CC
West Middlesex University Hospital (WMUH)Trust:
•
Featherstone Road HC (Midwife led AN, PN care)
•
Ealing hub (Midwife led AN, PN care)
•
Scans at WMUH site (combined with first visit)
•
WMUH will review need for Borough consultant-led clinics following
implementation
Horsenden
Lane CC
Islip Manor CC
Perivale CC
Grand Union
Village HC
Jubilee
Gardens HC
Southall
Broadway HC
Featherstone
Road HC
Hathaway CC
Mattock
Lane HC
Ealing
Hospital
Maples CC
Log Cabin
CC
Ealing Hub (Obstetric-led AN care, diabetes clinic)
•
Scans at Hillingdon and Ealing hub (high risk women only), use of
phlebotomy services at Ealing hub for obstetric –led clinics
West
Middlesex
London North West
Imperial College Hospital Trust (ICHT):
Acton
Park CC
Queen
Charlotte’s
Grange CC
South
Acton CC
Islip Manor CC, Southall Broadway HC, Jubilee Gardens HC,
Grand Union Village HC (Midwife led AN, PN care)
•
St Mary’s
John Perryn
CC
Laurel Gardens CC
The Hillingdon Hospital Foundation Trust (THHFT):
•
West
Twyford CC
Windmill
Lane CC
Hillingdon
Hospital
Imperial
Chelsea &
Westminster
Duke
Meadows CC
Chelsea & Westminster
Hillingdon
West Middlesex
Sites for community care
•
Windmill Lane CC,(shared with London North West Hospital Trust
(LNWHT)), Laurel Gardens CC, Grange CC, Mattock Lane CC
(Midwife led AN, PN care, Parent education)
•
Hathaway CC, Log Cabin CC, (Midwife led AN, PN care)
London North West Hospital Trust (LNWHT):
•
Ealing Hub (Midwife led AN, PN care)
•
•
Existing service provision out of Ealing centres will remain (Acton
Park CC, John Perryn CC, Maples CC, South Acton CC and West
Twyford CC)
Horsenden Lane CC, Perivale CC, Petts Hill CC, Windmill Lane CC
(shared with ICHT) (Midwife-led AN, PN care)
•
Ealing Hub (Midwife-led AN, PN care, Obstetric-led AN care)
•
Scans at Northwick Park or Ealing Hospital sites
•
Scans at Queen Charlottes and St Marys (combined with first visit)
ICHT will provide obstetric-led care at hospital sites above and will
review need for Borough consultant-led clinics following
implementation
London North West/Imperial
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Detailed description of the changes outside Ealing borough
Alongside the expansion of community maternity services in Ealing borough,
two community boundaries outside of Ealing are being modified. These were
developed as part of a wider review of the maternity community model
across NWL. This was an opportunity to redefine historical boundaries
across NWL and better align to current and future referral patterns. Both
proposed boundary changes are in areas where there is already a strong
referral pattern to the proposed new provider. Increasing bookings to the
new provider will be facilitated through the offer of full continuity of care to
women in those areas and targeted GP engagement.
Brent – reallocates area from Northwick Park to St Marys
• After the publication of Northwick Park’s CQC report, commissioners
decided to limit the flow of births from Ealing at Northwick Park to 250
births (as discussed at the Clinical Board on the 4th December 2014)*
Proposed antenatal and postnatal catchment areas in and around
Ealing borough
Northwick
Park
Petts Hill CC
Horsenden
Lane CC
Islip Manor CC
Perivale CC
Grand Union
Village HC
Jubilee
Gardens HC
Southall
Broadway HC
Featherstone
Road HC
Hathaway CC
Mattock
Lane HC
Ealing
Hospital
Maples CC
Log Cabin
CC
Acton
Park CC
Queen
Charlotte’s
Grange CC
West
Middlesex
London North West
Imperial
Chiswick – reallocates area from Queen Charlotte’s to Chelsea &
Westminster Hospital
St Mary’s
John Perryn
CC
Laurel Gardens CC
• The Maternity Project Delivery Board (PDB) decided to use this
opportunity to redress historic boundaries as part of a wider review of
community maternity model in NWL
• Parts of Brent (specific parts of NW2, NW6 and NW10) were considered
as appropriate for the transfer due to existing referral patterns. Across the
specific postcodes, over 70% of women already choose ICHT. The
intention, post implementation, is that this rises to 80%
West
Twyford CC
Windmill
Lane CC
Hillingdon
Hospital
London North West/Imperial
South
Acton CC
Chelsea &
Westminster
Duke
Meadows CC
Chelsea & Westminster
Hillingdon
West Middlesex
Sites for community care
• Chelsea and Westminster’s expansion of its MLU and Labour Ward has increased their capacity by 1,000 births. Due to its location with respect to Ealing and
other Ealing sites, the forecast demand at Chelsea & Westminster from Ealing has been far lower than their capacity to absorb additional births
• To spread the Ealing births across NWL’s providers, the Maternity PDB looked to increase the activity to Chelsea & Westminster through the redrawing of
community maternity service boundaries outside of Ealing
• Parts of Chiswick were considered as appropriate for the transfer due, through discussion with CCGs. Across the postcodes, women currently choose
approximately 50% Queen Charlotte’s and 50% Chelsea & Westminster; after the implementation, we intend for this to be approximately 25% Queen Charlotte’s
and 75% Chelsea & Westminster
* It should be noted that it was felt that no action was necessary after the publication of Hillingdon’s CQC because their report did not highlight anything ‘Inadequate” (red
in the report) and the key concerns raised related to the poor estate, which is being addressed as part of the planned refurbishment to support the transition
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Benefits of the proposed community model
For the first time, North West London will have a standardised service across the whole sector with common MI to manage the system and common
acceptance criteria at each site
This, alongside the development of both midwifery and consultant led community care aims to provide greater access to, choice and continuity of care
Current
Future
Women in Ealing who choose to deliver at
another hospital in NWL (~60% in 13/14)
can’t access their antenatal care locally
•
Ealing women currently have variable
continuity of care across the antenatal &
postnatal pathway
•
Women will experience improved continuity of care as a result of NWL units providing antenatal and postnatal
care in Ealing Hospital and children’s centres in the Ealing borough
Queen Charlotte’s currently cannot
accommodate Ealing demand and are
turning Ealing women away
•
Queen Charlotte’s will be able to accommodate more women from Ealing due to the expansion of its maternity
unit on both the QCCH and SMH sites
Units, including Queen Charlotte’s, will treat women from Ealing the same as women that live in their host CCG
borough, thereby increasing the number of women from Ealing able to access their first choice provider
•
•
Women will be able to choose to have their antenatal care at Children’s centres, Health centres in Ealing, Ealing
Hospital, community venues in their chosen providers borough or on the hospital site of their chosen provider.
Those choosing Hillingdon or LNWHT will be able to access consultant led antenatal care from the Ealing
hospital site
To explain to GPs how the new system will operate, example patient journeys have been developed to describe the
continuity care aspect of the proposed community model. These are documented in the following pages.
Simplified patient journeys and explanations that can be used with women are in development to help explain how
the new community model will operate.
19
Patient story 1: Cynthia, Northolt, Standard pathway
Cynthia is 26 years old and lives in Northolt (UB5). She is having her first child and she has no underlying health condition. Cynthia’s
pregnancy is considered to be on the standard care pathway (low risk).
Cynthia has various options for her maternity care. Two are explored below.
Choosing a unit
Booking
After considering advice from her GP, Cynthia chooses
Northwick Park as her first choice. Because she lives within
London North West Healthcare Trusts (LNWHT’s) new
catchment area, she is accepted to the unit (under 1st
admission criteria)
Cynthia meets her named midwife at Pett’s Hill Children’s
Centre (nearest LNWHT site to her home). The midwife
undertakes Cynthia’s booking appointment and will be her
point of contact for her care going forward
After discussions with friends who live nearby, Cynthia
decides to have her baby at Hillingdon Hospital. Although she
is not within Hillingdon Hospital Trust (THHFT’s) new
catchment, she is accepted under the 4th admission criteria
(women within NWL)
Cynthia meets her named midwife at Islip Manor Children’s
Centre (nearest Hillingdon site to her home). The midwife
undertakes Cynthia’s booking appointment and will be her
point of contact for her care going forward
Cynthia’s receives her antenatal care at Islip Manor Children’s
Centre by the Hillingdon midwifery team
Antenatal care
Cynthia’s receives her antenatal care at Pett’s Hill Children’s
Centre by the LNWHT midwifery team
Antenatal care ultrasound scan
Cynthia goes to Ealing Hospital for her ultrasound scans (1012 weeks and 20 weeks) as it is on a direct bus route (282)
from her home.
Cynthia goes to Hillingdon Hospital for her ultrasound scans,
the first one of which is combined with a tour of the unit
Cynthia has her baby at Northwick Park’s maternity unit
Cynthia has her baby at Hillingdon Hospital
Delivery
Postnatal care
Cynthia is visited by a midwife from LNWHT midwifery team at
her home for postnatal follow up
Cynthia is visited by a midwife from LNWHT midwifery team at
her home for Postnatal follow up
20
Patient story 2: Amal, Southall, Intermediate pathway
Amal is 33 year old Somali woman who lives in Southall (UB1). She recently moved to Southall from another part of the UK and has type
2 diabetes. Amal is pregnant with her second child and her pregnancy is considered to be on an intermediate care pathway (medium
risk).
Amal has various options for her maternity care. Two are explored below.
Choosing a unit
After conversations with her GP, Amal decides on Hillingdon
as her first choice. Amal lives in Hillingdon’s new catchment
area so is accepted by the unit (under 1st criteria)
After discussions with her GP and friends who have recently
had children, Amal chooses St Mary’s Hospital. There is
availability so Amal is accepted under 4th admission criteria
(women in NWL).
Booking
Amal meets her named Hillingdon midwife at Southall
Broadway Healthcare centre (nearest Hillingdon site to her
home) The midwife undertakes Amal’s booking appointment
and will be her point of contact for her care going forward
Amal meets her named Imperial midwife at the Ealing
Hospital Hub (nearest Imperial site to her home). The midwife
undertakes Amal’s booking appointment and will be her point
of contact for her care going forward
Antenatal care
Amal receives her Antenatal care at Southall Broadway
Healthcare Centre. The midwife also provides intermediate
diabetes care.
Amal receives her antenatal care at the Ealing Hospital Hub.
The midwife also provides intermediate diabetes care
Amal goes to Hillingdon Hospital for her ultrasound scans (1012 weeks and 20 weeks)
Amal goes to St Mary’s Hospital for her ultrasound scans (1012 weeks and 20 weeks)
Amal has her baby at Hillingdon Hospital
Amal has her baby at St Mary’s hospital
Amal is visited by a midwife from Hillingdon team at her home
for postnatal follow up
Amal is able to request a Postnatal follow up by Imperial
midwifery team at the Ealing Hub or by the Hillingdon
midwifery team at her own home
Antenatal care ultrasound scan
Delivery
Postnatal care
21
Patient story 3: Jackie, Greenford, Intermediate pathway
Jackie is a 22 year old woman who lives in Greenford (UB6). She is expecting her first child. She has previous history of
substance/alcohol misuse. Jackie’s pregnancy is considered to be on the intermediate care pathway (medium risk).
Jackie has various options for her maternity care. Two are explored below.
Choosing a unit
Jackie’s GP refers her to Northwick Park for delivery. Due to
capacity restraints, Jackie is unable to book her delivery at the
site. Jackie is contacted by the Maternity Booking Service
and decides to choose Queen Charlotte’s as she can obtain
care locally and is likely to see continuity of care across the
pathway. As she lives in Imperial Trusts catchment area, she
is accepted into Queen Charlotte’s (under 1st admission
criteria)
Jackie’s GP refers her to Northwick Park for delivery. As she
lives in London North West Healthcare Trust (LNWHT)
catchment area, she is accepted into Northwick Park (under
1st admission criteria)
Booking
Jackie undertakes her booking appointment at Windmill Lane
Children’s centre by a named midwife from the Imperial team
Jackie undertakes her booking appointment at Windmill Lane
Children’s centre by a named midwife from the LNWHT team
Antenatal care
Jackie receives all of her antenatal care at the Windmill Lane
Children’s Centre by her named Imperial midwife
Jackie receives all of her antenatal care at the Windmill Lane
Children’s Centre by her named LNWHT midwife
Jackie attends Queen Charlotte’s Hospital site for her
ultrasound scans (10-12 weeks and 20 weeks)
Jackie attends Ealing Hospital site for her ultrasound scans
(10-12 weeks and 20 weeks) as it is closer to her home
(number 92/282 bus)
Jackie has her baby at Queen Charlotte’s maternity unit
Jackie has her baby at Northwick Park maternity unit
Jackie is visited by a midwife from Imperial midwifery team at
her home for postnatal follow up
Jackie is visited by a midwife from LNWHT midwifery team at
her home for postnatal follow up
Antenatal care ultrasound scan
Delivery
Postnatal care
22
Patient story 4: Priya, Southall, Intensive pathway
Priya is a 30 year old Asian woman who lives in Southall (UB2). She is expecting her third child. She has high blood pressure and
developed pre-eclampsia in a previous pregnancy. Priya’s pregnancy is considered to be on the intensive care pathway (high risk and
therefore requires specialist medical input).
Priya has various options for her maternity care. Two are explored below.
Priya decides on West Middlesex (WMUH) as her first choice
of delivery site as closest to her home. As she lives in
WMUH’s catchment area, she is accepted into WMUH (under
1st admission criteria)
Priya decides on Hillingdon as her first choice of delivery site.
She is accepted to Hillingdon under the 2nd criteria (medical or
vulnerable need)
Priya undertakes her booking appointment at the West
Middlesex Hospital site with an obstetrician.
Priya undertakes her booking appointment at the Ealing
Hospital site with an Hillingdon obstetrician.
Antenatal care
As Priya is on the intensive care pathway, she receives all of
her antenatal care within the West Middlesex Hospital setting,
by an obstetrician (takes bus route 195/267, approx. 30 mins)
As Priya is on the intensive care pathway, she receives all of
her antenatal care within the Ealing Hospital setting, by a
Hillingdon consultant obstetrician
Antenatal care ultrasound scan
Priya attends West Middlesex Hospital site for her ultrasound
scans (10-12 weeks and 20 weeks, plus any additional scans)
Priya attends Ealing Hospital site for her ultrasound scans (1012 weeks and 20 weeks, plus any additional scans)
Priya has her baby at West Middlesex’s maternity unit
Priya has her baby at Hillingdon maternity unit
Priya is visited by a midwife from West Middlesex midwifery
team at her home for postnatal follow up
Priya is visited by a midwife from West Middlesex midwifery
team at her home for postnatal follow up
Choosing a unit
Booking
Delivery
Postnatal care
23
APPENDIX B
Update on the maternity activity
and capacity modelling
9th March 2015
Context and purpose of this document
The purpose of this document is to explain the capacity modelling that has been undertaken to test how maternity activity currently
delivered at Ealing can be absorbed at other sites.
NWL Clinicians developed the Bed Model and Ealing Allocation Model. These have been stress tested and subjected to external review
which highlighted a number of areas that require further clarification. This document provides final updated analysis.
We have stress tested trust capacity plans using the Bed Model developed by the NWL Maternity Network and we have used headroom
analysis to understand the potential impact on women’s choice.
The development of this document provides an opportunity to update three aspects of the assumptions in the modelling:
•
Since the original modelling, we now have additional data of actual deliveries in 2014/15. This have been used to create a forecast for
2014/15.
•
A potential capacity concern at Hillingdon Hospital was discussed at the SaHF Implementation Programme Board on the 29th January
2015 and 2 postnatal beds have been added into Hillingdon’s plans for 2015/16 to address these capacity concerns
•
The trusts have been asked to confirm their maximum capacity in terms of births (based on their own internal trust estimates of
capacity)
Key Messages
Each trust has confirmed that it is confident that the planned bed and staffing capacity will meet the predicted
activity that will transfer from Ealing Hospital.
Further, most trusts forecast that they could take further deliveries if needed.
3
Executive summary (1 of 2)
Context
• The Bed Model used by SaHF was originally built to give a highly cautious recommended
number of beds. Alongside this, flexible bed usage in practice allows units to flex their capacity
further than the model suggests
• The Ealing Allocation Model estimates how Ealing Hospital’s deliveries will split between the
receiving sites across NWL by trying to understand the impact of different drivers of women’s
choice of unit
• Birth rates across NWL have declined each year since 2011/12, with this trend continuing in
2014/15. The predicted outturn for 2014/15 is 29,297 births (270 births below 2013/14)
• The number of beds since 2011/12 has increased slightly and in 2015/16, trusts are planning on
having exactly the same total number of beds as 2013/14 at 423 beds
• North West London managed in 2011/12 to deliver a higher number of births than we are
estimating for any scenario for 2015/16 with fewer beds than the planned bed base in 2015/16.
• Benchmarking (see right) suggests that there are units across the country who are managing
with fewer beds per 1000 births than is proposed in any 2015/16 Scenario for NWL
Scenarios used for stress testing the model
• Two scenarios of the number of deliveries at NWL sites are used to stress test the model. They
are:
– Scenario 1 – 29,297 births (the same number of births as predicted outturn for 2014/15).
This is based on the ONS prediction of no growth
– Scenario 2 – 30,565 births (predicted outturn for 2014/15 + 4.3%). This includes an
allowance of 3,000 births for Ealing Hospital, which is 15% above the forecast outturn for
2014/15 plus the planning assumptions used by trusts.
• These two Scenarios are tested with the different possible Allocations of Ealing’s births
NWL historic beds to births ratio
beds/1000 births
NWL 2013/14
14.3
NWL 2012/13
13.8
NWL 2011/12
13.3
NWL 2015/16 scenarios against other units
nationally
beds/1000 births
Wythenshaw (S
Manchester)
15.8
Bolton
15.5
Birmingham Women's
15.4
NWL 15/16 (Scenario 1)
14.4
Royal Free
14.3
NWL 15/16 (Scenario 2)
13.8
Liverpool Women's
13.4
St George's
13.2
North Middlesex
12.8
Guy's & St Thomas'
12.7
Barnet
11.8
4
Executive summary (2 of 2)
Stress testing bed plans
•
Stress testing each scenario, the NWL system has sufficient capacity using
all allocations of Ealing’s deliveries
– Scenario 1 base case – there is a surplus of 24-27 beds across NWL
compared to the bed model recommendations (equivalent of 1,890 –
2,120 births)
– Scenario 2 high growth case – there is a surplus of 3-11 beds
across NWL compared to the bed model recommendations
(equivalent of 270 – 870 births)
•
•
•
are flexible. A surplus of DAU beds allows the trust to flex antenatal beds
and Hillingdon is able to transfer women in maternity HDU to our main
hospital HDU ward.
Under permutations of the Scenarios and Allocations of Ealing Hospital’s
births, Chelsea & Westminster and Hillingdon are planning on having fewer
beds than the bed model recommends, but both trusts have historically been
more efficient than the number the bed model recommends
Chelsea & Westminster has 6-7 fewer beds than the bed model
recommends. The main contributor is having 6 fewer transitional care beds
than the bed model recommends. Chelsea & Westminster operates a
different transitional care model to other trusts. Postnatal beds are used
flexibly with transitional care beds, enabling beds to be flexed based on
need. Since the opening of the Midwifery Led Unit, there has been
increased capacity in beds across intra partum and postnatal and the trust
has more recovery beds which relieve pressure from the postnatal ward.
Transitional care is supported by nursery nurse lead on the postnatal ward.
There will be additional capacity for transitional care on the neonatal unit
which will be co-located with the postnatal ward as part of the planned
expansion of the neonatal unit. The trust has also secured funding to expand
the neonatal unit and add additional cots if required during 2015/16. This will
allow for shared workforce, more efficient working between the two areas,
and promote mother and baby early bonding by not separating them. As a
result, the trust have confirmed that they are able to manage with their bed
base
Under Scenario 2, Hillingdon’s planned number of beds is 3-5 beds fewer
than the number the bed model recommends. Hillingdon has the physical
space for 4 additional antenatal beds on its antenatal ward or overflow ward
if required. Alongside this, the site has an additional labour ward room that
can be used flexibly with MLU and its bereavement, recovery and HDU beds
Headroom and women’s choice
•
Most trusts are able to take more births than they are planning for 2015/16
•
Under Scenario 1, with most allocations of Ealing’s births including those
with strongest weighting, all trusts have sufficient capacity to serve the
women who choose them
•
Under Scenario 2, there are permutations in which trusts potentially do not
have the capacity to serve the women who choose them. These women,
however, can be accommodated at other sites in NWL
•
In the allocations with the strongest weightings, at least 99% of NWL women
receive their first choice of unit. In the worst case allocation under Scenario
2, 2.4% of NWL women do not receive their first choice, driven by a
shortage at West Middlesex. This allocation (women who deliver at Ealing
Hospital chose to deliver at the unit closest to their GP’s surgery) is not
seen as likely by NWL clinicians (reflected in the Clinical Board weighting of
allocations).
Maternity Booking Service
•
Maternity is a planned service and the Maternity Booking Service being
introduced across NWL will track deliveries and bookings across NWL,
enable the system to manage excess demand for any particular site in NWL
and enable specific sites and the wider system to respond early to changes
in demand
Additional
•
There is additional physical capacity in neonatal cots being developed and,
while neonatal staffing remains an issue for NWL and the nation as a whole,
each of the units are improving their neonatal staffing following the transition
so will be better positioned than currently
•
Trusts have developed detailed workforce and recruitment plans for
2015/16 that are being monitored by the programme as part of the
assurance process
5
Context and modelling
methodology
Historic and planned capacity for maternity and neonatal services
The table below shows that compared to 2011/12, when units experienced a peak in birth
activity yet managed their maternity services, NWL is planning to have more beds to handle
fewer deliveries forecast in 2015/16.
Deliveries
Beds
Neonatal cots
2011/12
2012/13
2013/14
2014/15
2015/16
31,600
30,700
29,600
419
423
423
432
423
-
-
158
158
165
29,300* 29,300**
* Predicted outturn for 2014/15 based on 8 months of data
** Forecast for 2015/16 applying ONS growth forecast
7
The modelling approach considers the system capacity in terms of
both births and beds
Different demand scenarios are tested against the maximum number
of births that trusts can take to understand the headroom at each trust
and the impact on women’s choice
Demand in births for NWL sites
Scenarios for births across
NWL
+
Different ways of
allocating Ealing’s births
to receiving trusts
Different permutations of
Scenarios and Allocations
give a distribution of births
across NWL sites
The Bed Model recommends a number of inpatient beds, by type, for
each site under different permutations. These are tested against the
planned number of beds at each site in 2015/16
Recommended number of beds for each site
Different permutations of
Scenarios and Allocations
give a distribution of births
across NWL sites
Recommended number of
beds for each site under
each permutation
This uses the Ealing Allocation Model developed by NWL Clinicians, which
uses six different ways (allocations) of understanding where the women
currently choosing Ealing Hospital may choose to go, based on historic activity,
proximity to sites, GP referrals, and women’s preferences.
This uses the Bed Model which was developed by the NWL Maternity
Network, using best practice sources including Safer Childbirth (RCM) and
Royal Colleges guidance. It recommends a number of inpatient beds for each
site depending on acuity and the number of births it is expected to receive.
Alongside this, different Scenarios for total numbers of births across NWL sites
are tested. Each permutation of Scenarios and Allocations gives a distribution
of births across receiving NWL sites.
For each permutation of Scenarios and Allocations, the Bed Model
recommends a number of beds for each site, by type of bed.
Headroom and first choice analysis is conducted by comparing
the number of births sites are allocated in each permutation of
Scenarios and Allocations by the Ealing Allocation Model with the
maximum number of births that each site can accommodate
Bed numbers are stress tested by comparing the number the Bed
Model recommends under each permutation of Scenarios and
Allocations with the planned number of beds for 2015/16
Maximum number of births that each site can accommodate
The planned number of beds at each site for 2015/16
Scenarios – the overall demand Scenarios for NWL births that have been used
Allocations – the different ways of understanding where the women currently choosing Ealing Hospital may choose to go
8
The Bed Model developed by SaHF provides generous capacity
The NWL bed model was developed by the NWL Maternity Network, using best practice sources including Safer Childbirth (RCM) and
Royal Colleges guidance. The result is a recommended inpatient bed model for a 6000 birth unit, dependent on the acuity of the unit:
Unit acuity
Level 1
Level 2
Level 3
Triage/
OPD
induction
6
4
6
4
6
4
Mid-wifery
Led Unit
DAU
Ante-natal
4
4
4
15
18
20
Labour
ward
11
11
12
Bereavement
2
2
2
Theatres
2
2
2
HDU
Recovery Post-natal
2
2
2
4
4
4
27
28
29
Transitional Care
6
6
6
Total
beds
73
77
81
There are various factors which contribute to the bed model recommending more beds than sites need
Model reviewed and
signed off by
The model was deliberately built to be highly cautious in its recommended number of beds for sites and therefore
• Heads of Midwifery
provides an overestimate of the required capacity at sites:
across NWL
• The bed model rounds up the required number of resources. Therefore, for a unit delivering 3000 births, the bed
• Maternity Network
model recommends 1 theatre, but for a unit delivering 3001 births, the bed model recommends 2 theatres
(because it rounds 1.0003 up to 2).
• Maternity & Neonatal
Project Delivery
• Beds are used flexibly in practice, based on adjacency and trust operating models but this is not reflected in the
Board
model
• The model does not factor in site efficiency (beds to births ratios or length or stay), so those sites which are more • SaHF Clinical Board
efficient potentially have fewer beds than the bed model recommends
• SaHF Programme
Board
• A very low level of home births is assumed and units are proactively encouraging women to chose home births
so this is expected to rise
• There are various types of beds which have been catered for in the model which are unlikely to be used in
practice in the same numbers. This is shown most clearly with bereavement beds. Currently, all receiving sites
apart from Northwick Park have 1 bereavement bed. Northwick Park use a labour ward room suitable for
bereavement. If an additional bereavement room are needed, then trusts use a appropriate delivery room
• Labour ward beds are the least flexible beds and therefore the model builds in occupancy at just 60% to allow for
surge.
9
Clinicians developed an Ealing Allocation Model to estimate how
Ealing Hospital’s deliveries will split between receiving sites in NWL
The Ealing Allocation Model uses six different ways (allocations) of understanding where the women currently choosing Ealing Hospital may choose to go,
based on historic activity, proximity to sites, GP preferences, and women’s preferences. NWL clinicians (SaHF Clinical Board) agreed a weighting of these
based on confidence in the different allocations to use as the best available predictor of where women will choose to go.
Description
Approach
Weighting
agreed by
Clinical Board
1
2
3
4
5
6
Practice proximity
Referral patterns /
practice proximity
Current referral
patterns
GP survey
Children’s centre
survey
Ealing Hospital survey
All Ealing CCG women
deliveries are
redistributed based on
women's practice
proximity to their
nearest provider
Women who deliver at
Ealing hospital transfer
to next closest provider
to the women's
practice. Women who
currently deliver
elsewhere remain
unaffected.
Visitors at Ealing
children’s centres gave
second choices and
these are applied
based on where they
are resident
Women who deliver in
Ealing Hospital transfer
in accordance to the
surveyed women's
response in each
respective postcode
0%
10%
10%
40%
Women who deliver at A GP survey provided
Ealing hospital transfer locality based
according to the
preferences.
proportions of women
at each practice who
use the alternate
providers
Two modifiers are applied to the outputs of this
•
Firstly, the implementation of Imperial’s site and clinical
strategy allocates 80% of Imperial’s Ealing birth allocation to
Queen Charlottes and 20% of Imperial's Ealing allocation to
St Mary’s
•
Certain boundaries for community services between trusts
are re-drawn in Chiswick and Brent, reallocating 264 births
from Northwick Park to Imperial’s two sites (mainly St
Marys) and 282 births from Imperial (mainly QCCH) to
Chelsea & Westminster
30%
10%
The weighted allocation
•
•
•
Model reviewed and
signed off by
The SaHF Clinical Board developed a Weighted allocation
• Heads of Midwifery
from these using the weightings above
across NWL
They agreed that: Allocations (3) and (6) have the
• Maternity & Neonatal
strongest weighting with the others having reduced
Project Delivery
weighting due to (1) ignores existing referral patterns (2)
Board
uses straight line distance rather than travel time and (4)
• SaHF Clinical Board
and (5) have low sample size surveys
• SaHF Programme
Therefore, the Weighted Allocation was agreed to produce
Board
an allocation that was considered the best available
predictor of where Ealing women will choose to go
Henceforth, these are referred to as Allocations in the remainder of this document
10
Detailed analysis
While number of deliveries has declined in NWL since 2011/2012,
the number of beds has increased slightly over this time period
Number of births
Number of births at NWL sites
40k
- 4%
- 1.5%
31.6k
30.7k
30k
Current outturn for 2014/15 suggests the trend of declining
births across North West London’s hospitals will continue
- 1%
29.6k
29.3k
Ealing
St Mary's
•
Over the past 3 years, we have seen a year on year decline in
the number of births across North West London, since the
sector’s peak in 2011/12
•
Using the first eight months of the year, we forecast that outturn
for the year is expected to be 29,297 a 1% reduction on 2013/14
deliveries
Hillingdon
20k
West Midd.
Northwick Park
10k
Queen Charlotte's
Chel West
k
2012/13
2013/14 2014/15 (F)
The bed base has remained relatively consistent over the
past few years
•
•
•
The number of beds has remained consistent over the
past few years, with growth in 2014/15 as a result of an
increase in MLU beds at Chelsea & Westminster,
providing the system with capacity for an additional 1000
births
The result of the slight growth in beds with the decrease in
births has seen the number of beds per 1000 births
increase from 13.3 in 2011/12 to 14.7 in 2014/15 (F).
None of the units across NWL has delivered their full
capacity in births in any of these years.
Number of beds at NWL sites
Number of beds
2011/12
The increase in capacity in 14/15 supports us to prepare to
transition Ealing’s service while retaining the same number of total
beds in 13/14. The increased bed number for 14/15 is driven by
the opening up of MLU and Labour Ward beds at Chelsea &
Westminster, providing the system capacity for an additional 1000
births. Alongside this, West Middlesex has beds ready to open.
500
419
423
423
432
423
Ealing
400
St Mary's
300
Hillingdon
West Midd.
200
Northwick Park
100
Queen Charlotte's
Chel West
0
2011/12
2012/13
13.3
13.8
2013/14 2014/15 (F)
2015/16 Planned
14.3
14.7
14.4*
Beds per
1000 births
* Based on Scenario 1
12
Two scenarios for deliveries are used to stress test the capacity of
the system
•
•
Scenario 1 – 29,297
births (the same number
of births as predicted
outturn for 2014/15). This
is based on the ONS
prediction of no growth in
births in NWL
Scenario 2 – 30,565
births (Scenario 1 + 4.3%).
This was arrived at by
asking trusts for their likefor-like planning figures for
2015/16 and including an
allowance of 3,000 from
Ealing Hospital (compared
to 2,614 births forecast at
Ealing Hospital in
2014/15)
The number of births in
Scenario 2 (30,565) is fewer
than the number of births
seen in 2011/12 (31,600) in
North West London and
NWL is planning a higher
bed base (423 compared to
419).
Total number of births at NWL sites – historic and applying ONS growth forecasts
Number of births
Two scenarios are used in
testing the capacity in the
system for 2015/16:
40k
Two scenarios used
40k
31.6k
30.7k
29.6k
29.3k
29.3k
29.2k
29.2k
30k
30k
Based on
ONS growth
forecasts
20k
Actuals for
NWL (inc.
14/15 forecast
based on first
8 months)
10k
k
11/12
12/13
13/14
14/15
(F)
15/16
(ONS)
16/17
(ONS)
17/18
(ONS)
29.3k
30.6k
20k
10k
k
Scen 1
Scen 2
Each of the two Scenarios is applied to different possible Allocations of Ealing births to the receiving
sites
•
Allocations (2) to (6) are used because they were the components of the Weighted allocation the SaHF
Clinical Board agreed
•
The Weighted allocation, agreed by SaHF Clinical Board, is used
•
(1) is not used as it did not form part of the Weighted allocation signed off by Clinical Board
•
We therefore stress test the total system with 12 permutations of Scenarios and Allocations
•
See slide for 9 for an overview of the Ealing Allocation Model
13
Stress testing each scenario demonstrates that the NWL system
capacity will be sufficient using all allocations of Ealing’s births
Beds/1000 births
NWL-wide bed capacity will be sufficient to handle demand in all permutations of Scenario 1 and Scenario 2
•
11/12
13.3
12/13
13.8
13/14
14.3
14/15 (F)
14.7
15/16
Scen 1
14.4
15/16
Scen 2
13.8
Scenario 1
– Across the different allocations of Ealing’s births, there are 24-27 more beds planned across NWL than
recommended by the bed model
– With the Weighted allocation, considered by NWL clinicians as the most likely allocation, there is a surplus of 24
beds across the NWL system
•
Scenario 2
– Across the different allocations of Ealing’s births, there are 3-11 more beds planned across NWL than the bed model
recommends
– With the Weighted allocation, there is a surplus of 10 beds
• While there are differences between the planned number of beds and the recommended by the bed model for different
types of bed, each service is able to flex beds differently (dependent on adjacency and operating model)
The programme has sought confirmation from each trust that individual sites are able to flex beds appropriately to
manage demand and each trust has confirmed it is confident it will be able to meet anticipated demand
Inpatient beds by type
Total
beds
The best and worst for each scenario is
based on the different ways of allocating
Ealing births between receiving sites. These
are given with the Weighted allocation
The variation between the different allocations
(even with splitting the same number of births
between sites) is driven by two factors in the
bed modelling – the rounding up and the
difference in acuity in sites
Midwifery
Led Unit
Antenatal
Labour
ward
Not inpatient beds
Bereavement
HDU
Recovery
Scen. Allocation
2015/16 planned
423
31
97
66
7
11
22
Scenario 1 - Difference between beds planned and recommended by bed model
24
Worst (All. 3)
0
7
6
-5
-1
-1
27
Best (All. 2)
0
8
8
-5
-1
0
24
Weighted
-1
6
9
-5
-1
-1
Scenario 2 - Difference between beds planned and recommended by bed model
3
Worst (All. 4)
-3
2
5
-6
-2
-2
11
Best (All. 3)
-2
4
5
-5
-1
-1
10
Weighted
-2
4
5
-5
-1
-1
Postnatal
Transitional
Care
Triage/
OPD
induction
DAU
Theatres
157
32
24
26
12
17
16
17
1
1
0
1
2
1
3
4
3
0
0
0
11
12
11
-2
-1
-1
0
1
1
2
3
3
-1
0
0
Currently, all receiving sites apart from Northwick Park have 1 bereavement bed. Northwick
Park use a labour ward room suitable for bereavement. If an additional bereavement room
are needed, then trusts use a appropriate delivery room. The model recommends that any
unit between 3000-6000 births has 2 bereavement beds i.e. 12 in total for NWL, which is 9
more than the current number of 4 bereavement beds and 6 more than the planned 7.
14
While there is sufficient capacity across NWL, there are two trusts
which are planning fewer beds than the model recommends
For each Scenario, the worst, best and weighted allocations (in terms of difference between the planned number of beds and the bed model
recommendations). The breakdown by trust is shows for each of these allocations.
Scenario 1 – difference between planned and recommended beds
2013/14
ACTUAL
NWL SYSTEM
St Mary's
Queen Charlotte's
Chelsea & West.
West Middlesex
Northwick Park
Hillingdon
Scenario 1
Worst (All. 3) Best (All. 2) Weighted
24
27
24
7
4
-5
3
5
-3
3
9
-7
11
7
1
5
19
-6
2
3
4
4
11
-6
8
6
1
Scenario 2 – difference between planned and recommended beds
2013/14
ACTUAL
NWL SYSTEM
St Mary's
Queen Charlotte's
Chelsea & West.
West Middlesex
Northwick Park
Hillingdon
Scenario 2
Worst (All. 4) Best (All. 3) Weighted
3
11
10
7
4
-5
3
5
-3
2
-1
-6
7
6
-5
2
7
-7
7
5
-3
2
8
-6
6
3
-3
Stress testing indicates that there will be sufficient capacity under all scenarios, but some choice may be decreased
• Under Scenario 1, the bed model recommends more beds for Chelsea & Westminster than the trust is planning
• Under Scenario 2, the bed model recommends more beds for Chelsea & Westminster and Hillingdon than either trust is planning
• Operational models at Chelsea & Westminster and Hillingdon are different from other trusts. For both trusts, we see (from the first column) that when we
compare this to actual births and beds for 2013/14, the bed model recommends more beds than the trusts used to manage their services.
• Chelsea & Westminster has 6-7 fewer beds than the bed model recommends, the main contributor being 6 fewer transitional care beds. Chelsea &
Westminster operates a different transitional care model to other trusts. Postnatal beds are used flexibly with transitional care beds, enabling beds to be
flexed based on need. Since the opening of the Midwifery Led Unit, there has been increased capacity in beds across intra partum and postnatal and the trust
has more recovery beds which relieve pressure from the postnatal ward. Transitional care is supported by nursery nurse lead on the postnatal ward. There
will be additional capacity for transitional care on the neonatal unit which will be co-located with the postnatal ward as part of the planned expansion of the
neonatal unit. The trust has also secured funding to expand the neonatal unit and add additional cots if required during 2015/16. This will allow for shared
workforce, more efficient working between the two areas, and promote mother and baby early bonding by not separating them. As a result, the trust have
confirmed that they are able to manage with their bed base
• Under Scenario 2, Hillingdon’s planned number of beds is 3-5 beds fewer than the number the bed model recommends. Hillingdon has the physical space for
4 additional antenatal beds on its antenatal ward or overflow ward if required. Alongside this, the site has an additional labour ward room that can be used
flexibly with MLU and its bereavement, recovery and HDU beds are flexible. A surplus of DAU beds allows the trust to flex antenatal beds and Hillingdon is
able to transfer women in maternity HDU to our main hospital HDU ward.
The programme has confirmed local plans from both trusts to ensure that they have sufficient flexibility in their bed base to deal with potential
demand.
15
99-100% of North West London women receive their first choice of
maternity unit in all likely permutations
Trusts have indicated that they would be able to accommodate more births than they have assumed in
their capacity planning (see chart right for the maximums). These have been used to understand
headroom at each site and the impact on choice*.
In most permutations of Scenarios and Allocations, at least 99% of women receive their first
choice (see table below)
• The number of women in NWL who currently receive their first choice is unknown. The introduction
of a Maternity Booking Service in North West London will enable this to be tracked and help the
system to manage peaks in demand across trusts.
• The worst case for both scenarios is under Allocation (2), in which women who deliver at Ealing
Hospital choose to instead deliver at the unit closest to their GP’s surgery. This scenario is not seen
as likely by NWL clinicians (reflected in the Clinical Board weighting of allocations).
• Using the allocations of Ealing’s births considered good predictors by NWL clinicians – (3), (6) and
the Weighted – the proportion of women who do not receive their first choice is 0.0% in Scenario 1
and 0.2-0.6% in Scenario 2
In all permutations where women do not receive their first choice there is enough capacity
across NWL to accommodate them.
The impact on women’s choice is therefore expected to be minimal for all women across NWL
including women from the Ealing.
40k
29.3k
30.6k
30k
31.8k
5,500
5,300
20k
West Mid
5,000 Northwick Park
4,000 Hillingdon
10k
6,000
6,000
St Mary's
Queen
Charlotte's
Scen 1
Scen 2
Maximum trusts
can take
The modelling suggests the following proportion of women will not receive their first choice unit under different permutations of scenarios and
allocations of Ealing’s births:
Scenario 1
Scenario 2
In both Scenarios 1 and 2, using
Allocation (2), the women’s whose
choice may be affected are those
who choose West Middlesex
(regardless of where they are from
in NWL)
2
1.2%
2.4%
3
0.0%
0.2%
The women’s whose
choice may be affected are
those who choose
Hillingdon (regardless of
where they are from in
NWL)
4
0.0%
0.9%
5
0.0%
0.0%
The women whose choice may be affected are
those who choose primarily Hillingdon (regardless
of where they are from in NWL). In this
permutation, some women who choose Queen
Charlotte may not receive their first choice (10%
of those whose choice might be affected)
6
Weight.
0.0%
0.0%
0.6%
0.3%
The women’s whose
choice may be affected
are those who choose
Hillingdon (regardless of
where they are from in
NWL)
The women’s whose
choice may be affected
are those who choose
Hillingdon (regardless of
where they are from in
NWL)
* Method applied - The total number of women who may not able to deliver at their chosen site from the headroom analysis are considered as a proportion of the total women in North West London.
These are calculated using the maximum number of births that each site can take and comparing to the number that each site is allocated under each permutation of allocation and scenario. These are
then represented below as a proportion of the total number of women.
16
Ealing women will also have increased choice in community care
There will be more choice for
Ealing women about where they
access their care and greater
continuity of care during their
antenatal and postnatal pathway
• The majority of women who live in
Ealing borough choose not to
deliver at Ealing Hospital (~60% in
2013/14)
• Continuity of care is currently
limited and women may not get
into their chosen units due to
preferential treatment of those
from more traditional boroughs
(this is currently the case for
Ealing women choosing QCCH
today)
• Those who would have chosen
Ealing Hospital will be treated by
the same principles as are
currently applied across London.
The extension of community
services into Ealing will enable
better continuity of care for Ealing
women (see example on right)
• For the first time, all NWL
providers have agreed common
acceptance criteria for women and
these will help to ensure that all
women in North West London,
including Ealing women, are
treated equally.
Benefits of the new proposed community model
Current
Future
Women in Ealing who choose
to deliver at another hospital in
NWL (~60% in 13/14) cant
access their antenatal care
locally
•
Ealing women currently have
variable continuity of care
across the antenatal &
postnatal pathway
•
Women will experience improved continuity of care as a result of NWL units
providing antenatal and postnatal care in Ealing Hospital and children’s centres
in the Ealing borough
Queen Charlotte’s currently
cannot accommodate Ealing
demand and are turning Ealing
women away
•
•
Queen Charlotte’s will be able to accommodate more women from Ealing
Units, including Queen Charlotte’s, will treat women from Ealing the same as
women that live in their host CCG borough
•
Women will be able to choose to have their antenatal care at Children’s centres,
Health centres in Ealing, Ealing Hospital, community venues in their chosen
providers borough or on the hospital site of their chosen provider.
Those choosing Hillingdon or LNWHT will be able to access consultant led
antenatal care from the Ealing hospital site
Worked example of what will happen to
Ealing women
Northwick
Park
•
Hillingdon
Hospital
St Mary’s
Queen
Charlotte’s
Ealing
Hospital
Chelsea &
Westminster
West
Middlesex
•
London North West
Chelsea & Westminster
Imperial
Hillingdon
London North West/Imperial
West Middlesex
If a woman living in the blue (West Midd) area
of Ealing chooses Queen Charlotte's, she has
the option to have her antenatal care at
Ealing Hospital, a children's centre in the red
Imperial area or Queen Charlotte's site if she
requires specialist input or a scan. She can
St receive her post natal care from either Queen
Mary’s
Charlotte's (at Ealing Hospital or a children's
centre) or from West Middlesex (either in her
home or a local children's centre in the blue
area.)
Chelsea &
Westminster
If she chooses
West Middlesex, she will
receive the full pathway from West
Middlesex, choosing between at home,
locally at a children's centre or at West
Middlesex Hospital itself.
17
There will be additional physical capacity in neonatal cots with all
receiving trusts implementing robust recruitment plans
There will be an additional physical capacity of 15 neonatal cots
Special care cots
120
Number of cots
100
87
89
86
92
104
5
99
92
80
•
There will be additional physical capacity across the system with
7 more cots planned and a potential additional 11 if required
(across both Special Care and HD/IC)
•
The 11 additional cots are made up of 6 HD/IC cots at Chelsea at
Westminster (budget approved and can be used as SC if
necessary) and 5 SC cots at West Middlesex (they have space
but subject to commissioning)
•
Trust plans to increase transitional care beds across North West
London will reduce the demand on special care neonatal cots
•
The capacity planning for neonatal cots has been reviewed and
signed off by:
Potential
additional cots if
necessary
60
40
Physical Capacity
20
0
2011/12 2012/13 2013/14
2013/14 2014/15 2015/16
Cot usage (activity at 80%
occupancy)
Physical Capacity
High dependency and intensive care cots
80
66
Number of cots
62
60
51
56
66
72
6*
66
40
Potential
additional cots if
required
20
Physical Capacity
2013/14 2014/15 2015/16
Cot usage (activity at 80%
occupancy)
Physical Capacity
Neonatal leads from each Trust
–
The Maternity & Neonatal Project Delivery Board
–
NHS England’s specialist commissioners for Neonatology
–
SaHF Clinical Board
–
SaHF Programme Board
Specialist nurses staffing levels have been considered in the
transition planning
•
The shortage of neonatal specialist nurses is a concern that has
been raised and reviewed nationally
•
The transfer of Ealing’s neonatal nurses has been planned to
broadly follow activity, which will enable trusts to meet the
potential increase in activity
•
Alongside this, the Neonatal network is sharing demand
management approaches between trusts, which will support the
introduction of transitional care, which in turn will reduce demand
0
2011/12 2012/13 2013/14
–
* Chelsea & Westminster has budget approved for up to 6 neonatal HD/IC cost if needed.
18
All trusts are making progress in 2015/16 towards meeting target
Total numbers across NWL
quality standards for workforce levels
Trusts have comprehensive workforce and recruitment plans which are supported by the transfer
of Ealing staff
•
All the trusts have developed workforce plans based on their capacity planning assumptions
(Scenario 2) and the weighted allocation of 3000 Ealing births
•
The implementation of SaHF (including the transfer of Ealing Hospital’s maternity services) is an
enabler for trusts working towards achieving London Quality Standards (LQS) by 2017/18
•
2014/15
in post
Role
Midwives
935
1040
+ 11%
O&G consultants
97
109
+ 13%
Neonatal nurses
259
322
+ 25%
Including Ealing transfer and local recruitment plans
All trusts are making progress in 2015/16 towards the achievement of LQS (a midwife to birth ratio of
1:30 and consultant presence on labour ward of 168 hours)
Midwifery ratios
14/15 in- 15/16 planned
post ratio
ratio
Trust
Midwifery ratios
• 4 out of 6 sites are expected to achieve the midwifery ratio of at least 1:30 in 2015/16
• Hillingdon and West Middlesex, the two sites not achieving the ratio in 2015/16 are
significantly improving their midwife to birth ratios as a result of the transition and have
plans to work towards meeting 1:30 midwife to birth ratio by 2017/18
• As a sector, NWL will achieve an overall average of 1 midwife to 30 births following
transition.
2015/16
planned Change
Chelsea & West.
Imperial
Northwick Park
Hillingdon
West Middlesex
Ealing
NWL
1:32
1:33
1:25
1:33
1:36
1:30
1:32
1:30
1:30
1:27
1:32
1:33
1:30
2015/16 ratio based on Scenario 2 births – trust plans
Obstetrics & Gynaecology consultant cover
• 5 out of 6 sites are planning to increase their Consultant cover in 2015/16
• All of the trusts are committed to working towards meeting the 168 hour consultant
cover target by 2017/18
• As a sector, the average will increase from 101 hours to 122 hours in 2015/16
Neonatal nurses
• The shortage of neonatal specialist nurses is a concern that has been raised and reviewed
nationally and the changes by SaHF will not affect this negatively
• The transfer of Ealing’s neonatal nurses has been planned to broadly follow activity, which
will enable trust to meet the potential increase in activity
• Alongside this, the Neonatal network is sharing demand management approaches between
trusts, which will support the introduction of transitional care, which will reduce demand.
Consultant cover in 2014/15 and 2015/16 (planned)
Chelsea and
West.
Queen
Charlotte's
St Mary's
110 to 115
98 to 134
98 to 108
Hillingdon
96 to 114
West
Middlesex
AVERAGE
Hrs cover in
2015/16
(planned)
stays at 98
Northwick
Park
Ealing
Hrs cover in
2014/15
144 to 164
60 hrs in
2014/15
101 to 122
19
APPENDIX C
Simon Weldon
NHS England London
Southside
4th Floor
105 Victoria Street
London
SW1E 6QT
Dr Mohini Parmar
Chair Ealing CCG
Cc:
Clare Parker Chief Officer CWHHE CCGs
Rob Larkman Chief Officer BHH CCGs
Thirza Sawtell SRO SaHF Programme
11 March 2015
Dear Mohini
Re: NHS England assurance on changes to Ealing maternity services
As you know, as part of Shaping a Healthier Future to transition Ealing maternity services to
other Trusts in NW London, NHS England has set out a three stage assurance process:
Stage 1: areas for assurance before a decision is made by Ealing Governing Body on the
timing of the transition
Stage 2: areas for assurance prior to the transition of services
Stage 3: areas for assurance in the year following transition of maternity services
I am writing to let you know the outcome of our Stage 1 assurance.
As part of our Stage 1 assurance, we commissioned a number of external reviews and
worked with NHS Trust Development Authority colleagues reviewing documentation
provided by the SaHF team. Set out below is a summary of the recommendations from:
1. The London Clinical Senate Review
2. Outcome of clinical conversations with lead clinicians in NW London Trusts
3. Review of SaHF demand and capacity modelling
4. Outcome of Stage 1 assurance.
1. The London Clinical Senate Report
In December 2014, NHS England commissioned the London Clinical Senate to advise on:
 Has there been any substantive change to the case for change since it was accepted
by Secretary of State in October 2013
 Do the clinical models remain appropriate
 The proposed timing of these changes.
NHS England received the London Clinical Senate report on 6 February 2015. The Review
Team found no material issues that alter the strategic case for change presented in 2013. At
an operational level, they found the drivers for change have accelerated since the case for
change was accepted especially in maternity, increasing risks to clinical quality and safety.
1
Overall, the Review Team found the clinical models remain appropriate. They found the
model for maternity services will improve quality and choice and is consistent with the
recently published guidance from NICE and the NHS Five Year Forward View.
With regard to timing, the Review Team advised very strongly that maternity services at
Ealing should move in line with a proposed transition date of June 2015. Retaining the
service beyond this timescale would significantly increase the risk of unplanned closure of
the unit.
The Review Team also recommended that NHS England sought assurance on the following:
1. Further detail on the emergency gynaecology service at Ealing Hospital
2. Satisfactory arrangements were in place for transitional and outreach neonatal
services
3. Development of an innovative paediatric service model at Ealing.
2. Clinical conversations between London Strategic Clinical Network Clinical
Director and North West London clinicians from Trusts affected by SaHF
proposals
In February 2014, NHS England commissioned the Clinical Senate to undertake
conversations with maternity, neonatology, gynaecology and paediatric clinicians in NW
London Trusts. Views were unanimous from maternity and neonatology clinicians that
Ealing services needed to transition to the planned timetable. Paediatric and gynaecology
clinicians at Ealing were confident about the services planned to remain at Ealing following
the transition of maternity services. All clinicians at London North West Healthcare, Imperial
College Healthcare, West Middlesex, Chelsea and Westminster and Hillingdon Hospital
Trusts were supportive of increased service provision at these sites and the timetable
proposed.
3. Review of capacity and demand models
In December 2014, NHE England commissioned Ernst and Young LLP (EY) to review SaHF
demand and capacity modelling for maternity and neonatal services underpinning the plans.
EY provided a report with recommendations. These recommendations together with
SaHF’s response formed the basis of a workshop held on 12 February and a final workshop
held on 19 February. The conclusions arising from the EY review and workshops are
contained in 4.II below.
4. Outcome of Stage 1 assurance
The Stage 1 assurance was undertaken in three sections:
I.
Case for change
II.
Impact of activity moving to receiving sites
III.
Impact on paediatric and gynaecology services remaining at Ealing Hospital post
maternity transition
The outcome of the assurance is summarised below with further detail given in the following
paragraphs.
Assurance section
Case for change
Impact of activity moving to receiving sites
Impact on paediatric and gynaecology
services remaining at Ealing Hospital post
maternity transition
NHS England decision
Assured
Partly assured
Partly assured
2
Case for change
As a result of the Clinical Senate Report and Clinical Conversations, NHS England are
assured there is a clear, well-articulated case for change that is supported by Trust
clinicians, strategic clinical network leaders and the London Clinical Senate. The risks of
delaying the transition of maternity services are clearly identified. The planned transition is
consistent with NICE guidelines and the Five Year Forward View. NHS England is fully
assured on the case for change.
Impact of activity moving to receiving sites
Demand
On behalf of the CCGs and providers, SaHF developed an allocation model to understand
how Ealing births may be distributed to receiving sites and developed a bed model which
recommended maternity impatient bed numbers based on acuity of site and number of
deliveries. The SaHF programme also developed a workforce model. EY reviewed the
distribution and capacity models for maternity and neonatal services. EY’s final report
confirmed that overall modelling was robust. The first workshop concluded that flat growth
for births was the most realistic assumption to model capacity on. Capacity plans for Trusts
include excess capacity for growth of 1300 births. NHS England is therefore assured that
sufficient capacity has been built into the plans.
Workforce
Detailed workforce modelling linked to demand planning, has been undertaken. Receiving
Trusts have comprehensive workforce and recruitment plans in place which are supported
by the transfer of Ealing staff. NHS England is partly assured on workforce. Further
assurance is sought that the numbers of staff as set out in the February 2105 workforce
plan, will be in place at all receiving sites before implementation.. Posts to support Trust
implementation have been established including an Operations Director and Trust liaison
posts. As part of Stage 3, further assurance will be sought on continued movement towards
London and national standards for improved staffing levels, where appropriate.
Physical capacity
Sufficient physical space is available at Northwick Park, West Middlesex, Chelsea and
Westminster, Hillingdon and St Mary’s to receive the transfer of maternity and neonatal
services. Sufficient space at Queen Charlotte’s is dependent on estates work being
completed in May 2015. NHS England is partly assured on physical capacity. Confirmation
is sought that work at Queen Charlotte’s will be completed in May.
Managing capacity and demand and supporting women’s choice
NW London CCGs have put in place a maternity booking system that helps women who may
not get their first choice of maternity unit and supports system wide monitoring of demand
and capacity to manage potential surges in demand. Based on an independent review that
the maternity booking system is well thought through with defined clear objectives and lines
of accountability, NHS England is partly assured that the maternity booking system is fit for
purpose. Further testing for Stage 1 is required on the flow of data between Trusts and the
system to ensure it can support monitoring and surge management. It is recommended for
Stage 2 assurance that the ability of the system to support women’s choice is tested.
Impact on paediatric and gynaecology services at Ealing Hospital
Based on the Senate Review and the Clinical Conversations, NHS England is assured that
the proposed retention of paediatric and gynaecology services on the Ealing site post
maternity transition are supported by London North West Trust clinicians, strategic clinical
network leaders and the London Clinical Senate. In line with the Senate Report
recommendations, further detail is sought on the emergency gynaecology model for Stage 1
assurance. For Stage 3 assurance, further detail will be sought on the paediatric model of
care in relation to day surgery, rapid access clinic and transition arrangements for young
people.
3
Summary of recommendations from Stage 1
My letter has identified those areas where NHS England is fully assured in Stage 1 and
those areas where further assurance is required. Areas for assurance in Stages 2 and 3
have also been identified in Stage 1 where relevant. It should be noted this is not an
exhaustive list of assurance activities for Stages 2 and 3.
A summary of all
recommendations relating to further assurance is set out in the table below.
Table of recommendations for further assurance
Stage 1 Pre decision
1
Confirmation that number of midwives, consultants, neonatal nurses and
sonographers, as set out in the SaHF workforce plan in February 2015, will be in
place at each receiving site by the time of transition
2
Director of Operations and Trust Liaison posts filled
3
Estates work at Queen’s Charlotte will be completed in advance of transition
4
Testing of maternity booking system for monitoring booking at Trusts
5
Details of gynaecology emergency model at Ealing Hospital
Stage 2 Pre Transition
6
Testing of maternity booking system to support women’s choice is tested by women
who are booked in at Ealing Hospital and may need to transition provider
7
Individual communication to women who are likely to be most affected by the
transition
8
Communication to women about the importance of booking early and choices
available and information to women about the maternity booking system
Stage 3 Following transition
9
Continued movement towards London and national standards on improved staffing
levels, where relevant.
10
Detail on the paediatric model of care at Ealing Hospital in respect day care and day
surgery, rapid access clinic and transition arrangements for young people.
11
External peer review of all affected services within the hospitals providing the
additional maternity, neonatal and gynaecology capacity is strongly recommended
before, during and up to 18 months after transition
We will be in touch shortly about the additional information we need to conclude Stage 1.
NHS England acknowledges the considerable work the SaHF programme, Ealing CCG and
Trust clinicians and managers have put into developing these proposals.
We are aware that there are other issues Ealing Governing Body may wish to consider in
making a decision on the timing of the transition. If so, please let us know and we will be
happy to assist you.
Yours sincerely,
Simon Weldon
Chief Operating Officer
NHS England London Region
4
APPENDIX D
Communications and engagement – update for Ealing CCG: 18th March 2015
Objectives
Raise awareness of changes and how they will improve maternity services in NW London
Help women make informed choices about maternity units
Provide reassurance about the changes
Provide information on maternity units in NW London
Hear feedback and answer questions
Ensure women and their families have access to information
Ensure regular and consistent information to women
Planned products
1. Booklet – includes information on the changes, map of NWL showing the 6 sites post closure and information on each of these units (mini prospectuses)
2. Travel map – Our Travel Advisory Group are working with TfL to develop a bus map showing links between key localities around Ealing and maternity units in NW London
3. Accessible materials as appropriate – to be agreed in discussion with lay partners and community groups
4. FAQs – For midwives and GPs
Planned activity
A – Direct to women currently
booked at Ealing maternity
unit
Phase 1 – pre-timing decision
Regular letters to provide updates
Phase 2 – timing decision until closure
THOSE UNAFFECTED:
Dedicated phone line for any queries
Letter x 2: to confirm date means no change to birth
plan.
Phase 3 – post closure
Relevant Trusts to decide if further
communications required to women who
have moved from Ealing.
THOSE AFFECTED:
Letter to confirm they will no longer be able to give
birth at Ealing and to explain the next steps.
Booklet included with letter
Phone call to ensure receipt and understanding of
letter
Contact from maternity booking service to discuss 2
rd
and 3 preference location
B – Clinicians (GPs, midwives,
HVs)
Regular contact to provide update and
remind to continue booking to Ealing
until date known
nd
Confirmation letter from MBS once re-booking and
appointments confirmed
Letter to provide confirmation of closure date, next
steps and to confirm bookings cease.
FAQs
Booklets delivered to all GP surgeries, Ealing Hospital
and available to community midwives
Staff-engagement with Ealing
midwives regarding their roles
Posters delivered to all GP surgeries showing
maternity units in NW London
Letter to confirm unit now closed and to
remind of maternity units in NWL
Updates at Practice Manager forums
Updates at Network meetings & Council of
Members
Restock booklets if required
Updated FAQs provided
Electronic leaflet uploaded to computer system
Updates at Practice Manager forums
Updates at Network meetings & Council of Members
MBS/Trust (tbc) confirm new booking for individual
patients as appropriate
C – Children’s centres and NCT
Meetings with leaders
Update email to all contacts
Face to face sessions at all centres and
all NCT groups as appropriate to
provide reassurance and answer
questions
Booklets and posters delivered to all sites
Continuing face to face engagement on all
health and social care in NW London
Information provided for websites and newsletters
Provision of newsletters, leaflets and
materials as appropriate
Update email/letter to all contacts providing update
and offering meetings
Continuing face to face engagement on all
health and social care in NW London
Booklets and posters delivered to all sites
Provision of newsletters, leaflets and
materials as appropriate
Testing of planned materials
D – Wide community groups
Letter to all groups to provide update,
point of contact and copy for
newsletters/website
Face to face meetings to provide
update on progress and next steps
Information provided for websites and newsletters
Updates on relevant NHS websites
Press release in local media
Testing of planned materials
E – Hard to reach communities
Tender out to identify community
groups to undertake work with groups
where there are language or cultural
barriers
Update email/letter to all contacts
Booklets and posters delivered to all sites
Information provided for websites and newsletters
Meetings with leaders to identify
languages and accessible materials
required
Continuing face to face engagement on all
health and social care in NW London
Chosen provider to undertake intensive engagement
with hard to reach communities
Provision of newsletters, leaflets and
materials as appropriate