Agenda item

North Central London Integrated Care Board and NHS England (London) Specialised Commissioning are consulting on proposed changes to maternity, neonatal and children’s surgical services. The report sets out the options and the possible impact of the proposals on Brent residents, and outlines the approach to consultation and how residents, staff and stakeholders can give their feeback.

Sarah Mansuralli (Chief Strategy and Population Health Officer / Interim Deputy CEO for NCL ICB) introduced the report, which detailed the proposals to consolidate maternity and neonatal services, known as NHS Start Well. In introducing the report, she highlighted that North Central London Integrated Care Board (NCL ICB) recognised that this would have implications for both staff and residents using or working in those services, but there had been some detail lost in the overarching narrative around the proposals that she wanted to clarify. Having listened at many stakeholder engagement activities, there seemed to be an assumption that the proposals were being driven by an attempt to achieve cost reductions and efficiencies in the NHS, but she affirmed that this was not the case. Instead, the proposals focused on creating high quality services that offered personalised care to deliver improved outcomes in maternity and neonatal health. To deliver either option that NCL was consulting on would require approximately £40m in capital investment, and a substantial revenue investment into workforce. There was also a public perception that consolidating the workforce onto fewer sites was due to recruitment and retention challenges within the NHS. She highlighted that, whilst consolidation would improve resilience on sites, the purpose of the proposals was to ensure that staff saw and treated the right amount of cases to maintain their clinical competencies. Due to the low volumes of births on some sites currently, maintaining clinical competencies was a challenge, and this drove staff to go to other units where they could maintain their competencies, exacerbating existing retention challenges within the workforce.

There was a number of improvements the proposals would deliver for both NCL and North West London (NWL) populations, and the Royal College of Midwives was clear that personalised care, together with continuity of care, was critical in improving outcomes in maternity and child health. Without significantly improving both the workforce and facilities, it became difficult to provide that level of care and give time and attention to deliver personalised care that responded to the diverse needs of NCL and NWL communities. NCL ICB appreciated that there was a variety of perspectives on the proposals, and assured the Committee that they had been clinically developed by the professionals delivering the services, and that the models of care represented best practice as well as evidenced based clinical standards, which would ensure that maternity and neonatal care met the recently published standards in the three year maternity plan. NCL ICB was engaging extensively with populations in all affected boroughs and Brent and Harrow were a key part of that.

In continuing the introduction, Rob Hurd (Chief Executive – NWL ICB) explained that inequalities in maternal and child health were fundamental to this programme of work, and the impact assessment and acknowledgement of those for the most deprived communities, including ensuring no detrimental impact, was forefront as the ICB went through the consultation. In relation to NWL ICB, colleagues were working with NCL ICB and Brent Council to ensure assurances were sought before final decisions were made. In concluding, he advised the Committee that NWL ICB considered the proposals to be a positive step in addressing maternal and neonatal health inequalities.

The Chair thanked colleagues for their introduction and invited comments and questions from those present, with the following issues raised:

The Committee asked how funding would work following any shift in service. They were advised that any funding would follow where the activity took place. There were units in NWL ready to do significantly more work than was currently flowing through NWL maternity units, so it was clear that the funding of those would lead to better use of all resources. As such, the funding followed the patient, and as a person chose where to give birth, the funding for their care followed them.

The Committee highlighted the opposition they had heard from Brent residents in relation to these proposals, who felt that they had been pushed forward at the expense of coverage. With the option to close the Royal Free maternity unit Willesden and Harlesden, where there were existing poorer health outcomes, had been identified as areas that may be affected. As such, the Committee asked what support could be offered to those communities who would be impacted by the changes, if they were to be implemented. Sarah Mansuralli explained that implementing the programme of work had positive benefits for the population at large, but there would be specific parts of the community that the ICB would need to focus on to mitigate any adverse impacts. The ICB had looked at groups of service users across the whole population from an outcome point of view and found that those in Willesden and Harlesden often had worse outcomes, which was why those areas had been highlighted as areas to pay close attention to in the option where the Royal Free was modelled to close. To mitigate that, the ICB was taking a hyper local approach to engagement in those areas to ensure that the changes were well understood and that residents had a chance to give their views. In the interim integrated impact assessment  (available on the ICB website) the ICB had focused on some actions it would need to take to support those communities such as language and communication support, transitioning from one model to another, and additional transport options. The ICB had set out and worked with local community groups and health professionals to think about the first assessment of those mitigations for both options that were out to consultation, and a key question being asked during consultation was what else the ICB should be thinking about in terms of mitigations, which could then be built into a final integrated impact assessment. Colleagues in NWL would be an integral part of that conversation to garner feedback at a local authority level, health service level, and the individual voices from Brent’s communities. As such, there would be a need to commit to working in a joint way with Councils and local NHS organisations to ensure the pathways in the option where the Royal Free was modelled to close worked in the way that was needed for those affected populations.

In considering the consultation exercises being undertaken, the Committee asked how widespread those would be and what methods were being undertaken to consult the population of NWL and Brent. Anna Stewart (Programme Director – NHS Start Well, NHS NCL ICB) informed the Committee that NCL ICB was almost halfway through its 14-week public consultation. She felt the ICB had done a lot of work already in Brent, and councillors, as community leaders, had many links with voluntary and community sector organisations that the ICB was actively following up. Widespread promotion activity was taking place through social media, including Facebook, X, and the consultation website. The consultation materials had been translated into over 15 different community languages which took account of languages spoken in Brent and Harrow as part of that. Promotional activity had been sent to all GPs, to Brent Connects groups, the Brent ‘Your Say’ website, and individual meetings and drop-in events were taking place with various different organisations. Most recently, NCL ICB had been to Brent Central Mosque and Willesden Pakistani Centre, and there were a number of further engagement events planned. It was agreed that a list of activities/events could be circulated to the Committee.

The Committee highlighted that women would take a view on continuity of care, and asked how much focus there was on choice in the proposals. Sarah Mansuralli confirmed that the modelling underpinning the business case had looked at choice. Currently, if women from NWL or Brent chose to go to Northwick Park Hospital or St Mary’s Hospital to give birth, there was continuity of care because community and universal services were geographical to where they chose to give birth.  Whereas, when women choose to give birth at a hospital in NCL, e.g. Royal Free or the Whittington, then there was a lack of continuity of care, leading to fragmented care between antenatal, delivery and postnatal care. In future should the proposal to close the services at the Royal Free be taken forward, if a woman chose to go to either of those hospitals, they would receive continuity of care through antenatal, delivery and postnatal, and would then get connection with universal services commissioned by the Council such as health visiting and community midwifery. Anna Stewart added that the needs of the baby also needed to be taken into account. For example, Royal Free Hospital Maternity Unit only had a level one neonatal unit, meaning any mother giving birth at less than 34 weeks gestation, where there may be a need for additional care, would likely be moved to a level two or level three unit in the period before they gave birth or if they needed additional care after going in to labour. For this reason, it was important to take into account the complexity of the case and ensuring that there would be no adverse impact of giving birth in the preferred unit.

In relation to continuity of service, the Committee asked whether there would be capacity within the community for antenatal and postnatal care should the option involving the closure of the services at the Royal Free be taken forward. Rob Hurd highlighted that, as part of the final impact assessment, the ICB would need to take account of the variation that would be required in those services, and the funding and capacity would follow patients in antenatal and postnatal care as it would for hospital care. Capacity in the community would be in place at the point in which the preferred option comes into play.

In considering any expansion of activity and services at Northwick Park Hospital, the Committee highlighted that there was a negative perception of maternity services in the general public following the CQC inspection. The Committee acknowledged that the hospital had since made improvements, therefore the Committee asked what work was being undertaken to improve those perceptions following the improvements. Rob Hurd agreed it was fundamental to promote the improvements being made at Northwick Park Hospital, which had moved beyond the issues of the past. North West London had a critical mass of safe units with high quality services that would be enhanced by the proposals, so communication activity would take place to promote those benefits to local residents in the event that the proposals around the Royal Free Hospital were taken forward. Mike Greenberg (Medical Director, Barnet Hospital) added that the more patients giving birth at Northwick Park the more this would improve the expertise of staff through clinical practice, enabling them to maintain their clinical competencies.

The Committee raised a query specifically in relation to the proposed closure of the birthing suites at Edgware Birthing Centre, asking whether this deprived patients the choice of a small, intimate, and nearby centre. It was difficult for residents close to Edgware to travel to Royal Free Hospital and many patients felt wary of Northwick Park Hospital. Sarah Mansuralli advised the Committee that they would listen to consultation feedback on that proposal, but had put the option forward because only 37 babies per year were delivered in the Edgware Birthing Suites which amounted to less than one delivery a week. The complexity of births was increasing across the board for a variety of factors such as later in life births, long term conditions and comorbidities, which meant many pregnant people were not eligible to deliver at Edgware Birthing Centre. Keeping up clinical competencies with the small number of births was difficult. The proposal was to close the Birthing Suite at the Edgware Birthing Centre and relocate the activity alongside midwifery led units, which were co-located with the Obstetrics Units in order to respond to population need, so there would still be antenatal, post-natal and community services available at Edgware Birthing Centre.

The Committee highlighted the cost to an individual of being pregnant and having a baby in terms of additional expenses, particularly if a pregnant person had difficulties and was required to travel to attend multiple appointments. They had concerns that this would result in less choice for residents as they would need to go to the nearest and cheapest place, and there was a risk of people not getting to appointments on time or not attending appointments because of travel costs. They asked whether these considerations would factor in to how the ICB would understand the impact. Rob Hurd explained that the process of the consultation would include listening and working out some of that detail around what the transport options would look like and what mitigations would need to be put in place to ensure better transport options were available for either of the options on which the public were being consulted.

Having highlighted best practice as one of the areas of focus of the proposals, the Committee asked whether this was being emphasised as a result of any failings in maternity services, and whether a training programme would be better suited to mitigate any failings rather than a reconfiguration programme. Mike Greenberg explained that the number of births was declining, and there were not enough births in certain units, such as the level one neonatal unit at Royal Free Hospital, for staff to be able to maintain the skills and expertise required to deliver that care. Looking at the whole of NCL, even if the ICB was to make Royal Free Hospital a level 2 unit, there was not enough births to maintain the expertise of staff. As such, this was why the proposals were to reduce and consolidate units.

The Chair invited Councillor Nerva, as Cabinet Member for Public Health and Adult Social Care, to contribute to the discussion. Councillor Nerva stated disappointment that this work had gone on for a considerable period of time without the local authority being informed, as he had only been made aware of the upcoming consultation in early December 2023. He highlighted that, as a local authority, the Council had a lot to offer the work and was a key part of the consultation process outside of NCL. He had hoped for a joint approach across NWL and NCL to look into how maternity services might be improved in future. In addition, he highlighted the importance of focusing on inequality issues in considering any options in relation to NHS Start Well.

The Chair thanked those present for their contributions and drew the item to a close. He invited the Committee to make recommendations, with the following RESOLVED:

i)              For future reports to detail assurances that, as a result of the increase in demand should the changes in NCL take place and result in consolidated services, mitigations were in place against staff fatigue, human error, and overcrowding of facilities.

ii)             To recommend that the impact of cost to prospective parents in relation to patient choice is considered in the final business case.

iii)           To recommend that the ICB consult a wider geographical area of residents, and ensure interpretation services are available in a wide variety of languages to undertake that consultation.

iv)           To recommend that, post any changes that are implemented, the ICB take a view as to the impact they have made.

In addition to recommendations, the Committee made several information requests, as recorded below:

v)            For the Community and Wellbeing Scrutiny Committee to receive the detail of engagement activity undertaken to date, including the number of individuals and groups consulted, and geographical and demographic information.