Agenda item

To provide an update from North Central London NHS on the Start Well Programme.

Anna Stewart (Service Development Director, CYP, CAMHS, Maternity and Neonates, NHS NCL ICB) introduced the report, which described the public consultation outcome on the proposed changes to North Central London’s (NCL) maternity, neonatal and children’s surgical services that took place between 11 December 2023 to 17 March 2024. She highlighted that the Start Well programme was a long-running change programme in NCL that had started with a case for change looking at maternity and neonatal services and some children’s surgical services, looking at best practice care models, options appraisals on how best to deliver that care, and then moving through to the public consultation. In introducing the report, she reminded members that she had attended the Committee the previous year to present the options that North Central London Integrated Care Board (NCL ICB) would be consulting on around the delivery of maternity and neonatal care in NCL (inclusive of the boroughs of Camden, Islington, Barnet, Enfield and Haringey). Following consideration of all possible options, two that were seen to be deliverable were then consulted on. The first option was to close the maternity and neonatal unit at the Royal Free Hospital in Hampstead, which was identified as NCL’s preferred option at consultation stage. The second option was to close maternity and neonatal services at Whitington Hospital in Highgate. In both of those options, maternity and neonatal services would be retained at Barnet Hospital, North Middlesex Hospital and UCLH. The second area of the consultation was around the closure of the standalone midwifery-led unit at the Edgware Hospital site in NCL used as a place to give birth, which was being considered given the decreasing number of people using that as a site to give birth with only 28 giving birth there in the last financial year. Although NCL was consulting on closing the birthing suite there, Anna Stewart advised that NCL would retain and enhance the antenatal and postnatal care at the site.

Anna Stewart then moved on to the consultation period, which lasted for 14 weeks. She advised the Committee that NCL had conducted widescale engagement to hear resident views on the proposals and worked closely with both the NWL ICB and NCL ICB teams, receiving guidance and support from the Director of Public Health for Brent. She advised members that NCL had seen very good engagement and wide feedback, with over 3,000 responses to the questionnaire, over 200 meetings which were formally minuted, and some very targeted engagement in areas where NCL particularly wanted to hear people’s views on. Those areas were Harlesden and Willesden for the option to close Royal Free Hospital, and Holloway and Finsbury Park for the option to close the Whitington Hospital. To do that, targeted mailing to 1/3 of the residents in those areas was done, alerting them to the consultation and inviting them to feed back, as well as some focus groups.

The outcome of the consultation, which had been published in November 2024, was then outlined. Anna Stewart highlighted that, overall, there was strong agreement in the challenges NCL presented in the case for change, with a clear clinical case made for changing the way services were currently set up in NCL. Nearly 70% of those consulted agreed that something needed to be done to improve the way services were working. There was also strong agreement that NCL should offer a minimum level of neonatal care at all of its sites. Currently, NCL had one site that provided the lowest level of neonatal care, so there was agreement that all sites should offer level 2 neonatal care as a minimum as part of these changes. There were some mixed views about whether the answer to the case for change was to consolidate services, which NCL had expected. Overall, from the questionnaire responses, there were more people who responded favouring the option where services closed in the Royal Free site compared to the Whitington site, but there were strong views in both directions. There was also broad agreement and recognition of the challenges facing the Edgware Birth Centre, with around 3/5s of respondents to the questionnaire agreeing with the proposal to close the birthing suite there.

Providing an overview of the steps that had been taken since the results of the consultation had been published, Anna Stewart advised the Committee that work was now been done to take forward the themes of the consultation, including some very specific feedback from elected members in Brent and other members of the public, incorporating feedback from this Committee, the Cabinet Member, and the local MP and Assembly Member. NCL was in a period of considering carefully the outcome of the consultation and feedback received, refreshing some of the proposals and heading towards a formal decision-making meeting on those proposals over the next month. NCL was working with Brent’s Public Health team around incorporating the feedback received into the Integrated Impact Assessment, and with colleagues in NWL Trusts who had joined some of NCL’s Clinical Reference Groups to work through some of the very specific feedback received. She concluded by confirming she would be happy to return to the Committee when the formal decision-making process was done and the papers had been published. 

The Chair thanked presenters for their introduction and invited comments and questions from the Committee, with the following issues raised:

The Committee asked what NCL had learned from the consultation process about service users, how people experienced the service, and how well service users understood the challenges. Anna Stewart advised members that much of what people wanted to talk about was their overall experience of maternity and neonatal services which was not necessarily confined to the proposed changes. The theme of travel and transport came through, as well as concerns on the impact on NWL hospitals should the Royal Free maternity service close. There were general concerns about the risks there might be for other services and questions about the rationale for the case for change that officers had been able to talk through. Alice O’Brien (Head of Programmes, NCL ICB (Start Well)) added that there had been targeted engagement with groups with protected characteristics and a lot of rich detail had been drawn from that about how the proposals might impact them and how they might be mitigated. The Integrated Impact Assessment would be updated following that engagement to incorporate those considerations and mitigations. Consultation had shown that service users wanted to feel cared for and supported in their maternity journey, with an overall view that travel was important and that mitigations should be in place for service users who may find it more difficult to navigate changes like this.

In terms of whether NCL had heard anything from the consultation that would make it consider changing the preferred option, Anna Stewart advised members that she could not pre-judge the decision-making process on the final business case. Feedback that had been heard ranged from thoughts regarding the headline changes proposed to how people experienced the model of care, how they were communicated with, how they felt cared for, their experience of giving birth and interactions with midwives. Actions to address that specific feedback would be built into all of the maternity and neonatal services delivered in NCL. In relation to feedback from Brent specifically, this followed the general themes around travel and transport, experience of care, and concerns about impact on other services. It was highlighted that less than 1 in 10 women and pregnant people in Brent gave birth at Royal Free hospital, which was the hospital closest to Brent relating to the proposed changes. Most of the service users spoken to in Brent had given birth at Northwick Park or St Mary’s, so there was a much smaller proportion of residents impacted by the change and this was only one of the units where women and pregnant people in Brent may chose to give birth.

Members highlighted that for some, particularly in Harlesden, Stonebridge and Willesden, the proposed change would increase their journey time and there was often stress associated with getting to hospital. They asked what thought had been given to those service users to in relation to how long it would take them to get hospital through London traffic and how the service might mitigate that. Anna Stewart advised that a technical document known as an Integrated Impact Assessment had been conducted as part of the case for change, looking at all protected characteristics and through the lens of different demographics, including geographical location and levels of deprivation, in order to assess the areas there might be more of an impact. She explained this was how Harlesden and Willesden had been identified as areas to focus on to address any impact of the proposed change. It was added that, for residents in Harlesden and Willesden, they were at the edge of the border for Royal Free, so the vast majority of residents were closer to a unit in NWL. For them, the impact in terms of travel time would be less significant than the other option being consulted on to close the Whittington, where the impacted population from a deprivation lens may be more impacted. Alice O’Brien explained that the interim Integrated Impact Assessment that had been done prior to consultation had identified mitigations around travel times including ensuring care continued to happen in the community and patients were aware of their different routes, making that information available, consistent and accessible. The consultation having now concluded, NCL would be updating the Integrated Impact Assessment based on the feedback received for the full decision-making business case, and the updated document would include travel time analyses including public transport and private taxi. The updated document would also make patients aware of how they could access travel reimbursement schemes and other financial support available to pregnant people throughout their maternity care.

Noting the comments by presenters and information within the report that very specific feedback had been received from particular communities, the Committee asked whether mitigations would be put in place for those issues. For example, some feedback from Jewish communities highlighted that there were services offered at Royal Free that included Shabat rooms and Kosher food products, and there would likely be other specific needs impacting particular religious groups or groups of people with protected characteristics. As such, the Committee asked if alternative sites would be willing and able to service those particular needs. The Committee was advised that NCL had received particularly detailed feedback from the Orthodox Jewish community in Golders Green and Hendon regarding the nuances of the care they received and how they had built up trust with Royal Free over time, and this type of feedback was why NCL had felt the consultation was essential. There were flows of Orthodox Jewish people who gave birth at some other sites but there was a concentration of that care at Royal Free, so NCL had been doing work on that as part of the Integrated Impact Assessment to support the decision making cases about the list of services that would need to be in place should the decision be to close the Royal Free.

Acknowledging that the options consulted on would compromise a choice which may have an impact on existing departments, where some women and pregnant people giving birth may be dispersed to other hospitals, the Committee asked whether there would be increased capacity and staffing in those units that continued to remain open. Anna Stewart responded that NCL had worked closely with NWL ICB, who had sat on the Programme Board for Start Well alongside NEL ICB and Hertfordshire ICB to ensure any impact was considered and mitigated. In addition, the modelling done incorporated clinical implications received through clinical representation from Trusts in NWL through Clinical Reference Groups. In doing that clinical analysis, it had been noted that both NWL and NCL had declining birth rates, which had declined further in the time that NCL had undertaken the consultation. In addition, there was a clinical case for having units of a certain size and capacity in terms of meeting safety requirements and standards, so NCL had worked closely with NWL and NEL to look at capacity implications for both of the options consulted on to ensure there would be sufficient capacity to take any flows of patients that would be dispersed. This included building additional capacity in the units that remained open in NCL to ensure it could manage the potential additional numbers, and there were additional physical capacity units that could be used at NWL hospitals if the decision to close Royal Free was made. There were people in NWL and Brent who chose to cross the border to use the Royal Free for their maternity care, so it was anticipated that those patients would choose to give birth at a NWL hospital should Royal Free close. It was highlighted that there were benefits to that in terms of continuity of care, continuity of experience and links into local services. Anna Stewart added that changes would not be implemented immediately but would need an implementation period, lasting for approximately three years for building works to complete and detailed implementation planning with neighbouring partners and NCL Trusts to take place in order to carefully manage that process and transition.

The Committee highlighted that home births was an option for women and pregnant people, which would mitigate the need to travel to appointments, but members highlighted that home births might not be able to deal with emergencies that arose during a birth. Anna Stewart responded that choice was very important in maternity services, including choice of unit and choice of setting, which was complicated from a clinical point of view. There were a range of factors affecting where someone should give birth, incorporating both the person’s preferences but also their clinician’s advice about their care. Currently in NCL, pregnant people could have a home birth if they met the eligibility criteria, or they could give birth at the standalone midwifery led unit at the Edgware Road Suite which was closer to a home environment, but there were less women now choosing to do that. Women and pregnant people could also choose to give birth in an ‘alongside’ midwifery led unit, which was a midwifery led unit on a hospital site, meaning it was close to backup clinical care but had a more homely feel, or there was the option to give birth in an obstetrics led unit, usually for more complex births. In the model of care that NCL had consulted on, the proposed model continued to offer home births alongside midwifery led care and obstetrics led care, and the option that was potentially being removed was the standalone midwifery led unit. NCL wanted to ensure women and pregnant people had a choice all of the time, and the consultation materials had highlighted that when there were staffing shortages it was often the ’alongside’ midwifery led units that were temporarily closed to ensure there was adequate staffing on obstetrics led units. Anna Stewart advised members that one benefit of moving to the new model with larger units and more resilient staffing structures was that it would mean NCL would be able to offer that full range of choice all of the time. She did acknowledge that complexities were increasing, which might be one of the reasons less people were opting to give birth at the standalone birthing suite at Edgware Road, but NCL was committed to ensuring choice remained and there was dialogue with the clinician and pregnant person about that.

In terms of birthing before arrival at hospital when the plan had been to give birth at hospital, officers confirmed that they would not want to be in a position of that happening and the system monitored that. In London, there was a very small proportion of this happening compared to other geographic areas where it might happen more frequently, at less than 0.3% in the whole of London. Officers explained that all paramedics and midwives were trained to be able to cope with those situations. They acknowledged that the complexity of birth was increasing, largely because research suggested that delivering babies earlier for a proportion of women and pregnant people was the safer thing to do to reduce still birth rates, alongside the fact that people were having babies at an older age and that pregnant people who previously would not have been able to have children due to medical complications were now able to. This meant that the maternity pathway was becoming more medicalised. As such, officers advised there were many reasons maternity care was becoming more complex which was resulting in a bigger proportion of elective maternity care with approximately 50% of women and pregnant people no longer spontaneously going into labour but being induced or having C-Sections. These complexities had meant that the system needed to change the whole model of care to be able to provide what was required, but the most important part of changing any maternity configuration was ensuring choice remained and that there was not an increase in women and pregnant people giving birth before they got to hospital.

Pippa Nightingale (CEO, London North West University NHS Healthcare Trust) provided a response on behalf of NWL ICB. She explained that, when this work had initially been undertaken, NWL had designed a maternity service that could deliver 38,000 births. NWL was currently at 33,000 births so she highlighted that there was capacity in the NWL maternity system, most of which sat in the North of NWL. As such, the NWL system was set up in such a way as to be supportive to the proposed changes in NCL for maternity and neonatal capacity. She agreed with the advantages in terms of continuity of care as those in Brent would already have their post-natal care provided by NWL. This was highlighted as especially important if a baby needed readmission as they could return to the same unit which had their medical history, helping to streamline the clinical pathway from a patient safety point of view.

The Committee asked what the NWL model of care would be going forward, highlighting that there were 9 appointments in the maternity pathway, and for less advantaged members of the population they were less likely to travel to a maternity service 9 times for that care. Pippa Nightingale agreed that maternity services should be brought into the community where possible, and NWL already had a model of care which it committed to through ‘shaping a healthy future’ that looked to bring care into the community. As such, NWL now had Midwifery teams providing neighbourhood midwifery care in the community. The benefit of providing care in the community was that midwives could engage women in their own community where they had other support systems, which was important for the populations that NWL ICS was providing care for. She advised members that if patients were started on a clinical pathway well in the community then they tended to follow that for their child, ensuring their child received their immunisations and were socialised. As NWL already ran that model it would be proposing to expand that further north in Brent so that all women in Brent could receive that care model.

Noting that capacity at other hospitals had been reviewed to ensure the system could withstand the impact of a maternity unit closing, the Committee asked whether this had factored in any hard to predict factors such as a sudden increase in the birth rate, the number of new houses being built in Brent and young families moving to the borough. They asked whether those factors had already been incorporated into the forecasting so that planning was future fit. Anna Stewart confirmed that NCL had done some very detailed modelling as part of the consultation, including modelling a 10-year projection of neonatal usage and demographic factors including the birth rate, which was done at LSOA level which she saw as reasonably granular. She advised members that all change programmes involved multiple layers of assurance and advice before they could be implemented, and this particular business case had received a detailed review by the London Mayor, the recommendations of which had been incorporated into the final decision making business case. As such, she felt as confident as she could be in the modelling that had been done, which had accounted for choice, been done at a granular level, and considered different assumptions, so that there was now a robust model to make a final decision on.

The Committee recalled the retention and recruitment issues that had been detailed in 2022 when the Northwick Park Maternity Improvement Plan had first came to Committee and asked whether that had improved in order to alleviate any impact on capacity any closures would have. Pippa Nightingale responded in relation to NWL, highlighting there were no recruitment and retention issues currently, with NWL having only 7% vacancy rate in midwifery. She advised members that NWL midwives rotated across all areas now, with very few midwives working solely in one area. Midwives would usually do a year in the community and then a year on the labour ward, as this enabled them to retain their skills in all areas. Some midwives chose to just focus on community midwifery, which was becoming a more popular role now that midwives were being given a specific neighbourhood area to provide care for. As such, there had been no issues in the past year recruiting and retaining community midwives.

As no further issues were raised the Chair thanked officers for their time and responses and drew the item to close.