Written Statement - Evaluation of changes to maternity and neonatal services in Pembrokeshire and Carmarthenshire

In April 2013, Hywel Dda University Health Board’s proposals to reconfigure maternity and neonatal services in West Wales were referred to Welsh Ministers by the community health council for formal determination. In January 2014, I made that determination in accordance with established procedures.

Following the advice from an independent expert panel, I confirmed that neonatal services would be concentrated at Glangwili Hospital, in Carmarthen, where a new local neonatal unit would be created; consultant-led maternity services would also be concentrated at Glangwili Hospital and a new midwife-led unit would be set up at Withybush Hospital, in Haverfordwest. I required that a set of robust safety net measures were put in place at Withybush Hospital while the midwife-led unit was being fully established.

These measures included a dedicated ambulance vehicle and crew for emergency transfers to Glangwili Hospital for pregnant women and newborn babies and on-call consultant cover for obstetric and gynaecology emergencies out of hours. Hywel Dda University Health Board was required to undertake an independent evaluation of the changes after they had been in operation for 12 months.

The new model of care was introduced in August 2014. Hywel Dda University Health Board subsequently made changes to paediatric services in October 2014 – inpatient children’s services were concentrated at Glangwili Hospital and a new 12-hour paediatric assessment unit was opened at Withybush Hospital. The paediatric changes were not referred for Ministerial determination.

The Royal College of Paediatrics and Child Health (RCPCH) was commissioned to undertake the evaluation of the changes in June 2015. A review team, made up of representatives from the RCPCH, the Royal College of Obstetricians and Gynaecologists, the Royal College of Anaesthetists, the Royal College of Midwives and the Royal College of Nursing, evaluated the services, including extensive engagement with staff, the public and people who have used the services over the last 18 months.
A summary of the RCPCH’s report was today discussed at the Hywel Dda University Health Board’s meeting. It is available at http://www.wales.nhs.uk/sitesplus/862/opendoc/274532

The review concluded there is no evidence of any harm to any patients as a result of the changes and that they are sustainable in the long term. It found the new services are safe, are providing improved outcomes, better compliance with professional standards and more women are being cared for in the Hywel Dda area than under the old arrangements.  

The main conclusions of the report are:

• There would be no clinical sense in reversing the major decisions of reconfiguration made last year; 
• There is a need to progress the second phase of improvements to estate at Glangwili Hospital without delay. This will improve the physical condition of the labour ward which the report said is currently “too small with insufficient facilities and provides a poor environment for women and staff”;
• The dedicated ambulance vehicle team has provided an excellent service and must remain in place for a further 12 months when it should be reviewed again. It has averaged two trips a day compared to the planned nine. The ambulance crew has spent their downtime supporting other teams in the hospital, including the emergency department and children’s unit, providing staff training in emergency procedures and where appropriate, covering for some non-emergency transport;
• The on-call obstetric and gynaecology consultant cover at Withybush Hospital should be phased out as it has not been needed and is hampering the development of other services at the hospital. These resources can then be better deployed to increase services;
• The fears of the public about service safety were largely unfounded but anxiety generated by their experiences and those of others was real and damaged their confidence in services;
• The health board needs to prioritise an active and evidence-based dialogue with patients, advisory groups and clinical staff to mitigate the “misunderstandings and anxieties” that have arisen in the past.

Additionally, the review team has commented:

• There has been a gradual increase in the use of the midwife-led unit at Withybush Hospital, consistent with implementation of units elsewhere in the UK, and women using the facilities are almost universally positive about their experience;
• There is capacity to increase the activity at the midwife-led unit, enabling more women to give birth locally in Pembrokeshire but their confidence, and the morale of the staff, is being partially damaged by public negative messages about the service based on anecdote and speculation rather than evidence;
• Despite this, survey data collected from 500 women after they gave birth at all three sites during the past year – since the changes were made – have shown overwhelmingly-positive responses;
• Medical management should consider consolidating on-call obstetric cover at the Glangwili site with increased daytime activity at Withybush Hospital.  

   
I welcome the review, which provides further reassurance to people in Pembrokeshire and Carmarthenshire that these services are safe and have led to improved outcomes for mothers and babies. A more detailed report by the RCPCH will be discussed by the health board at its next meeting in November.

Where the review team has made recommendations in relation to elements of the safety net, which I required to be put in place in my determination of January 2014, I accept them. In relation to those recommendations which require improvements to the estate at Glangwili Hospital, the health board will be submitting a capital business case early in the next financial year.