Lincolnshire hospital trust board opts to defer decision on temporary of children's ward at Boston Pilgrim Hospital for further investigation

The United Lincolnshire Hospitals NHS Trust board meeting in Sleaford called for further research into all four proposed options on temporary measures to maintain safe paediatric services at Boston after it was felt that there were still too many unanswered questions and insufficient detail on impact to patients to make such an important decision.

The Board asked for more detailed work to be completed and a report be brought back to the next meeting on May 25 before a decision will be made.

This follows a Trust review of temporary options for children’s services at the hospital due to concerns raised by paediatricians and senior nurses, who have said that although current services are safe, they may struggle to provide safe care in the future if things remain as they are due to severe staffing shortages, particularly among middle grade doctors.

Interim chairman Elaine Baylis summed up saying: “We want to see something much more detailed in terms of equality of access. This is about being very clear and open.

“We are in a situation I would prefer us not to be in. A lot of work has gone on over months to avoid this situation but things have deteriorated to where we have had to consider what we need to do next.

“I think there is further analysis of data needed into what that might mean going forward. I don’t want to be bounced into taking a wrong decision before we have got all the information because it is such an important decision to take.”

From the answers given tp board members, she saw there might be more that could be done to fill the staff roles, while also needing to see the sustainability and risk assessments for the options, as well as assessments on the impact to quality of service, as she said it would affect different patients in different ways.”

This alluded to points raised by board members as to the struggle that parents may face travelling from the south and east of the county, especially if they have children with conditions cared for at home that may deteriorate and need to be brought into hospital.

The Board agreed that a task and finish group be set up to fully develop the four temporary options and carry out detailed quality and equality impact assessments to inform decision making at May board.

They will continue to take advice from partner organisations, the Clinical Commissioning Groups and surrounding hospital trusts as well as NHS monitoring bodies.

They have sought independent reviews from experts in the East Midlands Clinical Senate on May 21 and the Royal College of Paediatrics and Child Health on June 14 to provide safe parameters within which any temporary closure would work. The Board’s decision will be informed by this expert clinical advice.

Board members were told of all the methods the managers have tried to recruit more doctors. This has been hampered by it becoming harder to get overseas doctors due to the prospect of Brexit and hold-ups in securing work visas as well as having to pass competency and language tests before getting their General Medical Council registrations.

Without more staff, from June there will not be enough paediatric doctors to provide emergency and non-urgent care on the children’s ward, A&E, maternity and neonatal units 24 hours a day, seven days a week, to keep services safe for patients. They were told by doctors and nursing managers that it had run up till now using locums and consultants working as lower grade staff, as well as staff filling in extra shifts where needed but the situation had become unsustainable with the impending departure of more doctors for career development that ULHT has not got the infrastructure to provide.

Medical Director Dr Neill Hepburn said they had even sought help and advice from the medical college supplying their trainee doctors and been warned that it could pull out all its trainees if a suitable learning environment was not maintained.

For all of Pilgrim’s children’s services to run 24/7, there should be eight middle grade doctors at the hospital. This is to cover all rotas, annual leave and sickness and to make sure safe care can be provided for patients at all times. In June, the Trust is forecast to have 3.5 middle grade doctors, and only one middle grade doctor in July.

The staffing situation is volatile and constantly changing and the Trust is very reliant on short-term agency doctors and nurses, many of whom only work occasional shifts. In February, ULHT reduced the number of inpatient beds to eight and suspended all planned (not urgent) children’s surgery at Pilgrim as nursing staffing shortages became worse.

Dr Hepburn said, “We understand how concerning the potential loss or change to any service can be, particularly when it involves children. We haven’t made a decision yet and we are working hard to avoid moving services. I want to reassure the public that we won’t make any decision lightly.

“A temporary decision will be made for one reason and one reason only and that is to ensure our children’s services remain safe, as in July we forecast that we will only have one substantive middle grade doctor working at Pilgrim. This isn’t about saving money, it’s about safety. All options being discussed will cost more money than now.

“We have had a long-standing shortage of children’s doctors and nurses at ULHT and have carried out extensive worldwide recruitment. Since November 2017, we have received 54 applications from international doctors. Of those, we interviewed 23 doctors but just four people have accepted a job offer and don’t yet have visas to work in the UK. These efforts haven’t resulted in the numbers of doctors needed to maintain current services.”

Before May’s board meeting, the Trust will carry out detailed risk assessments on the options and carry out public, staff and stakeholder engagement to get a full picture of the quality and equality impacts on the options. They will also continue to recruit to maintain safe services in the future.

The next board meeting will be on Friday May 25, at 10.30am in Sleaford.

The four options are:

Option One

○ Maintain current services at Pilgrim hospital, this is reliant on finding additional multi-professional staff from agency to cover children’s, maternity and neonatal services and getting the right balance between substantive and temporary staff.

○ Following advice, the trust is currently unable to identify nationally that a middle grade tier run solely by locums is safe and whether it could carry a bigger risk and therefore need to seek assurance as to whether it is safe to do so.

Option Two

○ Temporary closure of the children’s inpatient ward at Pilgrim with effect from 4 June (providing additional staffing cannot be secured)

○ Temporary redirection of paediatric emergencies transported by ambulance to Pilgrim – redirected to nearest A&E or urgent care centre

○ Temporary re-direction of urgent GP paediatric referrals to neighbouring organisations

○ Paediatric support with emergencies in A&E at Pilgrim hospital

○ Increase gestational age for delivery within the high risk birthing unit from 30 weeks to 34 weeks.

Option Three

○ Temporary closure of paediatric inpatient services at Pilgrim with effect from June 4 (providing additional staffing cannot be secured)

○ Temporary redirection of paediatric emergencies transported by ambulance to Pilgrim – redirected to nearest A&E or urgent care centre

○ Temporary re-direction of urgent GP paediatric referrals to neighbouring organisations

○ Paediatric support with emergencies in the A&E department at Pilgrim hospital up until July 1

○ Retaining consultant led obstetrics and neonatology at Pilgrim until July 1 when medical staffing reduces beyond the ability to support neonatology. From July 1 temporary closure of consultant led obstetrics and neonatology at Pilgrim until the staffing gaps could be addressed

○ Increase gestational age for delivery within the high risk birthing unit from 30 weeks to 34 weeks

○ Establish midwifery led birthing unit at Pilgrim hospital and a co-located midwifery led birthing unit at the Lincoln hospital to facilitate increased activity on the consultant led unit.

Option Four

○ Maintain current paediatric inpatient services, consultant led obstetrics and neonatology services at Pilgrim and Lincoln, temporary transfer of staff (medical and nursing) from Lincoln to Pilgrim.

○ Stop all paediatric inpatient and day case elective (planned) activity for all paediatric specialities at both Lincoln and Pilgrim hospitals. (This will require adjustment to bed numbers at Lincoln and cancellation of some elective activity at Lincoln)

○ Stop all general paediatric outpatient appointments

Campaigners are still unhappy, Sarah Stock of Fighting4LifeLincolnshire claimed managers were not accepting their offers to help with recruitment publicity and claimed that many local nurses were still unaware that there were vacancies that needed to be filled. It was warned that nursing staff working at Pilgrim would struggle to transfer, even temporarily, to Lincoln due to the lnegth of shifts and additional travelling time.