St John’s Hospital (Paediatric Services)

– in the Scottish Parliament on 29th January 2019.

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Photo of Kenneth Macintosh Kenneth Macintosh Labour

The next item of business is a statement by Jeane Freeman on paediatric services at St John’s hospital. The cabinet secretary will, as usual, take questions following her statement.

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I am grateful for the opportunity to update members about the progress that has been made on the provision of paediatric services at St John’s hospital in Livingston. I recognise the excellence and dedication of the staff who work there in caring for and serving patients and families in the surrounding communities and the support that the service has from local parents. I also emphasise my commitment to the hospital and its paediatric services.

When I came to Parliament last September to update members, I gave a commitment that I would return this January to provide a further update. I informed members that I had asked the director general for health and social care and the chief medical officer for Scotland to review progress by the end of January this year. I also asked the chief nursing officer for Scotland to liaise with NHS Lothian and provide advice and support on the training and development of advanced nurse practitioners. I record my gratitude to them for their support and their professional input.

I will not rehearse again the detail of why the interim service model has been implemented beyond one important point: the decision was taken by NHS Lothian in the best interests of children and their families in the circumstances at that time.

The interim model maintains the majority of children’s services at St John’s. The children’s ward is open from 8 am to 8 pm, seven days a week, providing a short-stay paediatric assessment service. The paediatric ward remains open for day-surgery activity, planned day-case procedures and programmed investigations. The paediatric out-patient services, neonatal services and community child health services have all been unaffected. The assessment unit has seen about 3,560 children since July 2017, and there have been more than 2,555 planned investigation unit attendances. The emergency department continues to see more than 11,000 attendances a year, and out-patient clinics have seen more than 4,000 new and review patients.

The board has evolved the interim model since it was first implemented, and that has seen a drop in the number of children who have been transferred but not admitted to the Royal hospital for sick children in Edinburgh. When the interim model was introduced, in July 2017, the average figure was 12 children a month; since March 2018, the average has been four, reflecting more confident triaging of patients. Additionally, although the original plan was for children to be redirected to the Royal hospital for sick children at weekends, the board has maintained a daytime weekend rota on all but three weekends from July 2017 to the present.

A wide range of children’s services continue to be available at St John’s, and the vast majority of children who require services locally receive them there. However, I am acutely aware of how important the reinstatement of the full in-patient service is to the community. When I met a group of parents with Ms Constance on 29 November last year, I heard at first hand about their experiences at St John’s and about the excellent care that their children received in the in-patient unit. I heard about the dedication of staff to the service and about their willingness to go above and beyond to provide care for the local population. I am grateful to all the parents who attended that meeting for their openness. I understand the anxiety and share the concern of members and the community to have the service fully reinstated.

The follow-up report from the Royal College of Paediatrics and Child Health to NHS Lothian in 2017 reiterated that its preferred option remained a 24-hour model, which reflects the population projections for West Lothian. In turn, the board has confirmed its absolute commitment to reinstating the 24/7 model through discussions with Paul Gray, Dr Calderwood and Professor McQueen.

The board has continued to work to develop and deliver a safe and sustainable 24/7 service. That requires a staffing rota that ensures resilience to sick leave and any other short-notice reductions in staff availability. It requires the majority of shifts to be filled by permanent staff, so that rotas can be planned for six-month periods. It also requires a model that equates to having two tiers of trained staff to look after the children of West Lothian overnight—that means consultant paediatricians supported by a second full rota of other medical and nursing staff.

The NHS Lothian paediatric programme board met on 9 January, when two interim options to enhance paediatric service provision were considered. The options were to reopen the in-patient ward for four nights a week, from Monday to Friday, and to extend the opening time of the short-stay unit to 10 pm or midnight, seven nights a week. The programme board assessed both options in the context of the full 24/7 service reopening in October this year, which means that the interim option will be required for no more than six to seven months.

What emerged from the assessments was a clear preference for reopening the 24-hour in-patient service from Monday to Thursday from 18 March. On the remaining three days—Friday to Sunday—the assessment unit will continue to be open from 8 am to 8 pm. That is achievable because of improved medical and nursing staff numbers. From a nursing position, the ward will be fully staffed overnight for four nights a week, from Monday to Thursday, with a paediatric nurse in the emergency department for the remaining three nights—Friday to Sunday—as under the current arrangement.

NHS Lothian has three advanced paediatric nurse practitioners in post. Two of them already contribute to the out-of-hours rota and one is expected to contribute to it from March, which is an improvement on the position in September, when only one advanced paediatric nurse practitioner supported the rota. Of the three additional APNPs who were recruited last year, two will be ready to contribute to the rota from October and another will be available in 2020. NHS Lothian expects the improved staffing position to support its commitment to reopening the in-patient unit fully in October.

The programme board felt that reopening the unit for four nights a week would significantly enhance the service that is delivered at St John’s through a reduction in the number of transfers to the Royal hospital for sick children. Over the past 18 months, an average of 1.6 children a day have been transferred from St John’s to the RHSC, and the board expects most such children to be admitted to the St John’s unit over the four nights for which it is open. In addition, an average of four children a month are transferred to the RHSC but not admitted, and the board expects most such children to stay at St John’s. The board will monitor the arrangements and keep activity under review.

The board also felt that the four-night interim arrangement would improve further recruitment efforts, as it demonstrates its commitment to reinstate the 24/7 in-patient service fully from October. The board will go back out to recruitment for the two consultant posts that were not filled after its recruitment efforts in the autumn of 2018. Advanced nurse practitioner posts will also continue to be advertised. Where possible, NHS Lothian remains committed to overrecruiting, both to build resilience and to mitigate the risks associated with the impact of sickness or any other absences or long-term leave.

I know that members and the local community are anxious to know when the full 24/7 service will be reinstated, and I understand that. I believe that the board’s decision to reopen the paediatric ward for 24 hours on four nights a week, from Mondays to Thursdays, is welcome, and I hope that it provides assurance for members and families that full reinstatement of the in-patient service is on track to happen in October. The board’s chief executive has sought to assure me that reinstatement of the 24/7 paediatric service has the full commitment of the board and will continue to receive the highest level of priority. As I said in September, that, too, is my commitment.

As we have done, we will continue to provide assistance and support to the board, to monitor progress and to work towards delivery of 24/7 paediatric in-patient services at St John’s from October this year. That remains my commitment, and I hope that members will see the progress to date as further assurance of that.

Photo of Miles Briggs Miles Briggs Conservative

I thank the cabinet secretary for advance sight of her statement. The downgrading of the service that we are discussing today is especially key for families in Livingston. On three separate occasions—in 2012, 2015 and 2017—we have seen services being removed. Local families across West Lothian will, rightly, be cynical about the latest promises from the Scottish National Party. The main staffing concerns that are outlined in the cabinet secretary’s statement point towards the summer months, when, traditionally, it is very difficult to staff such services. Will the steps on recruitment that she has outlined be sustainable? From what she has said today, that will be clear only from the summer of 2020. How will she guarantee that the proposals are sustainable in the future?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I make it clear that we are talking not about promises but about an absolute commitment. Since September, I have done exactly what I said I would do, which is improve the existing service on the road to full 24/7 opening. We are on track for that, and I have returned to the chamber to report on it. I am disappointed that that has not been welcomed by Conservative members.

Mr Briggs asks how I will guarantee that the recruitment process is sustainable and remains on track. I will do so with the professional judgment and guidance of the Royal College of Paediatrics and Child Health and of the NHS Lothian paediatric programme board, which itself is committed to ensuring that the service will be sustainable.

It would have been all too easy for me to have come here in September with quick fixes, but those would not have been sustainable. There would have been no point in my making promises to the parents whom I met—or to any other parents in West Lothian—that I was not convinced I could keep. I have kept my promises so far, and I intend to keep them right through until October and beyond.

Photo of Monica Lennon Monica Lennon Labour

I, too, thank the cabinet secretary for advance sight of her statement. Anything that increases provision at St John’s—provided that it is safe—is absolutely welcome. However, it still falls short of the 24-hour, consultant-led paediatric care that the Royal College of Paediatrics and Child Health states is needed. We know that, since the closure of the out-of-hours service in 2017, more than 1,000 children have been transferred to Edinburgh, with all the extra stress and expense that that brings for families. Do the cabinet secretary and the health board have an estimate of how many more children will have to be transferred between now and October?

I welcome the cabinet secretary’s commitment that the reinstatement of the 24/7 service is her highest priority, but she must accept that families have been let down by assurances before. What contingency plans are in place should the 24/7 care, which is so badly needed, not be in place by October?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I am grateful to Ms Lennon for her comments and for her welcoming the progress that we have made.

I agree with Ms Lennon: we are not yet at the full 24/7 provision, which is not only what is required but what parents have told me very clearly is what they want—and rightly so.

It is difficult to estimate what difference the four-day 24-hour opening will make because, as I am sure that Monica Lennon will appreciate, the cases that come in are not all the same. The board’s expectation is that there will be a significant reduction over those four days in the number of children who are transferred to the Royal hospital for sick children in Edinburgh—in fact, no children will be transferred there unless they are very sick and would have been transferred there even if the children’s ward at St John’s was fully open.

The board estimates that no children who are admitted in that period who require a short stay—which is what the full paediatric service offered prior to the reduction that we have seen—will need to be transferred. Children who require to stay in hospital for longer than 24 hours or who are very sick and whose stay in hospital would take them beyond the Thursday might have to be transferred to the sick kids hospital in Edinburgh. Such decisions will be clinical decisions that are made on a case-by-case basis. For children who require 24 hours’ admission, that service will be open to them at St John’s for four nights a week from March.

Monica Lennon asked what the contingency plan is. With the support of the director general and chief executive of NHS Scotland, our chief medical officer and the chief nursing officer, I intend to keep progress on track as the next step is taken, when the unit moves to greater opening from 18 March, and as further steps are taken on recruitment and engagement with advanced paediatric nurse practitioners. In that way, I will ensure that, month by month, we make the progress that we need to make by October. If, at any point, it looks to me that that is not likely to happen—at this stage, we have the paediatric programme board’s assurance that it can make the October date, as well as the royal college’s support for the options appraisal and the work that it is doing—and I receive advice that suggests that that might not be possible, I assure Ms Lennon that I will act quickly to identify whether there were ways in which we can get the programme back on track. She has my assurance that I will keep the chamber advised of that.

Photo of Alison Johnstone Alison Johnstone Green

I know that the cabinet secretary appreciates the extra travel, the stress and the expense that have been caused to families who have been required to travel to the sick children’s hospital in Edinburgh. I am pleased that progress is being made, but I am sure that none of us—including the cabinet secretary—is satisfied yet.

Will the hard-learned lessons of St John’s help to inform the Health and Care (Staffing) (Scotland) Bill, which is currently going through Parliament? Should overrecruitment become the norm so that we never again find ourselves in such a position?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I am grateful to Ms Johnstone for her comments. The experience at St John’s, along with all the other experience elsewhere in our health service, has informed the propositions that we have included in the

Health and Care (Staffing) (Scotland) Bill, which is being considered by the Health and Sport Committee, the amendments to the bill that we have lodged and our position on the other amendments. Our experience at St John’s has been part of that mix.

Overrecruitment works when a board understands and can demonstrate that, if it has overrecruited in one area, it can make good use of those skills and expertise elsewhere and it has a sustainable model that takes account not just of planned events, such as holidays, but unplanned events, such as sickness and long-term leave.

Overrecruitment is not particularly new in the St John’s case; it is used elsewhere in our health service. It remains a feature of our discussions with chief executives of health boards, directors of nursing, medical directors and others so that, where appropriate, it is the approach that a board adopts.

Photo of Alex Cole-Hamilton Alex Cole-Hamilton Liberal Democrat

I welcome today’s statement and assure the cabinet secretary that the proposed reinstatement of 24/7 coverage by the paediatric service at St John’s has the full support of Liberal Democrat members.

The cabinet secretary mentioned the fact that the number of cases that are referred to the sick kids hospital in Edinburgh has dropped off to between four and 12 per month. Does she share my anxiety that that might be symptomatic of an understanding that there is no service at St John’s to sustain the provision of care to children in such circumstances, which means that people are going straight to the sick kids hospital and that, therefore, that figure is not a reflection of the demand for the service?

Secondly, if the re-establishment of 24/7 provision hinges on the appointment of two or three trained APNPs, will it be impacted by staff sickness and absence, given that margins are so tight? In that event, are there banks or locums that could be drawn upon to relieve the pressure?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I am grateful to Mr Cole-Hamilton for his question. I have no evidence that the drop-off in transfers from St John’s to Edinburgh is a result of anyone going straight to Edinburgh. Actually, it is the result, as I said, of more confident triaging of patients at St John’s as people understand better what they are there to do with the particular services that they can offer in the restricted hours for which it has been operating. They will now be translated into the longer operational period for the children’s ward at St John’s.

The member’s point about tight margins is the reason why we had to do the work to get to this point and be able to open 24 hours over the four nights, but no longer at this time. We did that precisely to ensure that we have a sustainable model that is not only built on taking account of rotas, planned leave and planned holidays but, as far as possible, based on the overall evidence about how the staff numbers work out and the inevitably unexpected periods of sickness, including periods when sick leave is lengthy.

What the board has done, with our support and that of the paediatric programme board, is in line with how the royal college wants us to progress towards a 24/7 model, which it supports, as Ms Lennon rightly said. All that is in line with that progression as it ensures that we have a sustainable model so that, when we open for the four nights in the week, we do not have to close again because somebody goes off sick. That is partly how the model has been built and it sits behind the proposition that the board has been delivering on to, as we have described it, overrecruit.

Photo of Angela Constance Angela Constance Scottish National Party

As the constituency MSP, I can say that this is a positive stride forward. It is not the final destination, but it is good progress nonetheless, and it will be welcomed by West Lothian parents of school-age children, including those in the chamber and the public gallery.

However, parents will want to know in detail—particularly those whom Ms Freeman has met, who have led a positive campaign—how the cabinet secretary and her team will continue to ensure that NHS Lothian does not rest, does not backslide and does not take its foot off the gas until our much-loved, first-class children’s ward returns to a 24/7 service, given that that is the preferred option of not just the wider West Lothian community but, crucially, the Royal College of Paediatrics and Child Health.

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I am grateful to Ms Constance for her support and her comments. I welcome any parents from West Lothian who may be in the gallery and who I may have already met.

The questions that Ms Constance raises are pertinent, because they are in everyone’s minds, and understandably so. As I have said, we will continue to act, as we have done, to provide assistance and support to the board, to monitor progress closely and to work towards delivery of 24/7 paediatric in-patient services at St John’s from October this year.

We will continue to have the involvement that we have had since September last year with the board, the chair of the paediatric programme board, the director general for health and social care, the chief medical officer and the chief nursing officer. That has proved to be very helpful and it will continue right through. I have asked the DG, Dr Calderwood and Professor McQueen to maintain that involvement, keep me regularly briefed on progress and alert me if, at any point, it looks as if we may be going off track, so that I can personally be assured that we are putting in place all the steps that we now know need to be put in place in order to return to the full in-patient service at St John’s from October this year.

Photo of Gordon Lindhurst Gordon Lindhurst Conservative

Can the cabinet secretary tell the Parliament what effect partial closure has had on the Scottish Ambulance Service? Has an assessment been made of ambulance response times and the cost to the service?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

The Ambulance Service has been consulted on the proposed improvement and is supportive of it. As I think that we said in September, NHS Lothian has made additional payments to the Ambulance Service to cover additional costs that the service has had to meet during the period—and where that continues through to October, those costs will continue to be met by NHS Lothian.

The Ambulance Service and other referring services will be notified well in advance of 18 March, so that they can ensure that their staff are briefed and know where they should take patients. Parents and staff at St John’s will also be briefed well in advance of that date.

From the overall data that I have seen, I have not identified a dip in ambulance response times that might be attributable to the situation at St John’s, but I would be happy to look further into the data and advise Mr Lindhurst of my conclusions in due course, if that would be helpful to him.

Photo of Gordon MacDonald Gordon MacDonald Scottish National Party

I welcome the commitment that full reinstatement of the 24/7 paediatric service from October is receiving the highest priority. Will the cabinet secretary say how she will scrutinise and support the work of the paediatric programme board?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I understand members’ concern to make sure that, although progress has been made, no one takes their foot off the pedal. I am also very conscious that parents in West Lothian will scrutinise what happens, to ensure that we deliver on the final part of the commitment that I have made.

As I said, I have asked Professor McQueen, Dr Calderwood and the DG for health and social care and chief executive of NHS Scotland to continue their active involvement—and it has been active; it has not been at arm’s length or distant—with the paediatric programme board and with NHS Lothian’s chief executive. We have made sure that there is, at a senior level in NHS Lothian, proactive interest in how matters progress.

Progress will be reported regularly to me. I have made a commitment that if it appears to be going off track at any point I will take steps to intervene, as far as I am able to do, to bring it back on track, and I will ensure that members of this Parliament are kept up to date on our progress.

Photo of Kezia Dugdale Kezia Dugdale Labour

The announcement is welcome news in West Lothian and for any family with a child who has required hospital attention.

The cabinet secretary will be aware that there will be a degree of scepticism about the announcement, given that the ward has opened and closed three times since 2012. In that context, will she give an assurance that there will be a 24-hour paediatric service at St John’s hospital for as long as she is health secretary?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I was thrown off by the final part of Ms Dugdale’s question, when she said, “for as long as she is health secretary”.

I am grateful for Ms Dugdale’s support. Yes, she has my assurance of that. I made that commitment in September; I fully support a 24/7 in-patient paediatric service at St John’s. I understand that that is needed now, as the royal college’s work reaffirms, and given the welcome expansion in the number of families in West Lothian, as families move into the area—as I hope that people will continue to do—to benefit from its significant advantages and good standard of living.

I said in September that I would work with all the individuals whom I have mentioned and bring in the professionalism and experience of the chief medical officer, the chief nursing officer and the director general. I said that we would work with the paediatric programme board and that we would work to the royal college’s commitments. We have done so, to reach a next step towards the opening of the full 24/7 service in October. That is and remains my commitment, and for as long as I am health secretary I will continue to want and to work towards sustaining a full 24/7 paediatric in-patient service at St John’s.

Photo of Emma Harper Emma Harper Scottish National Party

In her response to Miles Briggs, the cabinet secretary was definitive about the sustainability of the service. Can I clarify whether the board has provided her with assurances that the current staffing model that is to be implemented at St John’s paediatric ward will create a sustainable solution that will ensure patient safety and avoid future disruptions to children’s services?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

Ms Harper probably knows better than just about anyone in the chamber the importance to our health service of a sustainable rota that takes account of all the issues that I have set out in my answers. I am sure that she agrees with me about the significant value of advanced paediatric nurse practitioners—and of advanced nurse practitioners as a whole—across our health service. We recruited additional advanced nurse practitioners in September so that we could begin to bring them on to the rota. Members will know that it takes a period of time to do that. With the engagement of those practitioners and with the consultant and medical profession engagement that we already have, we have reached the stage at which the rota is sustainable for the four-night 24-hour opening of the in-patient ward at St John’s.

The next steps are to continue to look to recruit two more consultants, to continue with the additional recruitment of advanced paediatric nurse practitioners and to bring those practitioners who are going through the training on to the rota when it is clinically safe to do so. All that work will take us to a point at which we can say that the in-patient service will be open 24/7 from October.

Photo of Brian Whittle Brian Whittle Conservative

How will the cabinet secretary ensure that adequate resources will be made available to St John’s to ensure that this crucial service overcomes the pressure on the staff that caused the initial restrictions in the first place?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

My understanding is that it was not a resource issue—in terms of pound notes—that led to the situation that we are working so hard to resolve by ensuring that there is sustainability. There was a staffing issue, which obviously connects to resources, but NHS Lothian has the resources—and will have them in 2019-20, depending on what the Parliament does with our draft budget—to deliver on the commitments. I do not come to the chamber to make commitments that I do not believe I have the resources to deliver. As I said, depending on what happens with our draft budget, I have the resources to deliver, NHS Lothian will have the resources to deliver and, consequently, St John’s will have the resources to deliver.

Photo of David Torrance David Torrance Scottish National Party

Does the cabinet secretary share my concern that the end of the free movement of people following Brexit will harm future recruitment drives for clinical staff across Scotland’s health boards?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

I share that concern. Let me give Mr Torrance and the chamber the benefit of a couple of quotes from people who work and represent people in our health service. The British Medical Association’s council chair said:

“The only thing that is certain, is how disastrous leaving the EU will be for the NHS, its workforce, its patients and the health of the country”.

Donna Kinnair, from the Royal College of Nursing, said:

“our ... healthcare system is fast losing its most important asset—its staff.”

We know that European Union nationals are already leaving our health service. From memory, I think that, of those who were asked, 78 per cent of EU national doctors in the United Kingdom said that they found the UK Government’s assurances deeply unconvincing, and just over 35 per cent of them planned to leave. We need to try to address those serious problems in taking forward our health service and—more importantly—in taking forward our country.

Photo of Mary Fee Mary Fee Labour

The cabinet secretary has said that there are plans to recruit to two new consultant posts, which remained unfilled after a recruitment round last year. What additional steps is the board taking to fill those posts? Does the cabinet secretary have confidence that those posts will be filled before the service opens in October? What impact will not filling the posts have on the service?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

The board is advertising those posts for recruitment again. The board believes—this point was also made to me by the parents whom I met—that the more that we can do to improve the provision of paediatric in-patient services in St John’s, the more attractive those posts become to people who might consider applying for them. We are hopeful that the next step that I have announced will assist the recruitment exercise, along with the absolute commitments that we have restated.

The move to four-night 24-hour opening makes good on those commitments and will encourage individuals to think seriously about coming to work in what is an excellent hospital that provides very high-quality care.

The board will put out the advertisement and seek to recruit to those posts. In anticipation of that, and given that there was a difficulty in the autumn recruitment that meant that the two posts were not filled, the board, along with the paediatric programme board and with the support of the Royal College of Paediatrics and Child Health, looked to realign its model, which has resulted in some of the advanced paediatric nurse practitioner recruitment that I spoke about in my statement.

The two consultant posts are important to the consultant rota. However, the additional steps that I set out in my statement, including those relating to the advanced nurse practitioner roles—in addition to those that I announced in September—will help to take us towards that sustainable 24/7 model.

Photo of Colin Beattie Colin Beattie Scottish National Party

The cabinet secretary has outlined some of the challenges currently being faced in recruiting staff. Can she outline how NHS Lothian figures today compare with staffing figures in 2007?

Photo of Jeane Freeman Jeane Freeman Scottish National Party

In NHS Lothian, since 2007, consultant numbers have risen by 54 per cent. Emergency medicine consultants have risen by 252.7 per cent, qualified nurses and midwives are up by 9.6 per cent and allied health professionals are up by 18.8 per cent. Overall, the staff numbers in NHS Lothian have gone up in total by 14.8 per cent. We continue to seek to recruit in order to deliver the quality service that families in West Lothian and elsewhere across Scotland deserve.