Meeting of the Parliament

Meeting date: Thursday, September 27, 2018

Official Report 1254KB pdf

---

St John’s Hospital (Paediatric Services)

Good afternoon. The next item of business is a statement by Jeane Freeman on paediatric services at St John’s hospital. The cabinet secretary will take questions at the end of her statement, so there should be no interventions or interruptions.

I am grateful for the opportunity to update members about progress on provision of paediatric services at St John’s hospital in Livingston. I emphasise my commitment to St John’s, and recognise the excellence and dedication of the staff who work there in caring for and serving patients and families in the surrounding communities.

It is important to say why an interim service model for the in-patient paediatric ward at St John’s hospital has been implemented. In July 2017, the Scottish Government was advised by NHS Lothian that staffing levels were fragile and that there would be no backup available if a member of staff were to be absent at short notice. In those circumstances, there would have been an immediate withdrawal of the in-patient service, which would have caused confusion and anxiety for parents and, possibly, delays in emergency care.

As a result, the board took the decision to implement an interim service model, in the best interests of children and their families. Within the interim model, the majority of children’s services have been maintained at St John’s. That includes the children’s ward being open from 8 am to 8 pm seven days a week and providing a short-stay paediatric assessment service, and the paediatric ward remaining 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. Since last July, the assessment unit has seen nearly 2,800 children and has seen more than 2,000 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 evolution 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 began, the average figure was 12 children a month; since March, the average has been four, which reflects 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 in 2017, and every weekend so far this year.

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 at St John’s. Where there have been shortcomings, I have made it clear to the board that they must be addressed.

For children and their families who have to attend the RHSC, it is vital that support is provided. The case that was raised last week by Angela Constance at First Minister’s question time was of great concern to me, so I asked the board to confirm that an apology would be made to the family involved, and that expenses would be reimbursed. That has been done. The incident was a distressing time for the family, and the board has been left in no doubt that what happened was unacceptable and must not be repeated. The board has acknowledged the shortcomings and ensured that staff at St John’s and the Royal hospital are clear about the support that is available to parents and carers in respect of travel expenses.

Last summer, NHS Lothian asked the Royal College of Paediatrics and Child Health to review its efforts to secure a sustainable 24/7 staffing model, and the interim model that it had put in place. The college’s report reiterated that the preferred option remains a 24-hour model, reflecting the population projections for West Lothian. The college’s report envisages a three-year to five-year programme to develop a clear vision and to recruit sufficient trained medical and nursing staff to provide sustainable overnight care. The college concluded that, in the meantime, the current daytime-only paediatric assessment and decision-making service should be maintained.

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

One of my first actions on taking up post as health secretary was to write to NHS Lothian to press the board on how it could make further progress towards a 24/7 service. I asked the board to escalate efforts to recruit to the advanced nurse practitioner training programmes for paediatric and neonatal nurses, and I asked for confirmation that all activity on recruitment to those programmes is being undertaken in the speediest possible timeframe.

NHS Lothian has reviewed recruitment activity since the royal college’s original report was produced in 2016, and has concluded that a model of care that is delivered mainly by consultants and other medical staff will not fully deliver the board’s absolute commitment to reinstating the in-patient service at St John’s.

Currently, the board has enough staff to cover the extended-hours daytime service seven days a week. The board recognises that a different approach is required to provide a safe and sustainable in-patient service, and is actively progressing development of the multidisciplinary team, which is made up of medical staff and advanced paediatric nurse practitioners.

There is encouraging progress to report, with training being under way and one advanced paediatric nurse practitioner already able to support the out-of-hours rota. Another advanced paediatric nurse practitioner will be able to do that from October, and one nurse, who is currently on maternity leave, will complete training by the end of 2019. In addition, the board has just recruited three more trainees, two of whom will be available to support the rota in a year, with the third being available the following year. Two advanced neonatal nurse practitioners start training this month.

Recruitment activity to staff the model is live and, in order to build in resilience, the board has committed to overrecruit to the consultant and advanced paediatric nurse practitioner posts. That should mitigate the risks that are associated with the impacts of sickness and other absences, and long-term leave. It means that, in addition to putting into effect the next round of advertisements for two consultants—the advertisements are due to go out in October—the board will advertise for additional qualified or trainee advanced paediatric nurse practitioners, and will offer posts to all applicants, medical and nursing, who are assessed as being appointable through the recruitment process.

I have received an assurance from the chief executive that the board has set milestones for reinstatement of the service when adequate and safe levels of staffing are in place, with the aim of having the service back on a sustainable basis as quickly as possible. The board will continue to review progress regularly and will bring forward a contingency plan should progress fall below trajectory.

I have asked the director general for health and social care and the chief medical officer for Scotland to review progress by the end of January and to report to me. I intend to inform Parliament of the situation at that time, in order to ensure that members are updated on progress.

The board’s improved approach to developing a sustainable model of service is welcome. I have asked the chief nursing officer for Scotland to liaise with NHS Lothian and to provide advice and support to the board on training and development of the advanced paediatric nurse practitioner appointees. Discussions in that regard are under way, and I expect to receive a report by the end of October.

I know that members and the local community are anxious to know when the 24/7 service will be reinstated. I share that anxiety and concern. The board’s chief executive has sought to assure me that reinstatement of the full 24/7 paediatric service has the full commitment of the board and will continue to receive the highest level of priority. That, too, is my commitment. We will continue to act, as we have done, to bring that about.

The cabinet secretary will take questions on the issues that were raised in her statement. I will allow around 20 minutes for that.

I thank the cabinet secretary for advance sight of her statement. Since the closure of the children’s ward to in-patients last summer, more than 700 West Lothian families have had to go through the stress and inconvenience of being forced to travel to Edinburgh for hospital care for their children and babies.

Will the cabinet secretary outline for local people what the milestones that she mentions are and what the health board is doing to put in place a timetable for when we will see what she has outlined today? Will she also agree to visit the children’s ward, with elected representatives from across this Parliament, and personally ensure that when the ward returns to a 24/7 service, it will be on a sustainable basis, as she has outlined, and that, in the future, we will not face repeated closures such as the ones that we have experienced over the past few years?

The milestones that the board will put in place, which I am happy to share with members, are about the recruitment and training of the advanced nurse practitioners and the two additional consultants, which I outlined in my statement. Their purpose is to ensure that we remain on track and that the training is completed as we anticipate, in order to allow those individuals to join the rota. Of course, joining the rota is about taking steps towards returning to a 24/7 service.

There is an initial timetable on the basis of what I have set out and there will be an additional timetable as a consequence of the advertising exercise that I said would begin in October to recruit for the two consultant posts and the advanced nurse practitioner posts.

I have asked the director general and the chief medical officer to remain in constant touch with the board to ensure that those milestones are being met, take action where there is any slippage on progress towards those milestones and report back to me in January, at which point—as I have said—I will make sure that Parliament and members are informed of what progress has been made.

On ensuring stability, I could not agree more with Mr Briggs. The key here is not simply to bring back a 24/7 service; it is to bring back a sustainable 24/7 service, precisely for the reason that the member indicated, which is not to have a future situation in which we cannot sustain that service and families and children in West Lothian are put in the position that they are currently in, which I agree is not an acceptable one, although it is the safest position at this point.

That sustainability is absolutely critical and that is why, as a consequence of our discussions with the board, it has agreed to that open recruitment exercise, which may result in it overrecruiting according to the strict numbers that it needs to return the service. We have said that it is better that the board does that so that we are absolutely certain of sustainability than it is to be one short, which would mean a further delay while it has to advertise and try to recruit again.

I thank the cabinet secretary for prior sight of her statement. It is now six years since the staffing problems at St John’s were identified. The 24-hour service closed for the third time in July last year and has not reopened since, despite continued promises. That has understandably left families feeling let down, anxious and angry.

Does the cabinet secretary accept that the situation at St John’s is symptomatic of a wider issue of workforce shortages across the whole of the national health service in Scotland and that that requires a credible and deliverable workforce plan? The cabinet secretary mentioned the milestones in response to Miles Briggs. Will she set out how those milestones will be communicated to local families, so that they are kept in the loop? Finally, what was missing from the statement was a commitment to when a sustainable 24-hour service will resume. Will the cabinet secretary give a target date today? Otherwise, local families will be left to believe that this is yet again nothing more than warm words and false promises.

Mr Sarwar said “despite continued promises”. I have not made any promises. As the Cabinet Secretary for Health and Sport, I am dealing with the situation now and the action that I have taken since June, and I am now reporting to Parliament on that. I do not believe that my predecessors or I have issued

“warm words and false promises”,

so I also disagree with Mr Sarwar on that.

On the situation being symptomatic of wider workforce issues, I agree and have said before that there are workforce challenges in our health service and that a robust workforce planning mechanism is critical. Earlier today, Mr Sarwar and I discussed the bill on safer staffing that is before the Parliament. That is a critical element in contributing to robust data in order to have wider workforce plans and local health board workforce plans. I think that Mr Sarwar and I share a commitment to the broad position that he has set out. We may well disagree about how far we have got and what we might do next, but I think that, by and large, we are starting from the same place.

Mr Sarwar asked for a target date. For me, giving that would constitute

“warm words and false promises”.

I have said that I will come back to Parliament on the matter in January. I will do that because I will know by then how well we have got on with the recruitment of the additional staff and what I have said about when people will join the rota—how well have met the milestones that Mr Briggs asked about. At that point, I hope to be able to say when we expect the full 24/7 service to return and whether there are possible interim steps in extending the service between January and the final date. I will do that then.

The first two questions from the main Opposition parties and the answers to them have been fairly full, as is agreed parliamentary procedure. If there are fairly succinct questions and answers for the rest of the session, we should manage to get through every question.

How will the cabinet secretary scrutinise NHS Lothian, oversee the work of the paediatric programme board—that is crucial—and ensure that it picks up the case and provides a clearer plan with interim steps and timescales to return to a 24/7 service as soon as possible? Will she meet me and West Lothian parents who want to positively support recruitment by endorsing our first-class children’s ward and our local hospital, given that West Lothian is a great place to live and work in?

I will absolutely scrutinise the progress of the paediatric programme board. I hope that Angela Constance agrees that the pace has picked up. We need to maintain that pace and maintain the scrutiny, and that is precisely what I have asked the director general for health and social care and the chief medical officer to do. The chief nursing officer will be involved in that in the specific work that I have asked her to undertake and, in a few short months, the Parliament will be able to see whether we have delivered on what I have set out so far.

I will, of course, be happy to meet Ms Constance and local parents. I could not agree more that the service is excellent and is staffed with very dedicated and skilled professionals, as is the rest of the service in St John’s hospital. I hope that our commitment to it is clear. Mr Briggs asked a similar question, which I did not answer. I would, of course, be happy to meet any member who has a relevant interest in St John’s hospital.

Will the steps that the cabinet secretary has outlined flag up in advance whether there are insufficient applicants during the overrecruiting cycle?

Yes, it will. Obviously, we see who the applicants are when we advertise.

I will make two brief points. First, the advertising process will flag up whether there are insufficient applicants. We would then need to look at what we would do. That is one of the milestones.

Secondly, it is also about the stage that the applicants are at as advanced nurse practitioners. They may already have gone down that route and want to work in that particular part of NHS Lothian, or they may be starting from scratch. In that case, the timescales for their completing the qualification will be different. That will be flagged up.

The current situation at St John’s is clearly in the interest of patient safety. Will a high level of collaboration continue across NHS Lothian to ensure that, when children are treated elsewhere, it is done in a timely manner?

I have made my expectations about appropriate timely care very clear to NHS Lothian, and I will seek to ensure that there is the high level of collaboration that Mr Beattie is looking for. We will continue to undertake discussions with the board to ensure that those expectations are met.

The case of the Mackenzie family is not a one-off—far from it.

During the six-year period over which there have been problems at the ward, how many children have had to be driven past their local hospital to go to Edinburgh for treatment when they should have been treated at St John’s? When will a 24/7 service be reinstated? What is the view of the Royal College of Paediatrics and Child Health on the model of care that the cabinet secretary has outlined? It is not the model of care that people expect to be reinstated. They will see it as a downgrading of the service.

I will be happy to supply the numbers that Mr Findlay requested after today; I do not have those details with me.

I must absolutely and firmly disagree with Mr Findlay. The model that I am talking about is the model that is supported by the Royal College of Paediatrics and Child Health and, from my understanding, by very many people locally, including the staff at St John’s, so it is not fair, accurate or correct to say that it is not supported. It is certainly not correct to say that what I have set out represents a downgrading of the service—far from it. It represents the taking—at pace—of the measured, planned steps that we need to take to reinstate the full service. That is what I am committed to, and it would serve us all well if Mr Findlay would recognise that. Legitimate challenge is one thing, but misrepresentation is quite another.

The cabinet secretary mentioned the efforts to recruit advanced nurse practitioners. There are 2,700 nurse practitioner vacancies across the UK. What steps will be put in place to ensure that the necessary staff will be recruited as soon as possible?

We have the beginnings of a very good track record in Scotland on our nursing staff workforce seeking to become advanced nurse practitioners because of the additional opportunities that that offers them and the additional skills that it enables them to acquire. When I was at Wishaw general hospital on Tuesday, I met a number of newly qualified advanced nurse practitioners, who had just joined the rota, and some trainees. They said to me that they never expected that their career would be so fulfilling and rewarding, or that they would continue to learn so much. Those are our advocates for the new position, and we will make as much use of them as we can. In Wishaw and, I believe, elsewhere, we now have a second cohort and a waiting list for the third cohort to train.

I think that the post of advanced nurse practitioner is one that our nursing workforce will increasingly embrace, and we very much welcome the additional skill, commitment and compassion that they will bring to that work.

Lothian MSPs have been assured by NHS Lothian on an on-going basis that the lack of an in-patient ward at St John’s is being given the highest level of priority. Frankly, we have heard that for years. Today, we are told that two trainees will be available to support the rota in about a year’s time, and that there will be another a year later. There has been a complete lack of urgency on the matter. The fact that there is no target date in sight greatly concerns me. Can the cabinet secretary assure the Parliament that she will insist that the period of waiting and inactivity is finally over?

I had hoped that I had already done that. NHS Lothian might have given assurances to local MSPs, but what members are getting today is an assurance from me, as the cabinet secretary. There has been an increase in the pace of the board’s activity as a consequence of our intervention.

Ms Johnstone’s characterisation of what I said about the additional staff who are joining the rota and those who are in training somewhat understates what I said. I have given assurances, laid out a plan, made a commitment to return to the chamber in January to update members on where we are and said that there will be additional scrutiny at the most senior level of our NHS in Scotland. That comes from me. I have given those assurances to the chamber, and I will undoubtedly be held accountable on them.

The cabinet secretary said in her statement that

“The college’s report envisages”

that

“a three to five-year programme to develop a clear vision and ... sufficient trained ... staff”

will be necessary to bring the unit back to 24/7 sustainability. Given that a lot of the kids who depend on the hospital will be adults by then, that seems an incredibly long period. Will the cabinet secretary confirm whether that is the outer limit of the period for which those kids can be expected to wait? Might the changes be delivered earlier? If we are truly in for the long haul, will the cabinet secretary undertake to come back to Parliament regularly to update us on progress?

My first point to make on that is that the college in question is the Royal College of Paediatrics and Child Health, and it, rather than me—or, with the greatest of respect, Mr Cole-Hamilton—is the clinical expert. The member set out what the college’s 2016 report said. The health board asked the college to come back in 2017, and at that point the college said that a 24/7 model was still the right model for St John’s and West Lothian. However, we have made it clear to the health board that it needs to have a multidisciplinary and multiskilled team to deliver that 24/7 model. I set out how far the board has got on that so far and where it will get to by January, and I said that I will report to Parliament at that time.

Therefore, my timescale is shorter than three to five years, and I believe that the model that we are now progressing, which is clinically safe and which will provide the right care for children in the right place, is shorter than three to five years. However, as I said to Mr Sarwar, I am not prepared to give a target date at this point. The right thing for me to do is to ensure that the milestones are met and that the steps are taken. As I have said, I will come back and report to the Parliament in January on where we have got to. By my calculation, that is four months away; I think that every four months is relatively frequent, so I hope that Mr Cole-Hamilton is satisfied with that.

Earlier in the year, the Nursing and Midwifery Council reported an 87 per cent decline in the number of nurses and midwives from Europe joining the United Kingdom register. Does the cabinet secretary agree that the UK Government’s hostile approach to immigration will result in similar figures being replicated across the medical workforce, including at St John’s hospital?

Mr Paterson is undoubtedly correct about that reported 87 per cent decline. No one in the chamber can argue with the fact that the impending Brexit, whatever form it may take—whether it is no deal or we do not know what kind of deal—is of serious concern in a number of areas across health, not least of which is our workforce. The issue is not just about whether people want to come and work in this country, although we have benefited greatly from that; it is also about the mutual recognition of qualifications, but the UK Government still has not reached a decision on that matter. There is a great deal of uncertainty for our current workforce who come from the European Union and for others who we would wish to join us. Equally, there is uncertainty among staff from this country who might wish to go elsewhere, which we would benefit from if they train and work abroad for a few years and then come back, bringing that expertise with them. All of that contributes to the environment of uncertainty in which we in the health service—in our boards and nationally—are doing our best to plan what we might do in those deeply unfortunate circumstances.

Can the cabinet secretary outline what additional costs the Scottish Ambulance Service has faced as a result of transporting patients to and from Edinburgh?

I am afraid that I cannot do that now, but I am happy to look into that and provide Ms Harris with the detail.

The cabinet secretary will know that Scotland and the UK are in a global competition for clinical talent. Does she agree with me—and with the leader of a public authority who told me last night that one third of its EU members of staff have left in the past 18 months—that recruitment drives are clearly hampered when the prospects for EU staff following Brexit are so uncertain?

Mr Brown is absolutely right. We have two difficulties in the current situation—actually, we have a range of them, but let me stick with two. One is for EU nationals who are currently living and working in our country, a large number of whom are working in our health service, who are unsure about their future position. We the Scottish Government have done everything we can to try to reassure people. I wrote again to those staff members in the health service just this week to assure them that we very much value the contribution that they make and to say that, as far as we are concerned, Scotland is their home and we want them to stay. I understand the uncertainty in their minds about their position and that of their families.

The second difficulty is for individuals who would want to come and work in our health service and benefit from that but who are anxious about the status that they might have, whether their families can come with them and what will happen in the months and years to come. I completely understand all that, which simply makes the job much more difficult.

Given that we are enriched by the experience of having those people in our health service, the difficulties that I have outlined will diminish the overall quality of what we do as a health service across the piece.

That concludes questions on the statement about paediatric services at St John’s hospital. [Interruption.] Before we move to the next item of business, we will have a short wait while the Minister for Mental Health dries off her speech.