Meeting of the Parliament (Hybrid)

Meeting date: Tuesday, December 7, 2021

Official Report 1034KB pdf

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Maternity Services (Moray)

The next item of business is a statement by Humza Yousaf on the independent review of maternity services in Moray. The cabinet secretary will take questions at the end of his statement, so there should be no interventions or interruptions.

15:21  

I am delighted to update members on the action that will be taken following the publication of “Report of the Moray Maternity Services Review: Review of maternity services for the women and families of Moray”—namely, our next steps for the reintroduction of consultant-led maternity services at Dr Gray’s hospital in Elgin.

I am currently considering the review’s 37 recommendations in greater detail. I want to take the time to do so in discussion not only with NHS Grampian and NHS Highland but, importantly, with local people and communities, including elected representatives. It is important to say that the Government has not ruled out any of the options that are being presented.

Members will be aware that I have been committed to the safe and sustainable reinstatement of consultant-led maternity services at the hospital. That commitment was reiterated as part of our manifesto. Members will recall the members’ business debate that Douglas Ross held on the topic back in June.

I welcome the much-anticipated report. In particular, I welcome the thorough and consultative approach that the review team took. I met Ralph Roberts, the chief executive of NHS Borders, who led the review, on Friday. He told me that around 300 individuals contributed views and that the team held nearly 50 evidence sessions. The outputs of those discussions are evident throughout the report.

I thank Mr Roberts and the review team for the thorough and substantial report that they have produced. I also thank the members of staff and professionals from NHS Grampian, NHS Highland and the wider Scottish health service for their contributions. In particular, I thank local people, local elected representatives and, most important, the women and families who shared their views and experiences. Without them, the report would not have been possible. It certainly would not have been as impactful and powerful.

I will speak to the report, but am keen not to pre-empt any final decisions that I will make on the matter. I will then say a bit more about the immediate actions that have already begun, and I will touch on the medium and long-term issues, which are of great importance.

I am heartened by the response to the report thus far. NHS Grampian and NHS Highland have welcomed the report and have signalled their intention to work together and with the Scottish Government to work through the challenges to implementation of the recommendations. The Keep MUM—maternity unit for Moray—campaign, which led and continues to lead the campaign for maternity services, has also responded fairly and positively. It has welcomed the fact that the voices of women and their families have been heard in the review. I know that people need time to digest and consider the findings, and that they are waiting for a strong signal from the Government about the next steps and implementation.

When, in March this year, we appointed Ralph Roberts to chair the review, we asked the review team to work with NHS Grampian, NHS Highland and stakeholders who have an interest in local maternity services to explore the best obstetric model through which to provide a safe, deliverable and sustainable high-quality maternity service for the women and families of Moray, in line with the Scottish Government’s ambition as described in “The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland”. I am sure that members who have had the opportunity to read that extensive report will agree that it is comprehensive. It is also grounded, pragmatic and realistic. The review report is not the first report into maternity services at Dr Gray’s in recent years, so it is important that we acknowledge the work that is already under way in NHS Grampian through the best start north programme to consider maternity services across the whole of the north of Scotland.

This afternoon, I wish to set out how we intend to move forward in the immediate and short terms; I will also touch on the medium and long terms. The report sets out a preferred approach and includes a detailed plan on how that could be taken forward.

The report also has a number of supporting recommendations. On existing service provision, the report highlights actions that will support safe reintroduction of elective caesarean sections at Dr Gray’s. On culture, the report covers cross-site working for staff and the commissioning of a cultural safety programme. It demands leadership not just from the board but from the Scottish Government.

The report also makes important recommendations on the workforce and recruitment, which we know is absolutely key and has been a challenge to long-term sustainability. We are already making inroads through our implementation of “The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland”, but I recognise that further work clearly remains to be done.

On infrastructure, I commit today to working closely with NHS Grampian and NHS Highland to secure the future of Dr Gray’s hospital. We will invest in its future development, in whatever form that takes.

I want to pause just for a moment to reflect on the fact that national health service staff in maternity and neonatal services, like all our NHS staff, have continued to provide high-quality maternity and neonatal services each and every day for the past 20 months. I pay tribute to them for their on-going hard work, and I thank them for their dedication, resilience and determination in the face of the global pandemic.

I will move on to the immediate actions that we intend to take on maternity services at Dr Gray’s. I was able to meet representatives of both NHS Grampian and NHS Highland briefly this morning, and they expressed to me their determination and commitment to taking forward the recommendations in the review. I have made arrangements to travel to Moray in less than a fortnight, on 20 December, to meet local people, including local campaign groups including Keep MUM, clinicians, elected representatives and representatives of the health boards, to discuss the report’s recommendations with them. If it has not already sent out invitations, my office will be sending invitations to interested parties by the close of play today. Douglas Ross has told me that that date is his wife Krystle’s birthday. I am sure she will be delighted that Douglas has chosen to spend it with me, rather than with her.

We will work at pace with NHS Grampian to consider what is possible in the short term, including the rapid reintroduction of elective caesarean sections, which will quickly double the number of women who can deliver at Dr Gray’s to up to 40 per cent, which is around 400 births per year. I have heard the comments that have been made by colleagues including Richard Lochhead, who—members will not be surprised to know—continually, and often, asks me about and raises issues around Dr Gray’s. That figure still means that the majority of pregnant women in Moray will not give birth at Dr Gray’s. We therefore need to consider the medium and long terms. The issue was also raised during a parliamentary debate in June.

Those discussions will obviously need to include NHS Highland, in recognition that the report highlights the critical role of Raigmore hospital as a choice of place for women to deliver their babies once the maternity unit has been improved and expanded. I want to be clear, however. For that to be sustainable, a number of relevant actions first need to take place. I know that we have previously tried to implement that model, but it quickly became unsustainable and came undone, so I am determined to ensure that, prior to implementation, we have the relevant infrastructure to support change.

That brings me on to the medium-term and longer-term recommendations in the report—in particular, model 5, which is the development of a midwife-led consultant-supported unit that would be located in Dr Gray’s hospital in Elgin.

I am pleased that the Keep MUM campaign group supported that option in its recent response to the report. Under that model, having consultant-supported births—including emergency caesarean sections and instrumental deliveries—would allow up to 70 per cent of Moray women to deliver their babies in the local community. The report highlights challenges and preconditions for that model that cannot be ignored. The model is set in the wider context of a vision for development of Dr Gray’s that will require a clear strategic plan for the hospital. Serious practical and financial considerations will need to be worked through to support such a change.

That brings me back to the commitment to reinstate consultant-led maternity services safely and sustainably. We want to deliver that commitment quickly, safely and sustainably; I fully expect that models 4 and 5 would allow us to return consultant maternity services to Dr Gray’s in such a way. Without a shadow of doubt, we will do that in concert and in consultation with the local community, clinicians, elected representatives and health boards. The process will be done such that the Government is open and transparent about the challenges, but I hope that the community will see that we will work on it with pace.

I could talk at length about the report, given how extensive it is but, as I said, my focus now is on meeting local people to discuss the findings and on getting on with action. I give the absolute commitment that we will waste no time—there will be no lack of pace—and that we will urgently drive forward our work to restore consultant-led maternity services at Dr Gray’s.

The cabinet secretary will now take questions on the issues that were raised in his statement, for which I intend to allow 20 minutes. As ever, members who wish to ask questions should press their request-to-speak buttons or place an R in the chat function now or as soon as possible.

I, too, acknowledge the work of Ralph Roberts and his review team. In particular, I thank the women, families and staff in Moray who shared their experiences. I know from personal experience that the staff at Dr Gray’s and Aberdeen maternity hospital are the very best we could hope for in our area. Throughout the report, they are—rightly—commended by everyone for everything that they do.

The review said that the status quo was

“promptly considered to be inappropriate”.

Of the current model, it said:

“both Professor Cameron in his report and the Review Group believe there are potential risks to patient safety.”

Given that, I must ask the cabinet secretary why we have been living with that model in Moray for more than three years.

Does the cabinet secretary believe that the staffing and capacity can be found at Raigmore hospital to take hundreds of additional women from Moray each year, given that the number who are transferred to Inverness has fallen every year since our maternity unit was downgraded? The figure was just 16 last year. I welcome the return of elective caesareans, but does the cabinet secretary believe that induction of labour should also be made available at Dr Gray’s, if possible? Once he has looked through the recommendations, will an action plan with key milestones be provided so that everyone locally can keep up to date with the progress—or otherwise—that is being made?

I hope that as many women in Moray as possible can give birth locally. As a family, we are blessed with two great boys, but they were born in different circumstances. Alistair came into this world at Dr Gray’s and, after a few days of great care and support, we travelled a few miles home with our newborn.

With James, the scenario was different. As Krystle’s labour progressed, his heart rate started to dip every time she had a contraction. Given that she had been on a green pathway up to that point, I was rocked to hear that. I tried to be strong for Krystle, because I knew that the situation was stressful for her. Seeing my wife taken on a trolley through the hospital, strapped into the back of an ambulance and taken to Aberdeen was one of the worst experiences that I have faced. At that moment, you feel utterly helpless, when your wife and unborn child need you most.

Whether it is 40 miles to Inverness or 65 miles to Aberdeen, the journey adds stress, anxiety and worry at an already emotional time. I hope that, across the Parliament, we will agree to do everything possible to maximise the number of women who can give birth in Moray and to minimise the number who must leave our area to have their children.

I thank Douglas Ross for his questions, and I speak to him first as a father, rather than as the health secretary. I would have hated to be in the position that he was in. When my wife gave birth to our daughter Amal, she was already on a high-risk pathway. We had, unfortunately, miscarried a number of times previously, and my daughter was transverse and therefore not in the right position. In addition, she decided—just for fun—to arrive three weeks early.

We were only 20 minutes away from the hospital where we had to be, but I recognise the feelings and emotions that Douglas Ross expressed around being helpless—let alone having to drive for a period of time while your wife is being transported in the back of an ambulance, as his wife Krystle had to be. As a father, rather than as the health secretary, let me say how unacceptable I find that entire situation.

Douglas Ross asked me whether I found it acceptable that we have had that model in place for the past three years. I do not find it acceptable, and he is right, on behalf of his constituents, to be upset, angry and frustrated. I have no issues with his characterisation of the current situation in that way.

I have been impressed by the cross-party campaign. As I said, my colleague Richard Lochhead was, as members can imagine, one of the first to phone me on Friday, when the report was published, to put to me his constituents’ concerns, not as a Government minister but as a local MSP. Douglas Ross has done exceptionally well to raise the issue in Parliament, and I pay tribute to the cross-party campaign.

On the specific question about Raigmore, I asked that very question of Pam Dudek, Boyd Robertson and the team at NHS Highland. As Douglas Ross will know, Raigmore is undergoing significant development and we have promised to invest in that. I absolutely believe that there is capacity in place to deal with the additional women who may have to go to Raigmore, but I will give him further assurances in and around that.

On his question about consultant-led induction of labour, it will be important for me to go up to Moray to visit Dr Gray’s hospital and speak to the clinicians. I am not a clinician, and therefore it is not for me to say what can be done safely. I say to Douglas Ross—and to the community that is watching—that we want a consultant-led maternity service in Dr Gray’s and that we want as many women as possible, when it is safe, to give birth at Dr Gray’s. We will do that with urgency and pace, but we have to recognise the significant workforce challenges that exist.

That is where Douglas Ross’s last point, which I will end on, is really important. There has to be an implementation path with clear milestones. Members might not always like the timescales. They might challenge us and tell us to go even faster—as the local community might, too—and that is their prerogative. However, I will be up front and realistic about the milestones for implementation. The next stages are that I will visit Moray, to speak to the local community, local clinicians and elected representatives, and then come forward—early in the new year, I would hope—with further detail of the recommendations that we are taking forward, with an implementation plan to follow.

I welcome the minister’s statement. It is positive to see progress on the issue. That progress has been led by Ralph Roberts, who is the chief executive of NHS Borders, in my region. I thank him and the review team for their work, alongside the hard work of local campaign groups that have pushed the issue forward.

Despite the progress that was detailed in the statement, I ask the minister whether he can offer some clarity on what will be done to solve the underlying issues, which—as in many other parts of the country—arise from a lack of staff. There are 365 whole-time equivalent nursing and midwifery vacancies in NHS Highland and 465 such vacancies in NHS Grampian. On top of that, there is a known lack of paediatricians. The minister’s statement barely addressed that issue. What can be done about that?

That is a fair challenge, which goes to the crux of the issue that NHS Highland and NHS Grampian spoke to me about today. Plans are already under way to increase recruitment in both health boards. That is the crux of the issue, and it is why I have to be realistic. It would have been unrealistic for Ralph Roberts’s report to suggest that model 5 can be implemented in a few months or even a year. There is no way that we would be able to get the required workforce, and there are also infrastructure aspects that we have to develop with that model.

I assure Carol Mochan and the campaigners—I know that they will be watching today’s statement—that we understand that the workforce and infrastructure at the hospital are the two key issues that we have to demonstrate both progress on and investment in. I have already given a commitment that we will invest in both aspects.

I thank the cabinet secretary for his statement on this comprehensive report. I also thank the people with lived experience who came forward and shared their experiences, which must have been distressing for them, in order to push for action. I am glad to hear that there will be on-going conversations with them.

My question relates to the issues that Carol Mochan raised. Will the cabinet secretary outline the action that the Scottish Government is taking to increase the number of appropriately trained clinical staff? He has already answered the question in part, but will the action include other rural healthcare centres?

In short, yes. I know that issues with workforce recruitment and retention have been raised by members across the country, particularly those in remote, rural and island areas. We are working with those health boards, and we understand the unique challenges that exist. In some respects, we have already seen an increase in the workforce; however, in relation to Dr Gray’s, we must tackle the workforce challenge, which is the crux of the issue. We must also deal with the infrastructure aspect, although that is the slightly easier part because we can invest in it. The workforce challenge is far more difficult, but we must ensure that there is a sustained effort for consultant-led maternity services in Moray.

One of the preferred options for Moray is a midwife-led service, like the one in Caithness. The result in Caithness is that fewer babies than ever before have been born there—only about 20 to 30 per cent of all births in the far north happen in Caithness.

What work will the Scottish Government commission to assess whether NHS Highland can truly take on the additional work without disadvantaging its catchment patients? What will be the additional cost and who will fund it?

That is all part of the discussions that are taking place. During my discussion with Ralph Roberts on Friday, he said that there is no doubt that people will make comparisons between the situation in Caithness and what is happening in Dr Gray’s, and I can understand why the interdependency and interaction are mentioned. However, we are talking about two different scenarios.

It is fair to ask about the impact that the models and recommendations in Ralph Roberts’s review will have on other rural health settings. Therefore, I promise Edward Mountain that our conversations will be focused not only on Dr Gray’s, but on some of the other rural health sites that might be impacted by any decisions that are made in relation to the review. If Edward Mountain wishes to be part of the conversations in that regard, I am more than happy to involve him.

It is very welcome that the independent review focused on listening to the women, families and service users in Moray, as well as to the staff who are involved in delivering the services.

The cabinet secretary outlined some of the steps that the Scottish Government has taken to ensure continued stakeholder engagement. Does he accept that, for many reasons, not least their mental health, mothers in rural areas must have the choice of having their maternity care close to where they live? Can he provide assurances that their views will continue to be taken into account as decisions are made?

Yes, I fundamentally agree with Gillian Martin’s point. In my response to Douglas Ross, I spoke of my experience. I was lucky and blessed that the hospital in which my wife gave birth was 15 or 20 minutes away from our home.

A fundamental recommendation of the best start policy is that women have care delivered as close to home as possible. Of course—I know that every member understands this—that must be balanced with the safety of the mother and the baby.

The introduction of Near Me across the NHS has allowed many women to access care in their local area when they might have previously had to travel to big urban centres. In addition, the development of community hubs and teams under best start will provide as much antenatal and postnatal care in the community as possible.

Ultimately, Gillian Martin is right: the Government’s ambition is to provide care that enables women to give birth and have their baby delivered as close to home as possible.

The next two colleagues join us remotely.

I, too, welcome the review. I feel for families, who are rightly frustrated by delays. It would be good to have a clear indication of the timeframe for the restoration of full maternity services at Dr Gray’s hospital. In the meantime, what accommodation and childminding support is available to families who have to travel to Aberdeen or Inverness for maternity services?

Those are all very fair points. I completely accept the desire of the local community and other stakeholders that have an interest in the matter to see a detailed implementation plan from the Government. We will provide that.

As I have already said a number of times, in the first instance, I would like to meet the local community, including local representatives. If I have not invited any elected member who would like to be part of the discussions, I ask them please to get in touch with my office. I have no issues with inviting whoever to that conversation.

After that, we will give details of the recommendations that we are seeking to take forward. Alongside that, we would look to bring forward an implementation plan with key milestones.

In his review, Ralph Roberts details what he thinks those timescales should be. As members can imagine, as the Cabinet Secretary for Health and Social Care, I want to push those with as much pace as I can.

Rhoda Grant’s second question was about the support that is available for women and families who might have to travel to Aberdeen maternity hospital or Raigmore hospital. I will look into that. If we can do anything further in that regard, I would be very open that. The request is a fair one, particularly if accommodation and travel costs are involved. I can look into the matter offline.

We have five speakers and five minutes left. There should be succinct questions and responses as far as possible.

The delivery of the recommendations to the timescales that are set out will take time and, critically, dedication by all those involved. Will the cabinet secretary give an update on discussions with NHS Grampian to ensure that the board has a full leadership team in place in a timely manner?

I will respond briefly. This morning, I had a discussion with the health board and I will meet it again on 20 December. I can assure Emma Roddick that the points that she raises are very much part of our discussions, and the health board’s input into the matter is of vital importance as we progress the actions.

The independent review found that

“Maternity services are key to the wider economic and community wellbeing of a population”,

so it is vital that Dr Gray’s hospital is supported to improve its ability to provide high-quality maternity care for local families in Moray.

The review is not the first. The 2019 Alan Cameron report found that

“Working relationships in the Dr Gray’s Maternity Service are dysfunctional and damaged to the extent that they may impact upon patient safety.”

Is the Scottish Government supporting Dr Gray’s hospital to implement the recommendations from the Cameron review, particularly the recommendation to develop

“a full package of support for all staff who have been adversely affected by the issues within the Dr Gray’s Maternity Service”,

so that those recommendations do not get lost as work begins on implementing the new recommendations?

Yes. In short, we will not ignore previous recommendations. As I am sure that Ms Burgess is aware, there is a fair bit of detail on culture in Ralph Roberts’s report, and we will take forward those recommendations, too.

During the pandemic, we have seen the benefits that services such as Near Me, which the cabinet secretary mentioned a short time ago, can deliver to reduce the need for in-person appointments. Will he outline what role he envisages such technology might have in the delivery of services in Moray?

I mentioned the Near Me service in answer to a previous question. Technology has a possible role to play in antenatal care, and in postnatal care. It is a great enabler, but that does not detract from the desire of women, and of their families and the local community, that they should give birth as close to home as possible. That is what we want to progress as a result of the report.

Given the number of patient transfers that have had to be conducted, sometimes at short notice, to either Raigmore or Aberdeen, what impact does the cabinet secretary think the on-going problems have had on the already overstretched Scottish Ambulance Service in the Highlands and Islands?

The obvious answer is that I suspect that it does not help. That is part of our consideration about how quickly we can ensure that more births take place at Dr Gray’s and, indeed, as close to home as possible, whether people are in island communities or remote and rural communities.

A section of the recommendations references

“The importance of culture to quality and safety in any service”.

That is not only beneficial to service users but of equal importance to staff. Will the cabinet secretary give an indication of what work will be required to progress the delivery of a cultural safety programme?

In the interests of brevity, I would probably be better writing to Stephanie Callaghan with the detail of that. However, she is right to highlight it. As I said in my response to Ms Burgess, the extensive report from Ralph Roberts goes into the vital importance of culture in the workplace. We often focus on the clinical expertise and infrastructure that are needed to deliver the recommendations in such a review, but the culture of the workforce is also important. Ralph Roberts’s recommendation to invest in a cultural safety programme is a vital part of his report, which I intend to take forward.