National Clinical Advisory Team NCAT

Transcription

1 To: NHS Yorks & the Humber Paediatric Services at the Friarage Hospital, Northallerton Date of Visit: 12 December 2011 Chair: Dr Chris Clough King s College Hospital Denmark Hill London SE5 9RS Administrator Judy Grimshaw Tel: Judy.grimshaw@nhs.net NCAT Visitors: Dr Chris Clough, Consultant Neurologist, Chair, NCAT Prof Kate Costeloe, Consultant Paediatrician 1. Introduction 1.1. NCAT was invited by Vicky Pleydell, the shadow Accountable Officer Hambleton Richmondshire & Whitby Clinical Commissioning Consortia, along with Amanda Brown, Locality Director of NHS North Yorkshire and York, to consider the options for reconfiguring children s services at South Tees Hospitals NHS Foundation Trust. NCAT agreed to provide an advisory visit at this stage, in recognition that at some point in the future there may well need to be a formal assurance process prior to public consultation. See attached terms of reference (appendix 1) 1.2. Documents Received South Tees Hospital Briefing for GPs Friarage Hospital July 2011 July 2011 GP Briefing FHN Paediatric Services Hambleton Richmondshire & Whitby Commissioning Consortia Extraordinary Board Meeting Activity figures Clinical Futures Project Board Terms of Reference November 2004 North Yorkshire County Council Scrutiny of Health Committee A healthier future for the Friarage Hospital a communications, engagement and involvement strategy December 2004 FHN Maternity Statistics Complaints Report Datix Report NCAT Report p 1

2 2. Attendees see Appendix 2 3. Case for change 3.1. South Tees Hospitals NHS Foundation Trust has recognised publically that the sustainability of the paediatric services has to be kept under review given the problems the service faced in 2009 when there was a temporary closure of both inpatient paediatric and maternity services. There had been extensive discussions as part of the work done by the North of England SHA under the Our Vision Our Future process, which recognised the scale of the problems facing paediatric departments. The key drivers for change were: National issues A recent Royal College of Child Health report (RCPCH Publication: Facing the Future standards for paediatric services 2010) raised the challenge of the sustainability of safe paediatric services in light of the reduced availability of paediatric consultants nationally, the changing workforce legislation and increasing demands on the service. Lastly the change of the service itself with a diminishing requirement for inpatient services but increasing requirement for the care of long term conditions in childhood. The changing profile of paediatric services inevitably impacts upon maternity services since consultant led, in-patient obstetric units require 24/7 immediate availability of staff competent to resuscitate and stabilise an unexpectedly ill new-born baby. Local issues The paediatric service at Friarage Hospital Northallerton (FHN) is low volume with around 1200 acute admissions a year and 7000 A&E attenders. The obstetric service has around 1200 deliveries. There is no middle grade paediatric cover at FHN. The service is supported by 6 SHOs ; presently these are GP trainees, or trainees within military service. Presently there are 6 consultants. There have been some difficulties in recruiting to new posts, although recently a longstanding vacancy was filled by a novel arrangement of having a shared post for two applicants living in Newcastle but being resident on call when necessary. Further imminent retirements (2-3 in the NCAT Report p 2

3 next year or two) may put the service at risk. Consultants need to be generalists as they are not only covering the acute paediatrics but also the special care baby unit and will need to have resuscitation skills. Increasingly children have the need for, and paediatricians are developing, subspecialty skills and there is a requirement for more emphasis on paediatric subspecialties at the Friarage Hospital Because of these pressures on the service, the present consultant work force has recognised that they need to do something now to prevent problems occurring in the future. The options that have been discussed within the Trust are. Option 1: Do nothing, Option 2: Operate as a small and remote paediatric unit Option 3: 5 day working ward Option 4: Paediatric day unit model, 5 or 7 day service Option 5: Close all inpatient services with the provision of enhanced outpatient services (emergency as well as routine), increased specialist clinics and see and treat facility Option 6: Close all inpatient services with provision of outpatient services only (urgent as well as routine) Option 7: No paediatric provision at FHN Presently the preferred option for the Trust would be option 5. Whilst this would mean there would be no inpatient paediatric beds at FHN there is presently a plan for an arrangement to provide out of hours cover to the obstetric service and SCBU by trainees together with non-resident consultant support provision,. It is recognised that this is likely only to be a temporary arrangement and if option 5 is fully worked through it would lead to there being no on site paediatric cover outside the hours the paediatric assessment unit is open. The consequence of that would be the closure of the obstetric led maternity unit, with the option at that point of maintaining a midwife led birthing unit, or withdrawing the facility of births at FHN altogether (both these options recognise there would still be substantial maternity services provided at FHN other than birthing) The present situation for the obstetric unit is that there are about 1200 births at FHN. There is a strong tradition of low intervention at FHN, the unit having NCAT Report p 3

4 a significant cadre of senior midwives thus there are low levels of epidural anaesthesia and over the last few years, low levels of caesarean section (17%). The unit functions with having on site obstetric registrars, who rotate to James Cook University Hospital (JCUH), and four consultant obstetricians who provide in and out of hours cover. There is the appropriate cover from obstetric trained anaesthetists. If the trainee has a low level of experience the consultant will come in, and this would take a maximum of 20 minutes. Out of hours the emergency staffing for theatres is off site and has to come in, we were assured that this is achieved within 20 minutes. While this is within professional guidance it leaves no margin for error in an obstetric emergency. Some staff expressed anxiety about this and it does appear to us to present a potential clinical risk. 4. Views Expressed on the day of the visit 4.1. We have very long journey times within our patch, for instance it can take 1½ hours to get from Hawes in Wensleydale to Northallerton and the journey times to Middlesborough, where the JCUH is, can be even longer Essentially we need to meet the challenges of the small hospital. These issues have been discussed since 2005 and they have not really changed since that time (the Clinical Futures Review) We face a very challenging situation the public think this is all about money but it is not, it is about sustainable clinical services There were concerns when Friarage Hospital merged with South Tees JCUH but now the two hospitals work as one and we see ourselves as part of the same clinical directorate and our problems are shared Things did come to a head 3 years ago when the unit was shut for the short term, which led to a closure of the inpatient beds paediatrics and consultant-led maternity. Although we recovered from that it did indicate that we needed to look for a future sustainable option We could do so much better here at FHN if we didn t have to invest our workforce resource in out of hours cover, and we could put it into the delivery NCAT Report p 4

5 of outpatient services. There is a potential here to develop sub-specialty services at FHN with the support of our colleagues at James Cook James Cook offers a full paediatric inpatient service with level 3 neonatal intensive care unit. There are two on call systems for paediatrics and the NICU Here at FHN we have about 20,000 A&E attendances a year, and of those about 7,000 are children. Patients come from a large geographical area and it is difficult to say what is the serving population. It could be anything from 17-25,000 children aged 0-19 years The future of Catterick garrison appears secure, indeed there is potential to expand the base and that might bring in more work We have about 5½ admissions per day, and there are 14 inpatient beds which are, at most, 40% occupied with an average length of stay of 0.7 days. A significant number of these admissions are for elective surgery, particularly dental, minor plastic surgery. This then characterises our unit as a very small paediatric unit as defined by the Royal College of Child Health. We are unable to employ 10 trainees or trust doctors on a rota as required by this report. However we are compliant with the European Working Time Directive All the consultants need to live locally, a maximum of 20 minutes journey time, in order to cover the unit Our preferred option is for option 5 which preserves a paediatric assessment unit at FHN which will include an observation ward Next year we will lose 2 SHOs and we are hoping to employ doctors from abroad to fill these posts We are worried about the ambulance service as there is increased pressure on ambulances who have difficulty meeting their targets because of the large distances that need to be travelled FHN does not have many specialist nurses, thus there are none available to step into roles on the paediatric unit or the SCBU. NCAT Report p 5

6 4.16. All round we will need to improve the capacity and environment at JCUH to accommodate both the paediatric and obstetric service There could be better integration between the acute and community paediatricians, but if the community paediatricians were required to be on the acute rota they would need additional training and this is unlikely to happen Transferring the inpatient beds will not mean a down-grading of the other children s services at FHN, indeed they can be developed. Children s services at FHN should be seen as a single service for the populations served by Middlesbrough and Northallerton We have a culture of low intervention within the maternity service here at FHN but we do recognise the pressures on the service. The big unknown is what will happen at Darlington, as that could put considerable pressure on JCUH The main issue for patients is about access and transport. It is very difficult for people living in the Dales to get to a hospital quickly if need be. The helicopter service is only part of the answer We are unsure whether there is sufficient parental accommodation at James Cook. Certainly it will be needed if parents are going to travel to JCUH in order to see their child. 5. Discussion 5.1. A good deal of thought has gone into looking at these proposals and we can see that the concerns of the Trust paediatricians are real. We agree with their conclusion that presently they have a first class service but also agree that it is not sustainable in this way for the future, and they must start planning now, particularly with the coming retirements of senior consultants. This is a small unit and when we visited we could see that at times it is very quiet indeed. Thus it is unlikely it would ever be selected as a site for inpatient training of paediatric registrars although it would be a very good place for trainees to master outpatient and other skills. We think that the majority of children presently attending the A&E or being referred by GPs could be seen and assessed within a paediatric assessment unit which would NCAT Report p 6

7 have the facility to observe children for a few hours to monitor their condition and to see the effect of any treatment (eg children with asthma attacks). If though children need inpatient care it should be in a unit which has the full support of on-site trainees and senior opinion, and backed up preferably by high dependency and intensive care facilities We heard from experienced GPs that they can assess sick children who need monitoring in this way, and what they need is the reassurance that, if they are to refer children, they will be dealt with by an effective inpatient unit. We think that in the future new GPs may not have the level of skills that these senior GPs have, and that there will be an increased requirement for paediatric assessment. In addition, if children are sick they need to be in a unit which has the full panoply of paediatric services. With the current level of activity at FHN not only does this not make sense from a financial point of view, but also a clinical point of view. When doctors are only seeing very few cases, the evidence is that they do not maintain their expertise. Even if it were possible to recruit and retain a trained workforce to support the inpatient activity, it may not be in the best interests of children if they are being looked after by doctors who cannot maintain their clinical skills. We would agree with the national guidelines that there is a requirement for fewer paediatric inpatient centres, and that will mean closing inpatient beds in smaller hospitals The good news though is that this will enable the Trust to deliver much more effective services. These start from having a properly organised paediatric assessment unit with easy access to senior opinion. At this stage the planning hasn t been developed to describe exactly what this may look like, but there are a number of good models around the country which should help FHN design a high quality service. Much of the activity generated by children occurs within the mid-morning, after the school run, and in the early evening following return home. A 12 hour 10am-10pm may well be a sensible use of resources. Consultants and trainees should work together to develop this service and there will be some very good training opportunities. In addition there should be ease of access to outpatient clinics and an observation unit, staffed with appropriate specialist nursing and within a child-friendly environment. This then describes a high quality model of care, which will provide a good service for the children of Northallerton and beyond. It will NCAT Report p 7

8 mean that, in and out of hours, children identified by GPs and ambulance staff as requiring an inpatient unit will go straight to the JCUH. This will mean longer travel times for some patients, particularly those living within the Dales. The number of children will be quite small as the majority of children will be dealt with by the PAU These plans would need to have the support of the ambulance services. It would be advantageous if ambulance crews attending patients in rural settings had advanced life support skills, and skills in the care of children. Whilst this may be an unrealistic expectation, to expect all crews to have at least one member trained in such a way, discussions should be had with the ambulance service to see if there are means to improving the overall availability of paramedics with the right skill mix to maximise assessment and resuscitation of children at home or at the roadside. It may well be that, looking at the overall resource, a case can be made to prioritise the needs of those farther away from hospital services The main challenge of reorganising the workforce in this way is the requirement for paediatric cover for the obstetric unit. This involves attendance at emergency caesarean sections and other high-risk deliveries together with the immediate availability of staff with skills to manage the airway, stabilise and initiate intensive care for unexpectedly ill new-born babies. Currently the only women routinely transferred for delivery at the JCUH are those with anticipated very preterm (<30 weeks gestation) birth. The requirement is, if there is an obstetric unit on site, there must be paediatric support to that unit. Currently this is provided by SHOs supported by the consultants who previously have all lived locally and who, out of hours, come in to the hospital for high risk births. It was also interesting to hear that a consultant when not on call may come in if there is a multiple birth or other simultaneous emergencies this possibility would be lost if the consultants lived further away. Other models have been considered such as the use of advanced care nurse practitioners, but there are few units in the country that have been able to sustain this model. A model with advanced care nurse practitioners would still require consultant paediatric supervision, and this could be done from home. The reality is that, without paediatric cover at FHN, it will not be possible to continue with an obstetrician-led service. The transitional plans whereby an out of hours work force of trainees continues NCAT Report p 8

9 throughout the night perpetuates the problems that are presently causing challenges to sustainability, and would still mean that the consultants would still need to provide cover out of hours from their homes, that is be 20 minutes away We concluded that, for the reasons as above, it would be difficult to sustain an out of hours paediatric presence to cover the SCBU and emergency births. In addition to that it needs to be recognised that this obstetrician-led unit is the smallest in the country. It has done remarkably well to sustain a unit of this size and provide high quality care with very good neonatal outcomes due to highly motivated midwifes and obstetricians. The number of deliveries is small, and although the case could be made that, due to expanding populations at Catterick and elsewhere, more births may be forthcoming there would need to be a substantial increase in the number of births to justify having an obstetric workforce and team back up to fulfil the requirements for future obstetric units as described by the Royal College of Obstetricians and Gynaecologists. There is very little likelihood of attaining a 98 hour consultant presence on the labour ward For both these reasons, the sustainability of the paediatric rota and the lack of consultant cover on the unit, other models of maternity services need to be explored. Much of the maternity service can be preserved on site provision of outpatients, midwife support for breastfeeding and mothers, and so on, but the key question will be can births be supported at the FHN site? The only alternative to an obstetric unit would be a stand-alone midwife led birthing unit (MLBU). Recent research has indicated that such units can have very good outcomes if low risk multiparous mothers choose to use the unit. This category of risk is much the same as for those selecting home births thus it might be argued why have a stand-alone unit if all it is doing is providing facilities for mothers who could have had the birth at home. There are other reasons to have a stand-alone unit which adds value above and beyond home birth. For instance, it could be a more cost effective service as there is a requirement for two midwives to be in attendance at home births whereas more flexibility can be used in an MLBU. We think that the present unit has a cadre of midwives who would be very capable of taking on the ethos and working patterns required for a stand-alone unit. This needs to be set against the clinical utility of such as unit and ultimately whether it is affordable. The NCAT Report p 9

10 evidence is that mothers will continue to use stand-alone units but that over time the activity falls, making them a less attractive and affordable option. Nevertheless these discussions need to be had with the local population and the case for a stand-alone unit needs to be examined carefully The other side of this coin is the expectation that JCUH, as the main provider, can absorb much of the inpatient activity both in paediatric services and maternity services. We heard today there were no concerns about the ability of JCUH to take on the inpatient children s services, although they may need to grow their nursing workforce. There may be real issues about JCUH s ability to absorb the increasing number of births if, as expected, the maternity services at FHN are redesigned. Other options may be more attractive for mothers who might choose other units rather than JCUH for a variety of reasons including the proximity of units, such as Harrogate and York. When the FHN unit precipitously closed 3 years ago activity flowed to several units and as far as we are aware there was no crisis of demand and capacity. Nevertheless this planning would need to be carefully considered in advance of any change in service For much of the public the main concerns are about access. The members of the public we spoke to fully understood the arguments about quality and that with modernisation of health services this inevitably meant that there would be an increase in specialisation and a requirement to build teams within acute hospitals such as the JCUH. The public are happy if it can be shown that services will be improved overall, but need to be reassured that, wherever possible, services are kept local.. The Trust needs to be completely transparent about when reconfiguration plans are considered and support the development of services at FHN. At the moment the public s sense is that the big hospital is swallowing the smaller hospital and it would be unacceptable then to see FHN progressively closed because of death by many cuts The Friarage Hospital is loved by its local community. They wish to see a vision for the hospital which sees it being sustainable into the future and we would strongly support this. Whilst it is accepted that acute services may well drift to JCUH, in response the Trust needs to ensure that other services do come down to FHN and this will be helpful overall to the JCUH site. Local NCAT Report p 10

11 people do have concerns about the availability of services, particularly for those with long distances to travel within the Dales. They can be very isolated. Not only that, there are young families on the military base at Catterick who have a lot of needs and can be very isolated because they are away from the rest of their families. Nevertheless the overall concern is that transport to and from FHN and JCUH needs to be improved. There is very poor public transport. There are also concerns that if children are transferred to JCUH it would be very difficult for some people to get there and back during the day, thus parent accommodation will be required at JCUH There are other concerns about the overall provision of health services in the North East. There is a big unknown about what is happening in Darlington. If Darlington Hospital services transfer to Durham, then there will be an increasing requirement for JCUH to respond to patients coming from that geographical area. Will this compound the capacity issues at JCUH? We agreed that certainly the bigger picture needs to be understood, and that there are now opportunities, with the development of the new Northern region which amalgamated the SHAs of North and Yorkshire and the Humber, to look at these problems across larger geographical areas. Certainly it would make no sense to reconfigure hospital services without understanding the impact on others within the region Another concern that has been raised is the need to integrate both community and acute services. Because these two services have been in separate trusts, there has been a lack of joined up thinking. With the greater emphasis on care of long term conditions it will become important that all the resources devoted to this particular group of patients is seen in its totality and used in an integrated and efficient way GPs were uncertain about the utility of increasing development of subspecialisation whereas Trust paediatricians wanted to see more development of subspecialties. At the moment FHN does have visiting paediatric cardiologists, endocrinologists, neurologists and others. The GPs said that most of the time they just wanted assurance from a good generalist paediatrician that nothing was seriously amiss with the child; that is reassurance for the parents. The key to this will be the development of agreed clinical pathways between secondary care clinicians, GPs and community clinicians. Work such as this will require the input of other NCAT Report p 11

12 agencies and parents, but hopefully will lead to more efficient use of resources. Secondary care clinicians should not be predominantly used to reassure the worried well, or in this case the worried parent, and there may be other ways of addressing this issue. Nevertheless the early insight of specialists can make a significant difference to improving the outcomes from common disorders such as diabetes, epilepsy and the long term management of cerebral palsy. Specialist paediatric services do need to relate to adult services. Apart from diabetes, the Trust has not addressed the issue of transition from children s into adult services. Any reconfiguration of service should begin to address this issue. Best practice is for children to attend joint clinics between paediatric and adult specialists to enable them to transition smoothly from the environment of a children s clinic to adult services. 6. Conclusions 6.1. NCAT can support the work done by the Trust to consider a redesign of the paediatric service. We think that the present low volume inpatient service is unsustainable for reasons of maintaining a workforce with the right skills, affordability and potentially clinical safety. We support the movement of the inpatient beds to the JCUH Middlesbrough We think the best option would be option 5, which will give the local population substantial paediatric services on site with a paediatric assessment unit. More work will need to be done to understand what would be the best model and opening hours for a paediatric assessment unit The process of public engagement needs to start as soon as possible to explain the clinical reasons why redesign of the paediatric services is necessary The main consequence of this service redesign will be on the obstetric-led inpatient maternity services at FHN. We do not think it will be possible to sustain an out of hours on site paediatric presence to ensure the safety of the obstetric unit, that is to provide intervention where necessary for those small numbers of births where the baby may need resuscitation. Additionally the maternity unit itself is small, with a low number of deliveries. This level of NCAT Report p 12

13 activity will not justify having a unit with the level of consultant obstetric cover required on the labour unit. Whilst the present obstetric unit appears to be functioning well, the Commissioners and the Foundation Trust needs to look to a more sustainable vision of maternity services on the FHN site Our conclusion is that the best option for maternity services on the FHN site is for a stand-alone midwife led birthing unit. The Commissioners and the Foundation Trust will need to explore with the public whether this would be a popular option, and whether it is sustainable, affordable and safe. The standalone midwife led birthing unit would be the focus of maternity services for this population with the panoply of other services including outpatient clinics, advisory services etc The Commissioners and the Foundation Trust will need to describe, in consultation with the public, a vision of children s and maternity services which is sustainable for the future, of high quality and affordable. This will ensure that those services, wherever possible, should be localised and placed at FHN and it would be only those services that require the support of a bigger hospital, that is the inpatient paediatric service and the obstetrician led care which will need to be transferred to JCUH Inevitably the public will see this as the thin edge of the wedge. Hence, even at this early stage, the Commissioners and the Foundation Trust will need to begin to describe, in consultation with the public, a vision for FHN which will sustain in the long run. The maternity and children s services work will need to be seen within the framework of a larger piece of work which describes the hospital of the future at Northallerton Transport is an important issue for the public and should be considered at an early stage. We would suggest that a working group is set up, perhaps led by the local authority and patient groups, which should consider all the options for improving transport services between the two hospitals of FHN and JCUH, and a wider remit to consider the transport issues for those living in the Dales Ambulance services have been raised as an issue. The PCTs, CCGs and Trusts should enter into a dialogue with Yorkshire Ambulance Service and the North East Ambulance Service to ensure that any future service NCAT Report p 13

14 redesigns are taken into account when planning future ambulance services. In particular there may be an issue of looking at the skills base for ambulance crews in remote and rural areas, and a requirement for training in management of the paediatric airway The Trust needs to consider the requirements for parental accommodation at JCUH We understand that merger of the community paediatric services into the South Tees Trust is anticipated and regard this as important. As a minimum we would expect there to be good and close working relationships between the community and acute paediatricians, and the potential for integrating their services We would expect there to be greater efficiencies to be made in the management of children s illnesses. We would suggest that the CCGs work closely with the children s clinicians in the acute trust and those paediatricians within the community to develop clinical pathways which would identify which resources are required at each step in the pathway, and who should be seeing which child, when and where. 7. Recommendations 7.1. That, in line with the above conclusions, the Trust proceeds with its work to redesign the paediatric service The Commissioners and the Foundation Trust start a process of public engagement as soon as possible The Commissioners and the Foundation Trust consider the consequences for the maternity services at FHN and look to develop a sustainable vision for maternity services on the FHN site in keeping with the above conclusions The Commissioners and the Foundation Trust, in consultation with the public, describe a vision of children s and maternity services which will be centred at FHN. This should be part of a bigger piece of work which describes the vision for FHN as a small hospital serving the community of Northallerton and beyond, which is of high quality, sustainable and affordable. NCAT Report p 14

15 7.5. The Commissioners and the Foundation Trust should approach the local authority and patient groups to consider the need to set up a working group with the aim of improving transport services between the two hospitals of FHN and JCUH 7.6. The Commissioners and the Foundation Trust should approach Yorkshire Ambulance Service and the North East Ambulance Service to discuss the needs for ambulance service provision in the light of the above future service redesign The Foundation Trust should consider the requirements for parental accommodation at JCUH South Tees Hospitals NHS Foundation Trust should ensure there are good and close working relationships between the community and acute paediatricians Clinical Commissioning Groups should lead the work required to develop clinical pathways in liaison with trust paediatricians and other key stakeholders. NCAT Report p 15

16 Appendix 1 NCAT REVIEW-Paediatric Services at the Friarage Hospital, Northallerton Terms of Reference 1. Advise on the clinical evidence base, including consistency of the options for the provision of paediatric, maternity and SCBU services at the Friarage with relevant national guidance/ reviews/ strategies and best practice taking into account the rurality of the communities served by the services and the distances travelled by patients, families and healthcare staff. 2. Advise whether the clinical case is made for reconfiguring paediatric services, taking into account the information provided by the Trust to Commissioners and any other relevant factors including the urgency of the need for change. 3. Advise on the options for future provision of paediatric services at the Friarage Hospital as set out by the Trust including identifying any additional alternative options which may be appropriate assessing how each of the options would contribute to the safe delivery of services, patient experience, equity and choice for patients and families. 4. Advise the PCT and CCG on any interdependencies between paediatric and other services and in particular how the changes proposed in paediatrics will affect future provision of maternity and SCBU services. 5. Advise whether the team are of the opinion that there is a service model which may best deliver safe, high quality, effective and accessible paediatric, maternity and SCBU services at the Friarage Hospital and in the community that is clinically viable, sustainable and affordable. 6. Advise on the extent to which each option has the support of clinicians assess the effectiveness of local clinical engagement development of the proposals, including how clinical views have informed and influenced the development of the proposals including the views of senior clinicians whose services are affected by the reconfiguration. 7. Provide a draft written report of findings and recommendations regarding the proposals by Friday December 23 rd 2011 and a final written report by Friday January 13 th The report will remain the property of NHS North Yorkshire and York but will be circulated to relevant parties. NCAT Report p 16

17 Appendix 2 List of attendees Name Job Title Organisation Derek Cruickshank Chief of Service, Women & South Tees Hospitals NHS Foundation Trust Children Division Dr Fiona Hampton Clinical Director, Paediatrics & South Tees Hospitals NHS Foundation Trust Community Child Health Jill Moulton Director of Planning South Tees Hospitals NHS Foundation Trust Simon Pleydell Chief Executive South Tees Hospitals NHS Foundation Trust Ruth Roberts Consultant Paediatrician & South Tees Hospitals NHS Foundation Trust Foundation Programme Tutor Fran Toller Divisional Manager, Women & South Tees Hospitals NHS Foundation Trust Children Division Prof Rob Wilson Medical Director South Tees Hospitals NHS Foundation Trust John James Consultant Paediatrician, FHN South Tees Hospitals NHS Foundation Trust Dieter Dammann Consultant Paediatrician, FHN South Tees Hospitals NHS Foundation Trust Jane Wiles Children s Directorate South Tees Hospitals NHS Foundation Trust Manager/Senior Nurse Jo Kelsey Ward Manager, Children s South Tees Hospitals NHS Foundation Trust Health Unit, FHN Mary Durrans Community Paediatric Nurse South Tees Hospitals NHS Foundation Trust Manager Anne Wall Clinical Matron Women and South Tees Hospitals NHS Foundation Trust Children s Services FHN Jane Tasker Senior Staff Nurse, NNU South Tees Hospitals NHS Foundation Trust Alison Smith Assistant Director of Nursing, South Tees Hospitals NHS Foundation Trust Children s Champion Paul Buckley Associate Medical Director, South Tees Hospitals NHS Foundation Trust FHN Yvonne Regan Maternity Directorate South Tees Hospitals NHS Foundation Trust Manager/Head of Midwifery Kay Hutchison Ward Manager Labour Ward South Tees Hospitals NHS Foundation Trust FHN Julie Larder Community Midwifery Manager South Tees Hospitals NHS Foundation Trust Fiona Bryce Consultant Obstetrician and South Tees Hospitals NHS Foundation Trust Gynaecologist FHN Kumar Kumarendran Consultant Obstetrician and South Tees Hospitals NHS Foundation Trust Gynaecologist FHN Lynne Patterson Nurse Consultant Neonatology South Tees Hospitals NHS Foundation Trust Jonathan Wyllie Consultant Neonatologist South Tees Hospitals NHS Foundation Trust Cllr Jim Clark Chair, Health OSC North Yorkshire County Council Health Overview & Scrutiny Bryon Hunter Lead Officer, Health OSC North Yorkshire County Council Committee Dr Vicky Pleydell GP Harewood Medical Practice, Catterick Dr Christopher Oates GP Mayford House Surgery, Northallerton Dr Sioban Watt GP Harewood Medical Practice, Catterick Dr Duncan Rogers GP Mowbray House Surgery, Northallerton Dr George Campbell GP Whitby Group Practice Judith Bromfield Chief Officer Richmondshire Council for Voluntary Services Sylvia Tibbitt LINk Rep Hambleton District Kevin Holt Development Officer Northallerton & District Voluntary Service Association Col Pete Sokolow Regional Healthcare Director Duchess of Kent Barracks, Catterick Garrison Alan Wittrick Programme Director North Yorkshire and York Strategic Review NCAT Report p 17

18 Natalie Lyth Consultant Community NHS North Yorkshire and York Paediatrician, Hambleton & Richmondshire Specialist Children's Services Alison Crabb Clinical Lead for Occupational NHS North Yorkshire and York Therapy, Hambleton & Richmondshire Specialist Children's Services Kathryn Shaw Senior Commissioning NHS North Yorkshire and York Manager Amanda Brown Locality Director NHS North Yorkshire and York Jim Khambatta Senior Commissioning Manager NHS North Yorkshire and York NCAT Report p 18