You can find answers to some of the most frequently asked questions about the Start Well programme and public consultation on this page.
This section covers why we started the Start Well programme, who is involved and what we hope to achieve
Why did you start the Start Well review?
There were several reasons for starting this work in 2021, which is being co-ordinated by the North Central London Integrated Care System (NCL ICS), overseen by the North Central London Integrated Care Board and NHS England London Region Specialised Commissioning, including:
- We know there are unacceptable variations in health, in that some groups are more likely to live with poor health and have poorer health outcomes than others and may find it harder to access the right services at the right time. We want to reduce these inequalities in outcomes and access.
- The opportunity to build on existing partnership working as an Integrated Care System and achieve our collective ambition to give every child the best start in life.
- The clear calls to action set out in the national NHS Long Term Plan and the initial and final drafts of the Ockenden Report
- The learning in north central London during the Covid-19 pandemic
- External reviews of services by the Care Quality Commission (CQC) and NHS England and Improvement.
What is the North Central London Integrated Care System?
North Central London Integrated Care System (NCL ICS) brings together local health and care organisations, councils and the voluntary, community and social enterprise sector to work in joined-up ways to improve health outcomes for residents of Barnet, Camden, Enfield, Haringey and Islington and tackle inequalities that currently exist.
What is the North Central London Integrated Care Board?
The North Central London Integrated Care Board is an NHS organisation which is responsible for developing a plan to meet the health needs of the local population, managing the NHS budget for our Integrated Care System, and arranging for the provision of health services in this area.
Which hospitals are involved with the Start Well programme?
The programme is focused on planned and emergency surgical services for children and young people, and maternity and neonatal services at:
- North Middlesex University Hospital
- Royal Free London which covers Barnet Hospital, Royal Free Hospital and Edgware Birth Centre
- UCLH
- Whittington Hospital
- Great Ormond Street Hospital (GOSH)
The links between local and specialist hospitals, particularly GOSH, have also been considered.
Who could be affected by the proposed changes?
The proposed changes we consulted on could potentially impact residents in Barnet, Camden, Enfield, Haringey and Islington and those in some neighbouring areas, such as Brent who use services in north central London.
The proposed changes could also potentially impact staff working at north central London hospitals as they may need to be supported to work in a different unit should changes be implemented.
This section covers questions relating to the proposals for maternity and neonatal care.
Why do things need to change for maternity and neonatal services?
There are many areas of excellent care across north central London, and we know our staff work incredibly hard and are committed to achieving the best possible outcomes for patients. There are opportunities for us to improve the quality of services and outcomes for local people, address areas of difference, and provide a better experience for our patients, their families, carers, and our staff.
Some of the challenges and opportunities include:
- The needs of local people are changing, and our services need to adapt to the falling number of babies being born and care needed during pregnancy and after birth becoming more complex.
- Our services are not currently set up to meet the needs of everyone that uses them and this can impact on their quality.
- The low use of midwife-led care is particularly stark at Edgware Birth Centre. On average fewer than 50 pregnant women and people (less than one a week) gave birth there over each of the last three years.
- We need to make sure there is sufficient neonatal care in the right places. Our neonatal units at UCLH and Great Ormond Street Hospital, that care for the most premature and unwell babies, are often full meaning babies are sometimes transferred to units further away from home. In contrast, half of the cots at the Royal Free Hospital neonatal unit, that cares for least babies requiring the lowest level of neonatal care, are not in use on any given day.
- We want everyone using services in north central London to have the best hospital environment. For example, labour rooms with en-suite bathrooms and neonatal units with enough space for parents to comfortably spend time with their baby. Some hospitals offer this, but some don’t.
- We need to address the staffing challenges we face. There are currently high numbers of staff vacancies in midwifery, neonatal nursing, and other health professions that care for babies. Not having enough staff can sometime impact on the quality of care we are able to provide. For example, staffing shortages sometimes mean that we need to temporarily close midwife-led units which then impacts on parents’ choice in terms of the sort of birth they can have and whether they are primarily supported by midwives or doctors.
What would the proposed changes to maternity and neonatal care mean for the range of maternity and neonatal services available in NCL?
Under the proposed model of care presented at the public consultation, pregnant women and people would still be able to choose to give birth at home, at a unit run by midwives or in a hospital, either in north central London or in a neighbouring area.
If choosing to give birth in north central London there will be a choice of care at either UCLH, North Middlesex Hospital and Barnet Hospital and one other hospital, depending on which option is implemented. Under option A, pregnant women and people would also be able to choose to give birth at Whittington Hospital. Under option B, pregnant women and people would also be able to choose to give birth at Royal Free Hospital. If we implement either of these proposed options, we would ensure that all units in north central London have at least a level 2 neonatal unit and that care would be provided in modern facilities that meet modern building standards guidance.
In addition, there is a proposal to close the birthing suites at the standalone midwifery-led birth centre at Edgware Community Hospital. This would mean that this standalone midwifery-led unit would no longer be a choice for people to give birth. We are proposing that ante and post-natal care remains at Edgware, and midwifery-led care would continue to be offered as a choice through home births and alongside midwifery-led units at other hospital sites. This proposal is being consulted on separately to the overall number of maternity and neonatal units in north central London.
We are proposing to continue to provide antenatal and postnatal care locally in non-hospital settings such as children’s centres. However, for birth and appointments that need to be at a hospital site, women would need to travel to one of the four remaining maternity units in north central London, or to the unit of their choice outside north central London.
How did you decide on the two proposed options for public consultation?
Through an options appraisal process we looked at the different possible combinations of options for the location of the proposed four neonatal and maternity units. This process – which involved clinicians, patient representatives, finance leads, and hospital chief executives – evaluated the strengths and weaknesses of different options against set criteria.
From this process, two options were considered to be implementable and taken forward for public consultation – option A which would see maternity and neonatal services close at Royal Free Hospital and option B which would see services close at Whittington Hospital.
Why was closing maternity and neonatal unit at the Royal Free Hospital the preferred option during the consultation?
Based on an assessment by experts, including local clinicians and patient representatives, we identified the strengths and limitations of each option. Both options are implementable and would deliver an improved quality of care, and at the consultation stage option A (Barnet, North Middlesex Hospital, Whittington, UCLH) was recommended as the preferred option for the future because:
- it would be easier to implement from a staffing perspective because it would mean fewer staff needing to move to a new location
- option B would mean some people would need to go to hospitals in north east London that would struggle to have capacity for this because of rising birth rates in some parts of north east London
- while option A would mean some people would need to go to hospitals in north west London, those hospitals have confirmed they have capacity for this as the number of births in north west London is falling.
What does 'preferred' option mean? Does it mean a decision has already been made?
Going into consultation, option A was our preferred option because, on balance, we think it had more advantages than option B. It is important that as the organisation consulting on the proposals and based on the work and knowledge that we have built up in developing them, that we were open and clear about the reasons for this.
This doesn’t mean that a decision has already been made. The consultation was an important part of gathering a wider evidence base about the proposals and also provided the opportunity to identify any areas that we might have missed, alternative solutions to our challenges and impacts of the proposals. Whilst Option A was our preferred option pre-consultation, further work post-consultation is required before a decision is made about which option is selected.
The final decision on the proposals and options will consider feedback from the consultation alongside all other evidence before reaching a final decision on the future location of services.
How many pregnant women and people would be impacted if Royal Free Hospital closes its maternity and neonatal unit?
Around 2,500 births happen at the Royal Free Hospital each year. This means that should the unit at the Royal Free Hospital close, around this number of births and any related neonatal care that is needed would take place at an alternative location. Pregnant women and people would be able to choose an alternative site for their maternity and neonatal care – and this could either be in one of the four other hospitals within north central London (UCLH, Barnet Hospital, North Middlesex Hospital or Whittington Hospital) or a hospital of their choice outside north central London.
How many pregnant women and people would be impacted if Whittington Hospital closes its maternity and neonatal unit?
Around 2,500 births happen at the Whittington Hospital each year. This means that should the unit at the Whittington Hospital close, around this number of births and any related neonatal care that is needed would take place at an alternative location. Pregnant women and people would be able to choose an alternative site for their maternity and neonatal care – and this could either be in one of the four other hospitals within north central London (UCLH, Barnet Hospital, North Middlesex Hospital or Royal Free Hospital) or a hospital of their choice outside north central London.
What would happen to antenatal and postnatal care?
As is the case now, women and pregnant people would continue to have access to a wide range of routine and, where needed, specialist, care and support while trying for a baby, during pregnancy and after giving birth. This would include routine midwife-led antenatal and postnatal care, scans and antenatal screening, access to metal health support before, during and after pregnancy as well as specialist services such as maternal and foetal medicine.
We want to provide antenatal and postnatal care as close to home as possible, making use of virtual appointments where appropriate. If the proposed model of care is implemented then as is the case now, a significant proportion of antenatal and postnatal care would be provided out of hospitals, at community and family centres and in community hospitals. For example, antenatal and postnatal care would continue to be provided at Edgware Hospital.
Some antenatal care, such as scans and screening tests, would continue to be provided at each of the four hospitals with obstetric and midwife-led birth units. This means there would be four hospital locations providing antenatal and postnatal care in the future, compared to five currently.
The detail of how this would work would need to be worked through in the next phase of the process, post consultation.
What would happen to the space in the hospital if a maternity and neonatal unit closes?
It could be an opportunity to use that space to provide other services which could benefit local people. As no decisions have been made, no plans are in place around about how any space would be used.
This section covers proposals relating to the closure of the birthing suites at Edgware Birth Centre.
Why are you proposing to close the birthing suites at the Edgware Birth Centre?
A key consideration in this proposed closure is the very low number of pregnant women and people choosing to give birth at Edgware Birth Centre each year, balanced against the NHS resources needed to keep the centre running. Having a centre that is delivering less than one baby a week, and birth suites that are used once a month, does not represent a good use of resources.
As a result of this, our proposals include the closure of the birthing suites at Edgware Birth Centre at Edgware Community Hospital.
This would mean fewer than fifty pregnant women and people a year would no longer be able to give birth there. Antenatal and postnatal care would still be provided at Edgware Community Hospital and the rooms that make up the birth centre would be reconfigured so that more people could be seen there for their antenatal and postnatal care.
If the proposal is implemented, we would continue to offer the choice of midwife-led care through high-quality alongside midwife-led units (small, non-medicalised facilities where people can give birth) and home birth services. The decision about the proposed closure of the birth suites at Edgware Birth Centre is independent of the decision about our other proposals for hospital-based maternity and neonatal care.
Why can’t you increase the number of births at Edgware Birth Centre?
The declining birth rate and increasing number of moderate to high-risk pregnancies means it is unlikely we believe that the unit would see enough deliveries to make it an effective use of resources in the long term.
Instead, we want to focus on the choice of homebirth services and alongside midwife led units to enhance this offer – and increase their utilisation.
What would it mean for patients who would have chosen to give birth at Edgware Birth Centre?
We would continue to offer pregnant women and people the choice of high-quality midwife-led care through enhancements to home birth services and alongside midwife-led units.
What would happen to the space at Edgware Birth Centre?
Antenatal and postnatal care would continue to be provided at the centre, and rooms could be reconfigured to allow more people to be seen for this care at the centre.
This section covers the proposals to change some children’s surgery (also known as paediatric surgery).
Why do things need to change for paediatric (children’s) surgical services?
The case for change, published in June 2022, identified a number of opportunities to improve the quality, timeliness and consistency of paediatric surgical services in north central London. We know that services cannot continue as they currently are for a number of reasons including:
- A lack of consistent and clearly defined emergency surgical pathways meaning that clinicians have to make multiple enquires to secure the right pathway for individual children who present to emergency departments.
- Multiple emergency surgical transfers required to find babies or children a bed in the right setting.
- Lack of clarity on the role of Great Ormond Street Hospital in caring for local children and young people in north central London requiring surgery, alongside its more specialist work.
- Access to workforce to deliver emergency surgical activity in children under 3 years or under 5 years (general surgery and urology) and planned surgery in children aged 1-2 years is not consistent across north central London.
- Low volumes of some planned surgery being delivered at some local units means there is reduced exposure to paediatric surgery and paediatric anaesthesia for staff. This can make it challenging to learn and practice the necessary skills and maintain their competencies.
These challenges mean that some children and young people are being transferred multiple times, sometimes to units outside of north central London to receive emergency surgical care. For staff at local units, the fragmentation and lack of clarity on the emergency surgical pathway can mean lots of time is spent trying to locate a bed for their patients and therefore delays in accessing the right care.
Why can't services stay as they are?
The vision for paediatric surgical services is to deliver high quality services and ensure that any child or young person requiring planned or emergency surgery is seen by the right people, at the right place and in the right setting. Leaving services as they are, has been reviewed and is not considered an option. This is because it would mean:
- A paediatric surgical care model that does not deliver the best practice and achieve the clinical standards as set out by professional bodies such as Getting It Right First Time (GIRFT).
- The opportunities for improvement of paediatric surgery would not be realised. This would mean that surgical services would remain fragmented, and surgical care for children aged under 3 or 5 years would continue to be delivered at local units where the expertise required to deliver the best quality care is not readily available. For surgical staff at local units, it would continue to be difficult to maintain and develop the skills and capabilities to deliver this service locally.
- Staff at local units would continue to spend time trying to find a suitable bed for young children requiring surgical assessment and treatment. This may mean being transferred multiple times and to units outside of north central London.
This section covers wider considerations of the proposals, decision making and next steps.
How much would this programme cost to implement?
We’re so grateful to everyone who shared their thoughts with us over the 14 weeks of the public consultation, including issues to consider, and alternative or additional suggestions to the proposals we described. All the feedback was collated and analysed by an independent research company, who have now written two extensive reports. You can read the reports on the Start Well webpage.
The consultation feedback reports are significant, and full of rich detail that will be an important part of our evidence base as we approach the next phase of our work and decide the future shape of these services.
Based on the feedback received, we have already identified some additional work that is needed to either incorporate the feedback, explore alternative solutions proposed, or update our impact assessment. This includes, for example, reviewing our ‘patient flow’ modelling with the most recent data now available, updating our integrated impact assessment, and some more detailed work on some aspects of maternity, neonatal and children’s surgical patient pathways.
What is the timetable for the change? When would this take effect?
We have published the full independent consultation feedback reports on the 6 November 2024 and they can be downloaded from the Start Well webpage. Our task is now to consider whether any of the issues and concerns raised will materially change our proposals and preferred option. Based on the consultation feedback we have identified areas where we want to do some additional work which is now underway.
Over the coming months, we will be developing a decision-making business case. This will bring together all the different evidence we need to consider when deciding the future shape of these services, including clinical evidence; population projections, health need and other modelling; workforce, estates and financial information; and the themes and issues highlighted by staff, patients, families, stakeholders and communities through the consultation. We will also show how we have responded to the feedback given as part of the consultation and any changes it has made to our thinking and planning.
It is planned that the business case will be presented to the North Central London Integrated Care Board and NHS England London Region Specialised Commissioning for them to decide if they agree to implement proposals. We are committed to holding this decision-making meeting in public and are working towards that being in early in 2025. We will update our website with relevant information nearer the time.
Even if a decision is taken in early 2025, this is a long-term piece of work and there is lots of work to do before any changes may be implemented.
In the meantime, there won’t be any immediate changes to the way services are delivered. Whichever decision is made there will be a detailed period of planning and transition for several years before any changes are implemented. This will include clear communication and information for staff and patients, and ample notice given to everyone affected.
How has engagement from staff and patients informed the proposals?
The pre-consultation business case sets out the proposals and how and why they have been developed in great detail, including engagement with staff, patients and other stakeholders. Engagement when developing the pre-consultation business case helped inform and shape the options we took forward for public consultation. In the public consultation, we engaged with service users, patients, staff and other stakeholders extensively over 14 weeks in early 2024. We engaged through questionnaires, face-to-face sessions, social media, letters and emails, phone sessions, public drop-in events and focus groups.
You can read more about how we undertook public engagement in our Start Well Programme methodology and activity report.
The consultation feedback reports will form an important part of our evidence base as we approach the next phase of our work and consider the future shape of these services.
What would happen to maternity and neonatal staff under each option?
We understand that change is unsettling, and we want to give staff as much certainty as possible, but at the moment no decisions have been made. This means it is too early to say what the future impact might be on groups or individual staff members. We want to reassure staff that we are not seeking to cut costs or reduce the number of overall staff working in maternity, neonatal or paediatric care in north central London.
One of the drivers of this programme is the high levels of vacancies in these services and we are keen to recruit and retain clinical staff to ensure we can provide high quality care to patients and service users.
We received a huge amount of feedback from staff during the consultation through both questionnaire responses (over 1,000), focus groups with staff and detailed written responses. We are taking this feedback on board as we continue to shape the proposals we will take forward for decision-making. We are committed to considering all feedback and making sure that any decisions prioritise interests of staff as well as patients and the wider community.
If a decision to change how services are organised is made in early 2025, there will need to be detailed and careful planning to implement any changes. No changes will be made without clear communication and information for staff. There are excellent examples about how this has been done elsewhere to minimise disruption to staff and services. We would envisage supporting staff working in maternity and neonatal care at the site that closes to move to other hospitals in north central London.
We believe there is an exciting future for maternity, neonatal and paediatric staff in north central London. We want north central London to be the place where staff choose to work and want to stay, with opportunities for training and ongoing career development.
Staff working in these services continue to be hugely valued and vital to the delivery of safe, quality care now and in the future. We will of course keep talking to staff throughout this process.