NHS GRAMPIAN

MATERNITY SERVICES STRATEGIC REVIEW

Introduction

NHS Grampian is conducting a strategic review of maternity services to support front line staff to continue to improve the services they provide to women and families. Staff can and do improve many things locally, but some bigger improvements need co-operation from other services or support and approval from the wider organisation. This paper covers the strategic aimsof the review, key service risks and opportunities, the process and potential timescales.

Aim

This paper is to inform Board members about the review and prepare for futurediscussions.

Discussion

1. Existing Strategic Position

NHS Grampian’s current Maternity Strategy expires in 2010 and its key recommendations are summarised in Appendix 1. Although there is no formal assessment of implementation or impact, many of these appear to have been achieved,however AberdeenMaternityHospital should still be considered for replacement.

2. Additional Strategic Commitments

This strategic review aims to achieve the following additional specific commitments:

  • a single Grampian wide sustainable service delivering consistent quality in multiple locations
  • the safest, most effective and person centred approach possible within current resources
  • consistent health outcomes irrespective of geography, socio-demographic or other attribute, including the best preparation for children’s early years
  • care as close to home as possible
  • alignment with the work of the Scottish Maternity Services Action Group
  • support families to have a healthy pregnancy and normal birth in pleasant surroundings, free from unnecessary intervention whenever possible, but with high quality specialist support whenever needed
  • support families to give their babies the best possible start, providing a firm foundation for a long and healthy life.

3. Key Service Risks

The service faces a number of key risks which the review must address as follows:

3.1 Increasing Complexity and Number of Births, Uncertain Future

The number and complexity of births in Grampian has risen significantly over recent yearsand relevant population centres have changed. Service capacity and location have not adapted sufficiently to match the current population configuration. Long term projections are that the number of births to AberdeenCity residents will fall, whilst Aberdeenshire’s births rise and Moray’s remain stable. However, the accuracy of these projections is uncertain, so the Health Intelligence team is assessing the feasibility of refining them locally.

3.2 Falling Natural Birth Rate

In 2002 Grampian had the lowest normal birth rate in Scotland. Local figures show some recent but slow improvement; national figures are expected soon. Nationally (and globally) intervention rates are rising whilst normal birth rates fall. Treating birth as a medical condition to be managed, rather than a natural physiological process to be facilitated, can be harmful to mothers and babies, and is a very high cost model.

3.3 Critical Incidents and Complaints

Grampian’s maternity services receive many compliments but the main cause of formal complaints is poor and ineffective communication.These, and Datix incident reports also cover quality of care. As well as poor patient experience, subsequent effects include managerial investigation time and potentially high litigation costs. Untackled, this poses a rising risk to quality of care, reputation and finances.

3.4 Service Variation

Maternity services across Aberdeen, Aberdeenshire and Moray have, until recently, all been managed separately. With the recent appointment of Aberdeenshire Community Health Partnership’sMidwifery Manager, midwifery teams are gradually coming under single management. In addition, the three Midwifery Managers are aligning standards, but this is difficult to achieve when resources and workload are spread across the three service structures. However, obstetric care continues to vary,impacting on midwifery practice and preventing single care standards.

3.5 Dependency on Paediatrics

First line neonatal support in Dr Gray’s Hospital is provided by on-site paediatricians and midwives. The medical component of this arrangement is thought to be difficult to sustain and high cost. If this model were to prove unsustainable, the knock-on effect to maternity services could be considerable, and although other solutions might be possible, could lead to Dr Gray’s becoming a midwife-led unit only providing care and support to healthy women experiencing uncomplicated pregnancies and birth.

3.6 Financial and Staffing Pressures

AberdeenMaternityHospital’s budget was overspentby almost £500k last year, most of which was nursing costs. Growing service demand means management currently see no way of reducing this, other than through additional funding. Dr Gray’s maternity team has submitted a business case to resolve the pressures on midwifery staff and budget but it will not be considered until after this review. Aberdeenshire’s birthing units are staffed to cover an on-call rota for births but do not currently have the numbers of births to match this capacity.

  1. Key Opportunities

The review also hopes to seize a number of key opportunities for example:

4.1 Shifting the Balance of Care

Despite theinterventionin birth rate, over 60% of births in Grampian are normal and do not need specialist obstetric intervention during labour. The World Health Organisation estimates that 70 - 80% of pregnant women may be considered low risk at the start of labour and therefore suitable for midwife-led care. Of these up to 20% might need specialist support during labour but some units achieve rates as low as 10%. The strategic review will explore whether, if transport infrastructure, facilities, staff training and informed choice were adequate, 50% of Aberdeenshire births could be in the community. As it is, around 80% are in AberdeenMaternityHospitalwhich can create capacity issues.

4.2 Post Acute Transfer to Community

For women who have a normal birth in AberdeenMaternityHospital, routine transfer to the community after two to six hours is possible but is not achieved consistently. Instead, women routinely stay for two to three days without clinical need. This is reportedly due to culture and a concern that community teams cannot provide the extra visits. Community teams report that although they do provide earlier visits, this time is re-paid in saved visits later. This is because women find it easier to establish and maintain breastfeeding, bonding, confidence in handling and general parenting skills. These are vital indicators of later good health in children. Consistent routine discharge could therefore save many bed days, improve experience, and improve public health, without jeopardizing the safety of women and babies.

4.3 Improving Patient Experience and Co-producing Services

Recent debate claims that society has become too reliant on state services creating an unhealthy dependency relationship. In line with NHS Scotland’s Quality Strategy many services could be more effective, efficient and better meet needs, if communities were supported to be more active in areas which do not need such high dependency on professionals. Such a shared approach is known as co-production because providers and communities co-produce joint solutions instead of the dominant provider-recipient model. Maternity services are suited to such approaches in many of their roles, for example public health and local maternity units.

5. Process

Like other projects being undertaken by NHS Grampian, the maternity review will promote Continuous Service Improvement but also use structured systems level analysis. This helps people look critically at every step of the “patient pathway” to decide which steps add value, which steps are needed for administrative reasons, and which steps are unnecessary. People then agree what the service would look like in an ideal world before looking at what is achievable within the resources available. These methods have a range of techniques and tools which can be used. One that will be used in thisstrategic review is called a Value Stream Analysis. This is a facilitated event to be held in June, in which the above steps are carried out rigorously with staff and public representatives.

6. Timescales

The above event in June will only take one week but the timescales for stages after that depend on what changes are proposed. For example, at the end of the event, there should be a range of agreed actions, from small improvements which can begin quickly, through bigger changes that may need more discussion and tests of how feasible they are, to formal public consultation on options. It is therefore impossible at this stage to predict firm timescales. However these will be kept to a minimum due to the pressing need to address the above risks and opportunities.

Key Risks (as a consequence of the strategic review)

Failure to Engage Key Stakeholders, Service Users and the Public

Recent history has taught NHS Grampian and other Boards that the public, politicians and media all have high interest and emotional attachment to maternity services. Any review of services must adhere to the national standards on “Informing, engaging and consulting people in developing health and community care services” or risk failure. NHS Grampian’s Corporate Communications department is fully involved, providing both strategic and practical support to ensure this is the case. The work to date is summarised in Appendix 2.

Insufficient Managerial Capacity

NHS Grampian faces a number of challenges, particularly in relation to the current financial climate and increasing pressures on staff capacity. Maternity services themselves are also under high pressure and scrutiny at the moment. A strategic review poses significant managerial burden which risks diluting effort. However, only a strategic review will address the key risks and opportunities, and if they are not addressed the impact will be much worse. Capacity has therefore been created with a Strategic Change Manager, a review team and an overseeing Leadership Group all in place.

Conclusion(s)

Maternity services are very different from most NHS services. They principally serve a time of joy and celebration for families, not illness. They also arguably represent the most significant opportunity to the NHS to improve public health. This is because we can identify those parents most at risk of having children with poor health and life opportunities. Supporting them to improve health and parenting skills from planning pregnancy onwards can break the cycle of ill health in the most disadvantaged communities. The strategic review must balance the need to address these critical opportunities with the need to sustain highly specialist medical intervention for those who need it. Some of these may require changes not just to service configuration, but to the relationship between services and the population we serve. Both staff and lay members have reported enthusiasm as a result of engagement with the review so far,but the Review Team does not underestimate the challenge ahead.

Recommendation(s)

The Board is requested to note this report and request regular progress reports.

Elinor Smith

Director of Nursing and Quality

21st May 2010

Appendix 1 – Existing Strategic Position from Current Maternity Strategy

The key commitments made in NHS Grampian’s 2007 – 2010 Maternity Strategy were for:

  • leadership by a Clinical Management Board
  • evaluation of the Birthing Unit concept
  • modelling the impact of demographic changes
  • targeting health promotion at pregnant women and linking to school education
  • providing pre pregnancy advice
  • health promotion (involving community pharmacists, smoking cessation and training)
  • asking pregnant women about domestic abuse
  • maintaining perinatal mental health progress
  • monitoring the substance misuse service and cascading skills to community staff
  • assessing the impact of substance misuse on the neonatal unit and not separating mother and baby
  • considering the impacts of alcohol misuse
  • providing child protection training
  • building neonatology expertise, cascading skills, supporting: Dr Gray’s, regional transport national resuscitation, and working with child health
  • developing risk management through incident analysis
  • developing written information
  • developing education events, assistant roles and staff
  • establishing effective Maternity Services Liaison Committees
  • meeting MMC and EWTD demands, modelling workforce requirements, new roles, regional working and ehealth improvements
  • considering replacing AberdeenMaternityHospital

Appendix 2 – Summary of Strategic Review Activities Undertaken

Service mapping across all maternity services in NHS Grampian of:

  • Health intelligence analyses (trends in routine data at various levels)
  • Activity levels (attendances, births, etc.)
  • Financial budgets, spends and variances
  • Staffing levels
  • Performance hotspots (problems)
  • Positive performance aspects

Staff briefings and consultations:

  • AberdeenMaternityHospital
  • Dr Gray’s Hospital
  • Aberdeenshire CHP Team Leaders
  • Staff survey launched for cascade by above teams to their colleagues
  • Newsletter issued (one for staff, public and other interested parties)

Public and external involvement:

  • Briefing of Members of Scottish Parliament
  • Three lay reps, one from each CHP (and deputy) on the Leadership Group
  • Lay reps helping improve review documentation for public consumption
  • On-line survey launched using Survey Monkey®
  • Paper based version of same survey handed out at clinics across Grampian
  • Focus groups with recent/imminent mums through attendance at toddler groups and antenatal classes to ask similar questions to above survey
  • Progress updates on NHS Grampian’s website

Internal Meetings of Core Group and Leadership Group:

  • Leadership meets monthly and oversees whole process
  • Core meets weekly to drive process ahead approved by Leadership Group

External Reporting to NHS Grampian’s:

  • Senior Management Team – to approve strategic aspects of the review
  • Continuous Service Improvement Group – to approve CSI aspects
  • Patient Focus Public Involvement Committee – to note PFPI aspects
  • Maternity Services Clinical Management Board – to note review progress

Activities Planned

  • Further newsletters, public updates, staff briefings and consultations
  • More detailed serviced mapping on all aspects
  • Reporting as above
  • Value Stream Analysis event for the week of June 14th