North East Essex Clinical Commissioning Group. Report of proposals for future of maternity services in north east Essex

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1 North East Essex Clinical Commissioning Group Report of proposals for future of maternity services in north east Essex Contents Executive summary 1.0 Introduction 2.0 Preparing to consult 3.0 Meeting the four tests for service change 3.1 Support from general practice 3.2 Strengthened public and patient engagement 3.3 Clarity on the clinical evidence base 3.4 Consistency with current and prospective patient choice 4.0 Equality and diversity 5.0 Service user engagement 6.0 Campaign materials 7.0 Independent analysis 8.0 Independent panel 8.1 scoring the options 8.2 Panel recommendations 9.0 Conclusion Appendix one Appendix two

2 Executive Summary The need to address the sustainability of maternity services across North East Essex (NEE) has been the subject of discussion for some time. In November 2013, the boards of North East Essex Clinical Commissioning Group (NEE CCG) and Colchester Hospital University Foundation Trust agreed the case for change document, identifying a commitment between both organisations to work collaboratively to develop a definitive, sustainable model of maternity services across NEE. Previous service user engagement exercises undertaken in 2012 captured the opinions about current maternity services from local women and their families. This also included feedback from a variety of health professionals including obstetricians, midwives, health visitors and specialist community nurses. Opinion at the time confirmed that the service across North East Essex was perceived to be inequitable. The development of a more consistent model of care and equitable distribution of midwifery resources, informed by national and local standards and feedback gained throughout the engagement process in 2012 would result in more women and their families experiencing a consistent and equitable level of service. This would result in a significant increase in service user satisfaction. From 15 th October-10 th December 2014 a public maternity consultation took place outlining two possible options. The consultation document, Right start offered two options for the future provision of services. Option One- Clacton and Harwich to remain as on demand midwife led units. Antenatal and postnatal care to continue. Option Two- Clacton and Harwich to return to the status of midwife led units-24/7. Antenatal and postnatal care to continue. In addition to the choice of options, respondents were asked a series of questions to help identify the key factors in the decision making process. A variety of consultation events and media were used to enable a comprehensive response to the consultation. In total, 233 people completed the public survey (online and in paper format) and an additional 16 narrative responses were received from individuals and groups. The narrative responses came from charities, the local council, midwives, hospital consultants, GPs and unions/staff side representatives. The Royal College of Midwives also responded. Following an independent analysis of the findings of the consultation a panel was convened on the 27 th February 2015 to score the options. The panel was chaired by Healthwatch Essex and included attendees from a number of organisations including a service user representative. The aim of the panel was to ensure a recommendation was made to both Colchester Hospital and the CCG boards on the preferred option.

3 1.0 Introduction In March 2014, the CCG was advised by Colchester Hospital University Foundation Trust that a decision had been taken to temporarily close the midwife led units at Harwich and Clacton due to ongoing concerns regarding midwifery staffing levels across the whole of maternity services. Closure of the Tendring Peninsula units enabled midwives to be deployed in the busier obstetric unit and Juno suite at Colchester Hospital. At the time of the temporary closures, a recruitment drive for additional midwives was expedited. On 12 th June 2014 the Colchester Hospital board agreed Clacton and Harwich midwife led units should re-open for births on demand, enabling a similar model of care to be provided. The only difference being that a woman requiring the services of the midwife led unit outside of normal working hours would contact the midwife on call who would meet her at the unit. This was opposed to a midwife being present within the midwife led unit 24 hours a day, often when no births were taking place. This change in care delivery enabled the CCG and Colchester Hospital to discuss and agree the proposed options for the future configuration of services and the subsequent formal consultation. The proposed options took into account the strong feedback from stakeholders and the public that the choice of maternity services should include the option to deliver in a midwife led setting at both units in Tendring. National guidance from the Royal College of Obstetricians and Gynaecologists (RCOG 2008) suggested that successful maternity services were those that enabled women and their families to choose the most appropriate care for each phase of their maternity experience. This too, is essential, for women with complex health needs where higher level intervention is required. Offering a range of options and discussing possibilities provides women with informed choices that best meet their needs (RCOG 2008). Guidance from the National Institute for Health and Care Excellence (NICE) supported choice, by advocating that women should have an option to have their baby in a variety of settings including both standalone and co-located midwife led units. The review of national guidance and service user feedback prompted the CCG and Colchester Hospital to remove closure of the midwife led units from the options for consultation. In June 2014, the CCG and Colchester Hospital jointly commissioned an external peer review of maternity services with the East of England Strategic Clinical Network. The main purpose of the review was to assess the opportunities for improvement in existing commissioned maternity service provision. Assessing the viability to continue to provide intrapartum care on three sites was also addressed. The review concluded that a longer term evaluation of strategic capacity was required across maternity services to ensure safety and sustainability for the future. In July 2014, maternity services were subject to an inspection by the Care Quality Commission (CQC) as part of a wider inspection of the care delivered by Colchester Hospital. Whilst suggestions for the sustainability of the Tendring midwife led units were not included in the report, mention was given to the closure of the costal units and the reduction in options available to women for birth.

4 In July 2014 the options appraisal paper for the maternity consultation was taken to both the CCG and Colchester Hospital boards who agreed the proposed options and the need to formally consult with the public The options agreed were; Option One- Clacton and Harwich to remain as on demand midwife led units. Antenatal and postnatal care to continue. Option Two- Clacton and Harwich to return to the status of midwife led units-one 24/7. Antenatal and postnatal care to continue. The principles underlying the public consultation were agreed by both organisations. These were to: 1. Ensure that women and their families have access to high quality, safe and effective maternity services that reflect the needs of the local population and are sustainable for the future. 2. Work to promote and maintain choice for women and their families, creating an environment that supports personalised care as integral to its service. 3. Ensure the best use of resources is made, creating fairness and consistency across north east Essex. 4. Ensure that any changes to service delivery do not disadvantage women and their families. 5. Work to maintain or improve continuity of care for women throughout pregnancy, labour and during the postnatal period. 6. Work with service users, clinicians and stakeholders in the development of any options for change. 7. Ensure that all recommendations for consultation are based on a clear rationale and where appropriate national and/or local guidance. The NHS Five year forward view, published in October 2014 supported the need to ensure that nationally, maternity services develop in a safe, responsive and efficient manner ensuring that choice is supported and not inhibited. Although published after the commencement of the consultation, it remained noteworthy to consider this as the consultation progressed. 2.0 Preparing to consult Commissioning services and implementing change involves a complexity that requires input from stakeholders, partners, providers, service users and the public. In 2012/13 the CCG, supported by the north east Essex Maternity Services Liaison Committee (MSLC), reviewed maternity services by undertaking a public engagement exercise with women and their families, community groups, midwives, obstetricians, GPs and other health professionals. A smaller review of the needs of women from black and minority ethnic (BME) communities was also undertaken in In the summer of 2014, further pre-consultation work was undertaken by the MSLC which included the development of an electronic survey (which received 100 responses) and a series of service user events across Colchester, Clacton and Harwich. These were hosted and independently

5 chaired by the CCG Health Forum and attended by representatives from Colchester Hospital, the CCG and MSLC. The events were conducted using an approach that supported a question and answer style panel. On the 9 th August 2014 a Communications and Engagement work stream was established by the CCG and Colchester Hospital to ensure stakeholder and service user input was integral to the development of the consultation programme. The main objectives of the communications and engagement work stream were: To ensure that service users and potential service users of maternity services locally, commissioners, providers and those with an interest in maternity services were aware and informed about the proposals for change. To ensure that those people with an interest had an effective opportunity to give their views on proposals and plans and that decision-makers had the benefit of a range of patient, public and professional viewpoints and expertise. To support clinicians, managers and commissioners in achieving a fair, transparent, well-informed and smooth-running development programme for improving maternity services in north east Essex. To ensure adherence to statutory guidance relating to the requirement for NHS bodies to consult their local communities on health plans set out by the NHS Act (2006), Cabinet Office Code of Practice on Consultation (2008), Equality Act (2010) and Health and social Care Act (2012). Membership of the work stream included: MSLC chair (service user representative). CCG and Colchester Hospital communications representative. CCG Children and maternity commissioner. Invitations were also extended to Outhouse (Lesbian/Gay/Bisexual/transgender group), TACMEP (migrant community group) and disability groups. On the 10th September 2014, the proposal for the maternity consultation was presented to the Essex Health Overview and Scrutiny Committee (HOSC). 3.0 Meeting the four tests for service change Recommendations made by the Secretary of State (2010) identified that prior to any major changes in NHS services there should be support from GP Commissioners, strengthened public and patient engagement, clarity on the clinical evidence base and consistency with current and prospective patient choice. The CCG and Colchester Hospital have ensured that these four tests for change have been integral to the maternity consultation process via a multitude of fora:

6 3.1 Support from General Practice NEE CCG has 43 GP member practices. The options for consultation were developed in conjunction with the GP elected members of the CCG. There are two GP elected members who take a lead on maternity services and who have been consulted regarding the options and consultation process. The consultation strategy and the consultation document were discussed at the CCG s Transformation and Delivery Committee (TDC) which clinically reviews and agrees on the CCGs clinical developments. The options for the consultation and the process for consultation was discussed at the CCG board The consultation was discussed extensively at general practice fora in north east Essex. 3.2 Strengthened public and patient engagement There has been extensive public and patient engagement during the development of the options and the pre-consultation phase. The chair of the MSLC (service user representative) was involved in the communications and engagement work stream and attended some of the public consultation events. The consultation strategy was approved by the HOSC. The consultation which ran for eight weeks (15 th October-10 th December 2014), was widely advertised and achieved coverage in local broadcast media and newspapers The pregnant population for north east Essex is approximately 4,000 per annum. 233 (5.86%) members of the pregnant population responded to the public consultation, which compares favourably with other public sector consultations. Service user representation was present at the independent panel convened on the 27 th February Clarity on the clinical evidence base The options were discussed at the CCG s Transformation Delivery Committee (TDC) which clinically reviews and advises on all CCG clinical developments. The option appraisal paper and consultation document were fully referenced using national clinical guidelines and quality standards and findings from national and local reviews of maternity services. Feedback from health professionals formed part of the public consultation. Feedback from the Royal College of Midwives was also obtained. Clinical representatives were members of the independent panel convened on the 27 th February The criterion used to score the options was based on national best practice as outlined by the Royal College of Obstetrics and Gynaecology.

7 3.4 Consistency with current and prospective patient choice Service user representation was present at the independent panel convened to score the options on the 27 th February Patient choice, both current and prospective, was included as a thread across all criteria used to score the options. Service user feedback from the consultation will inform the development of the CCG maternity strategy ( ). 4.0 Equality and Diversity The CCG and Colchester Hospital have a duty to comply with equalities legislation; to reduce health inequality; and to promote integrated health services where this will improve quality. Throughout the process of developing and implementing the consultation the CCG and Colchester Hospital involved service users from across north east Essex ensuring that both the proposals and the process met the requirements of equality and diversity policies and procedures. An equality impact assessment (EIA) was undertaken prior to commencement of the consultation which was circulated by the CVS to community groups for comment (see appendix one). No responses were received. Copies of the consultation document were translated into easy read, braille, audio and the most commonly used languages other than English. The consultation did receive responses from people with the following protected characteristics: disability, age, race and sexual orientation Service user engagement with vulnerable or hard to reach groups included: A pre-engagement survey was undertaken with BME groups which looked at religious and cultural issues as well as language barriers. Fathers were engaged as well as mothers. Events across the north east Essex area including Jaywick, Colchester, Clacton and Harwich. All of the venues were accessible for people with disabilities and for service users with pushchairs. Two events were planned with teenage service users although one was cancelled by Colchester Hospital due to staff sickness A migrant communities workshop A LGBT representative was invited to join the communications and engagement work stream although declined. A service user with disabilities was also identified although they did not attend the work stream. 5.0 Service User Engagement The consultation ran from the 15th October 2014 through to the 10th December Service user engagement forums were well publicised within the public maternity consultation document as well as on the Colchester Hospital and CCG public facing websites. Details of those organisations or persons contacted are outlined in appendix two.

8 Engagement methods included: Face to face meetings with service users at venues they were already attending including children s centres and antenatal clinics. Events held in each of the maternity units at Colchester, Clacton and Harwich. Panel events chaired by the CCG Health Forum in Colchester, Clacton and Harwich. Social media to generate interest in and commentary on the service as well as completion of the survey. Online survey and pull out survey in the printed consultation document to be returned freepost. Copies of the document were widely circulated. 6.0 Campaign materials A diverse use of media was utilised to promote the maternity consultation which enabled the public to feedback in a variety of means. In preparation for the consultation, the CCG worked with BBC Radio Essex to schedule a live interview with the Clinical Commissioning Group s Director of Nursing and Clinical Quality. During the consultation coverage was included on BBC Look East (morning, lunchtime and evening broadcast). A full news release was also issued at the start of the consultation and subsequent news features were published in the Daily Gazette and East Anglian Times. Full page adverts were also included in all editions of the Gazette. Online adverts were placed with Essex Baby and the Gazette as well as on the CCG and Colchester Hospital public facing websites. An online advert was also placed with Tendring District Council. Social media was utilised and links made to the CCG, Colchester Hospital and MSLC pages on both Facebook and Twitter. Visual displays and posters were provided both at the CCG and Colchester Hospital together with opportunities to drop in and talk to representatives from both organisations as well as other service user representatives. Copies of the consultation document were distributed to libraries, GP surgeries, Children s Centres and core health/social care and voluntary sector providers including: Colchester Hospital University Foundation Trust Anglia Community Enterprise North Essex Partnership University Foundation Trust Tendring and Colchester.community volunteer service Tendring District Council Colchester Borough Council

9 Healthwatch Essex made reference to the maternity consultation in their electronic newsletter. The CCG Health Forum Committee newsletters included reference to the maternity consultation and how to be involved. The minutes of the MSLC and Health Forum Committee made reference to the maternity consultation. 7.0 Independent Analysis Independent analysis of the consultation findings was undertaken by the Anglia Ruskin University post graduate medical institute. Anglia Ruskin University received a pre-agreed consultation fee for completing the independent review. The decision to commission ARU was based on the strong academic reputation of their research unit as well as their previous experience of providing detailed independent analysis reports. At no point during the process of analysis did the CCG or Colchester Hospital have access to or influence writing of the report. The completed report was sent to the CCG on the 23 rd February Independent Panel On the 11 th December 2014, the CCG Operational Executive Committee agreed that, following the closure of the consultation and analysis of responses, an independently chaired, multi-agency panel would be convened to score the options and make a recommendation to the CCG and Trust boards. The panel would be chaired by Healthwatch Essex and provided with clear terms of reference, as stated below The panel will comprise service user representatives and clinical and commissioning representatives from agencies involved in maternity services in North East Essex The panel will be independently chaired by Healthwatch Essex The panel will use an agreed methodology for assessing and scoring the options which aims to ensure objectivity and prevent bias. The principles agreed between NEECCG and Colchester Hospital prior to commencing the consultation is integral to the function of the panel. The panel will make a recommendation for the future of maternity services to the boards of NEECCG and the Colchester Hospital based on the scoring. The CCG and Colchester Hospital were clear that the views of the public would be part of a wider evaluation of the options; consultation on the options was not a vote for a particular or preferred option. This was supported by the panel that agreed that the report compiled by ARU was part of a multi-factorial approach to scoring the options and should not be considered in isolation. The methodology for scoring the options was agreed by the Independent chair and based on the 7 appraisal criteria set out in the public consultation document; Clinical effectiveness Safety Efficiency Acceptability/Service User experience Access

10 Equity Relevance. The seven criteria were expanded in line with the evaluation criteria for potential service models as outlined in national guidance relating to the reconfiguration of women s services in the UK (RCOG 2013). Prior to the panel date, all panel members were sent a data pack which enabled them to consider a number of factors that impact upon maternity services nationally and locally. The data pack included: National guidance- Reconfiguration of women s services in the UK. The Right start maternity public consultation document. Colchester Hospital maternity data- the previous 2 years service and birth data, workforce requirements, commonalities and differing needs of each of the Tendring midwife led units. Independent Review of Consultation Findings published by ARU. Panel terms of reference. The panel was convened on the 27 th February 2015 and included members from: Healthwatch Essex (Independent Chair) NEECCG- Director of nursing and clinical quality and commissioner Colchester Hospital- midwifery and obstetric clinical leads GP representative Practice manager Tendring Children s services lead Anglia Community Enterprise Children s services lead North Essex Partnership Trust Commissioner Essex County Council (ECC) Service User representative (MSLC) 8.1 Scoring the options All members were reminded of the options outlined in the Right start public consultation document and consideration of the service user voice and experience would inform deliberation of each criteria, rather than being scored as a criteria in its own right. The Chair and panel members agreed that, whilst the consultation response indicated a statistical preference for Option 2, the decision should rightly reflect the many relevant factors involved. The Chair and the panel agreed, that any additional views or recommendations related to or extending beyond, the terms of reference, should be recorded and form part of the overall report to the Boards of the CCG and Colchester Hospital. The options were set out as follows: Option One- Clacton and Harwich to remain as on demand midwife led units. Antenatal and postnatal care to continue.

11 Option Two- Clacton and Harwich to return to the status of midwife led units open 24/7. Antenatal and postnatal care to continue. Each of the options was considered in line with the individual appraisal criteria and associated questions. Each option was then scored accordingly (see section 8.2). A synopsis of the narrative of the discussion relating to each of the appraisal criteria was captured and recorded and is as follows: Clinical Effectiveness. There was general recognition that the on demand system (option 1) had been running well since the units re-opened in July There has been no increase in clinical incidents or Serious Incidents (SIs) and no increase in reported significant risks relating to the safety of women and their babies. The on-call arrangements across maternity services were extended to include access to each of the units out of hours. Workforce requirements were discussed for both options and it was agreed by all panel members that delivering a 24/7 service does not support a workforce model that is realistic or sustainable. Option 1 supports a more sustainable workforce model and is in line with national guidance that recommends that midwife led units need to attain approximately 250 births per year to warrant 24 hour cover. Staffing acuity assessments have been completed for both units. In line with local and national commissioning priorities around choice in maternity services it was agreed that option 1 did support this as well as a more flexible approach to service provision which had been echoed in service user feedback both pre and during the consultation period. There was acknowledgement that the funding stream for maternity services was in line with national tariff. The panel considered that the financial implications of option 2 were less favourable owing to the need to manage the overheads of the unit even when women and their families may not be present. It was agreed that education and training requirements were the same for both options 1 and 2. It was recognised that service users and the public may perceive the on demand service to be one that may result in a loss of midwifery services and therefore impact on clinical effectiveness. Panel members, including the MSLC representative, reported that previous closures of the units had resulted in a general anxiety amongst the public that closure was still a consideration. The CCG representatives reminded the panel that closure had been removed as an option at the preconsultation stage. The panel discussed the likelihood that these generalised anxieties about closure may have informed consultation responses. The panel strongly supported the need to reduce the anxiety amongst the public and provide clear information to families on their choices and asked that the boards of the CCG and Colchester Hospital address this. The options were scored as follows:

12 Option 1= 3 Option 2= 2. Recommendation: There was agreement that the CCG and Colchester Hospital needed to take steps to address public perception and anxiety and ensure women and families are offered information on choices in maternity services in NEE. Safety There has been no reported increase in clinical incidents, serious Incidents or significant risks relating to the safety of women and their babies since the re-opening of the midwife led units in July Work with East of England Ambulance service was already underway to review and enhance standardised operating procedures between the ambulance and maternity services.. While it was recognised there may be public perception that option 1 would be less safe than option 2, due to ambulance provision, it was determined by the panel this was incorrect. It was recommended that the CCG and Colchester Hospital should take steps to address this public perception and anxiety. There were general discussions that both models supported an approach to care that promotes, where possible, continuity of carer. The positive impact of this on the outcomes for women and their babies were acknowledged. It was agreed that option 1 may increase flexibility in the provision of antenatal and postnatal care by supporting families in their own homes and at other venues such as Children s Centres. This would enhance service user experience. There was recognition that option 1 did not allow for routine postnatal stays which historically had been offered at times at the midwife led units. This is inequitable practice and clinical evidence does not support postnatal stays as a safe option for women and babies and where possible the transition to parenthood should be supported by care closer to or in the woman s home. Both service models meet national guidance which suggests that commissioners and providers ensure that all 4 birth settings are available to all women in the local area or in a neighbouring area. These include: Home Confinement MLU Freestanding MLU (alongside Obstetric Unit) Obstetric Unit The options were scored as follows: Option 1= 3 Option 2= 3. Recommendation: Collaboratively review with the East of England Ambulance the protocol for the safe transfer of patients from Clacton and Harwich to Colchester Hospital where required.

13 Efficiency It was agreed that option one supported a more affordable financial model of care and that this was worthy of consideration in view of the current and forecast financial climate. Option 2 is not an affordable or efficient use of resources. There was recognition that efficiency and best practice could continue to be delivered by operating only 1 of the midwife led units in Tendring, although it was acknowledged that closure of either of the units was not considered as part of the consultation. The options were scored as follows: Option 1= 3 Option 2= 1. Access It was agreed that physical access for both options was equal. Option 1 enables the service model to be more flexible in the provision of care. Since opening on demand in July 2014, care provision has been expanded in other areas such as Children s Centres, at GP clinics and in the woman s home as appropriate. This is particularly so in relation to postnatal care where an increased need was identified from service user feedback To staff the midwife led units on a 24 hour basis as in option 2reduces the availability of service provision in children s centres, GP clinics and in the home.. The options were scored as follows: Option 1= 3 Option 2= 2. Equity It was agreed that equity of service provision would be the same for both options. Both options also support choice. Again, the panel agreed that it was important to tackle any perceived inequity in moving to an on demand model. The options were scored as follows: Option 1= 3 Option 2= 3 Relevance There was general discussion that an ageing population would have implications for maternity services in terms of the obstetric risk for women having a baby at a later stage in life. However this would not impact upon either option owing to the need for women classified as high risk to be advised to have their baby at Colchester Hospital. Service user feedback highlighted the need for more information on risk and choice. Option 1 was deemed a more sustainable approach to care, especially in relation to the NHS 5 year forward view which could have implications for maternity service providers as new providers are encouraged to enter the market. Option 2 would not support the national changes in the commissioning of maternity services now and in the future.

14 Option 1 supports a more sustainable approach to the workforce The options were scored as follows: Option 1= 3 Option 2= 2 Recommendation: Colchester Hospital to review the information given to women and their families around risk and choice. 8.2 Panel recommendation The panel was in full agreement and recommended Option 1 having agreed that service user experience and feedback had been fully considered and adequately reflected throughout. Clacton and Harwich to remain as on demand midwife led units. Antenatal and postnatal care to continue It was recommended that future consultations and service improvement should capture not just service user preferences but also the lived experiences as this can help better inform service design and delivery. It was suggested by the panel that the lived experience of service users is reviewed intermittently following conclusion of the consultation and that the MSLC would be in an ideal position to do this with the support of Healthwatch Essex if required. The final scores in relation to both options were: Option One Appraisal Criteria 1 Clinical Criteria Score Weighting Overall score (score x weighting) Effectiveness 2 Safety Efficiency Access Equity Relevance Total Option Two Appraisal Criteria 1 Clinical Criteria Score Weighting Overall score (score x weighting) Effectiveness 2 Safety Efficiency Access Equity

15 6 Relevance Total Conclusion The conclusion of the maternity consultation will bring to an end the uncertainty around local maternity services, enabling a model of care to be delivered that is efficient, safe and of high quality Clarity on the options available for women and families will enhance choice and promote well-informed decisions about maternity care. Both the CCG and Colchester Hospital are keen to ensure that the views of local women and their families continues to feature as a core aspect of service provision, guaranteeing that maternity services reflect the needs of the local population.

16 Appendix One: Summary of Equality Impact Assessment. Age Re-designing maternity services will affect the provision of maternity care for women of childbearing age. Specific groups such as teenage parents need to be considered in future service design and delivery. There is also an increasing number of women choosing to become pregnant towards the end of their child bearing years and this has an impact on whether or not they are classified as needing midwifery or obstetric led care. The Maternity Service Liaison Committee (MSLC) feels that older women should be able to make an informed choice rather than having the decision imposed upon them. Pregnancy and maternity The focus of the maternity re-design is on pregnancy and the postnatal period/transition to parenthood. How women access antenatal, perinatal and postnatal care may be affected. Disability The re-design of maternity services will affect women and their families across NEE. This includes those with a disability. Access to maternity services for those with a disability will need to be considered. Gender reassignment Maternity services changes will not affect this group Race A listening exercise undertaken by the Colchester MIND team in 2013 found that women accessing maternity services in NEE were generally satisfied with birth but required further information throughout pregnancy in a format suitable to them. Religion or belief The proposed re-design will need to take into consideration those with religious beliefs which include: no personal contact between the women and male staff Those who have beliefs regarding the use of blood products. Any other religious belief that impacts on maternity care delivery. Safeguarding The proposed re-design should promote pathways that support vulnerable people. However, it will not be designed to increase vulnerability. We acknowledge that complex social factors can play a part in the lead provider of care specifically midwifery versus obstetric. The safety of the mother and child/ren is more important than choice in these cases

17 Appendix 2 Consultation document and poster sent to: Group or individual Format Practice managers Electronic with instructions All GP practices Printed consultation documents and events poster Children s Centres Electronic with instructions Printed consultation documents and events poster Patient Participation Electronic with instructions Groups Tendring District Electronic with instructions Council Printed consultation documents and events poster Colchester District Electronic with instructions Council Printed consultation documents and events poster Essex County Council Electronic with instructions Printed consultation documents and events poster Voluntary sector via Electronic with instructions Colchester and Printed consultation documents and events poster Tendring CVS Maternity Units at Electronic with instructions Colchester, Clacton Printed consultation documents and events poster and Harwich Colchester Garrison Electronic with instructions Request to hold an event Essex University Electronic with instructions Request to hold an event Healthwatch Essex Electronic with instructions Essex Bernard Jenkins MP Electronic with instructions Printed consultation documents and events poster Douglas Carswell MP Electronic with instructions Printed consultation documents and events poster Bob Russell MP Electronic with instructions Printed consultation documents and events poster National Childbirth Electronic Trust Letter with copy of the document Royal College of Electronic Obstetricians and Letter with copy of the document Gynaecologists Royal College of Electronic Midwives Letter with copy of the document

18 Outreach events

19 Event Date and Time Number attending St Nicholas Children s Centre Harwich Highwood s Children s Centre Colchester Clacton Hospital Maternity Unit Fryatt Hospital, Harwich, Maternity Unit St Anne s Children s Centre Colchester Antenatal Clinic, Colchester General Hospital (Constable Wing) Clacton Hospital Maternity Unit Fryatt Hospital, Harwich, Maternity Unit Hemmington House Children s Centre,Jaywick Berechurch Health Centre Antenatal Clinic, Colchester General Hospital (Constable Wing) TACMEP workshop with migrant women First Site Colchester MSLC meeting Thursday 16 October AM Monday 20 October AM Tuesday 21 October 10.30am-11.30am Wednesday 22 October 10.30am-11.30am Thursday 23 October pm Thursday 23 October, 6pm-7pm Saturday 1 November, 2.30pm-3.30pm Sunday 2 November, 2.30pm-3.30pm Monday 3 November am Tuesday 4 November 4 2-4pm Tuesday 4 November, 5pm-6pm 5 November 30 6 November YES Colchester 7 November 10 Manningtree Health Clinic Wednesday 12 November am Early Years Starting Well event for Thurs 20 Nov professionals + parents Colchester stadium St James Children s Centre Monday 24 November 10-12am Colne Children s Centre Wednesday 26 YMCA. Brightlingsea November Colchester Health Forum Monday 1 December 2-4 Harwich Health Forum Tuesday 3 December 2-4 Clacton Health Forum Friday 5 December