Better Births Strategy and Implementation Plan for Lincolnshire /21

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1 Better Births Strategy and Implementation Plan for Lincolnshire /21

2 Table of Contents Pages Executive Summary 3 Better Births Plan on a Page Introduction 1.1 Ensuring Effective Change and Transformation 1.2 Our Vision for Lincolnshire The Case for Change The Key Stakeholders 3.1 Commissioning Model for the LMS The Development of the Plan Maternity Voices Background to the Lincolnshire Local Maternity System 6.1 Maternal Health, pregnancy and the first few weeks of life 6.2 Demographics 6.3 Risk Factors 7.0 Strategic Joint Needs Assessment 7.1 Breastfeeding 8.0 Maternal Mental Health and Physical Wellbeing 8.1 Maternal Mental Health 8.2 Maternal Obesity 8.3 Maternal Smoking 8.4 Domestic Abuse 8.5 Poor Social Support 8.6 Parents with a Drug and Alcohol Problems 8.7 Oral Health Current Service Configuration Regional Neonatal Services 10.1 Lincolnshire Neonatal Services 11.0 From Vision to Reality-The Local Maternity Offer 11.1 Personalised and Safe Models of Care P a g e

3 11.2 An Integrated Approach Maternity Safety Plan 12.1 Safety Leads and Champions 12.2 Serious Incident Reporting and System Learning 12.3 A-EQUIP 13.0 Strengthening Care Pathways 13.1 Antenatal Care Pathway 13.2 Postnatal Care Pathway 13.3 Neonatal Care Pathway 14.0 Continuity of Care and Continuity of Carer 14.1 Defining Continuity of Care 14.2 Roll Out of Community Hubs Better Pre and Post-natal Mental Health Services Bereavement and Palliative Care Support Multi Professional Working and Working across Boundaries Developing Digital and Technological Solutions Financial Case for Change Delivering the Plan Delivery Work streams Governance and Accountability 21.1 The Governance Framework Appendices Appendix 1- Lincolnshire LMS Gap Analysis Appendix 2 - Briefing paper to provide information regarding the Professional Midwifery Advocate Role Appendix 3 - Maternity Transformation Programme Communications and Engagement Plan 2017 Appendix Service Specification Appendix 5 Work Plan Appendix 6 Quality Metrics P a g e

4 Executive Summary The commitment to develop this plan arises from the national report and strategy Better Births, which sets out the Five Year Forward View for maternity services across England. This plan is intended to provide the framework for safe and improved local maternity and neonatal services that recognise and reflect the individual personal needs and choices of women and families in Lincolnshire. Consequently, the plan is built on extensive engagement with women and their families, staff and others involved in the commissioning, provision and support of local maternity services to ensure an honest and accurate assessment of current services and co-produce the vision for what best practice would look like in Lincolnshire. We are proud of our approach to communication and engagement in the development of this plan which is truly embracing inclusive ways of involving our diverse communities. We have fully utilising the power of social media, with a Facebook audience of 50,000, Twitter channel and Better Births website for Lincolnshire going live in October We have a strong vision and ambition to ensure that the maternity system in Lincolnshire is safe, personalised, kind, professional and family friendly. Every woman should have access to information to make informed decisions and access support centred on individual needs and circumstances. The model of care now proposed for Lincolnshire represents a fundamental review of the way that services are organised and delivered. It will improve both the health of women and their families now and for generations to come. Every woman will have a personalised maternity care plan led by a healthcare professional, to ensure continuity of carer and care is delivered as close to home as possible through local community midwifery teams. Women and their families told us that they would prefer care delivered closer to home, therefore, we established a pilot of four community hubs. We are actively involving our local Maternity Voices Partnership in developing and evaluating the pilot programme to ensure that the model of care is right. We recognise that achieving our local vision will be challenging, we have established a Local Maternity System (LMS) with the leadership, governance and the clinical commitment required to secure the delivery of safe and improved maternity care in Lincolnshire. We acknowledge that we have some way to go to bring about woman-centred and outcome based maternity care, to get there we will need to embrace the right data, information and expertise to drive forward continuous service improvement. We will participate in and make use of nationally developed data collection tools, clinical networks and the Maternity and Neonatal Safety Collaborative, using this intelligence to improve services, including learning from incidences of harm. We are currently working within environments where we need to use our resources intelligently to achieve the best outcomes for our women and their families. We have aligned our LMS with the Lincolnshire Sustainability and Transformational Partnership to ensure that there is a consistent strategic vision for maternity and neonatal care in Lincolnshire. Tracy Pilcher John Turner Chief Nurse Lincolnshire East Clinical Commissioning Group SRO Local Maternity System (LMS) Lincolnshire Accountable Officer South and South West Lincolnshire Clinical Commissioning Groups SRO Lincolnshire Sustainability and Transformation Partnership 3 P a g e

5 Co - production Better Births in Lincolnshire - Plan on a Page Our Vision Maternity services should be safe, personalised, kind, professional and family friendly. Every woman should have access to information to make informed decisions and access support centred on their individual needs and circumstances. Our Work streams Promoting Safe and Effective Care Perinatal and Postnatal mental health Continuity of Carer / Personalisation Workforce training and MDT working 2017/ / / /21 Engagement with women, families, and stakeholders Local Maternity System Board established Launch of Better Births in Lincolnshire Development and review of Community Hubs pilots Development of Lincolnshire s 5 year Better Births Plan Development and implementation of maternity safety plan Strengthening community and home birth pathway Launch of communication platform website, facebook and twitter, development of continuous communication and engagement University of Lincoln to review the research from the Community Hubs share findings and recommendations. Increase Homebirth rate from 2.5 5%. Implementation of the Care Portal. Create a whole women and children s workforce plan, with a schedule of joint training events First whole system maternity conference May Formal launch of revised maternity pathways Increase midwifery led care and achieve target of 20% Estates development of co-located birthing centre Development of new pathway following the findings from community hub research. Increase Home Birth Rate from 5-7.5% Increase midwifery led care 30% Increase Home Birth Rate from 7.5 to 10% Increase midwifery led care to 40% Development of Midwifery Led care plan to reach 60% 20% Reduction in Still Births with robust plan to reduce to 50% by 2030 Co - production 4 P a g e

6 1.0 Introduction It is now widely accepted that the foundations for our health and well-being start before we are born. Pregnancy is a time when women, their partners and families are motivated to make positive lifestyle changes and choices that impact on the whole family; in order to ensure the health and wellbeing of their unborn child. Preconception, antenatal and new born care can help lay the foundations for individual and family health and wellbeing in Lincolnshire; From cognitive development and emotional security in early life, to the prevention of obesity, diabetes, heart disease and mental ill health in adult life. Consequently, investing in the best start for women and children is an investment in the future health, wellbeing and economic sustainability of Lincolnshire. Ensuring that personalised high quality, evidence based, safe maternity and new born care is available to each woman and child in Lincolnshire is complex. It will require determined local leadership to champion the provision of an inclusive and sustainable family-centred service delivered at the right time, in the right place by a skilled and diverse workforce. This plan is therefore a Call to Action. It sets out how the Local Maternity System will provide local leadership to achieve the following strategic priorities: A multidisciplinary, collaborative, outcome focused approach to commissioning and providing women centred maternal and new born care model in Lincolnshire with localised approaches to delivering continuity of carer and effective transitions of care. The direct involvement of women and their families in understanding local need, developing innovative solutions to meet those needs and facilitating genuine co-design approaches to service development and evaluation to understand if the changes are proving effective. Safer care throughout the maternity pathway, by employing robust risk based approached to the planning of care, learning the lessons from local and national care failings and reviewing clinical outcomes through a new national and local maternity dashboard. Increased choice and personalisation across the maternity pathway, including choice in how and where women in Lincolnshire access maternity care, developing the capacity of midwifeled and home birth services to meet the needs of the local population and increasing access to Personal Maternity Care Budgets. Development of the local maternity offer through the development of a Community Hub model with 4 pilot sites piloting the model from November 2017 model based within children centres in Skegness, Boston, Grantham and Lincoln. Whole system clinical leadership at all levels with nominated clinical leaders driving forward our local call to action, harnessing the passion and expertise of Lincolnshire s clinical and non-clinical health and care workforce to channel a culture of learning and multi-agency working, utilising appreciative enquiry and the critical friends approaches to ensure a cascade of learning within the system. Using digital shared technology approaches to develop new electronic interoperable maternity records and Implementation of the care portal as an initial pilot project in Lincolnshire to share information across the system initially locally but with scope to expand. 5 P a g e

7 In striving to achieve these priorities the plan details the current position (where we are now), the aims and outcomes of the plan (where we want to be), and the actions required to achieve those outcomes, within the specified time period (how we are going to get there). It recognises the wider determinants of health and the broader public health agenda in Lincolnshire and as such the plan is underpinned by the Joint Strategic Needs Assessment for Lincolnshire and affirms the vision for maternity care outlined in Lincolnshire s Sustainability and Transformation Plans (STP) and The Children and Young People's Plan (CYPP) which sets out how Lincolnshire County Council will work with its partners to achieve ensure children are healthy and safe through early intervention and prevention. The plan describes in detail how the Local Maternity System will seek to ensure that the following aims are achieved by the end of 2020/21: Improving choice and personalisation of maternity services so that: a) All pregnant women have a personalised care plan. b) All women are able to make choices about their maternity care during pregnancy, birth and postnatally. c) Most women receive continuity of the person caring for them during pregnancy, birth and postnatally. d) More women are able to give birth in midwifery settings (at home and in midwifery units). Improving the safety of maternity care so that by 2020/21 all services have: a) Have reduced rates of stillbirth, neonatal death, maternal death and brain injury during birth by 20% and are on track to make a 50% reduction by b) Are investigating and learning from incidents and sharing this learning through their Local Maternity System and with others. c) Fully engaged in the development and implementation of the NHS Improvement Maternity and Neonatal Health Safety Collaborative. 1.1 Ensuring Effective Change and Transformation This plan describes a call to action for Lincolnshire in relation to delivering an ambitious plan for Better Births. It is recognised that to achieve this large scale change programme requires a number of aligned system programmes and methodologies to drive forward the changes required. A Maternity Transformation team has been established consisting of programme managers, project leads and project support. This team will work across the Lincolnshire system to galvanise clinical and managerial resource and expertise to drive an effective programme and vision for the delivery of Better Births in Lincolnshire. 6 P a g e

8 Our Vision for Lincolnshire Lincolnshire maternity services should be safe, personalised, kind, professional and family friendly. Every woman should have access to information to enable her to make decisions about her care and where she and her baby can access support that is centred around their individual needs and circumstances To realise this vision, the Local Maternity System have identified four key principles which will guide service development: 1. Promoting Safe and Effective care 2. Improving Perinatal Mental Health 3. Continuity of Carer and Personalisation - models of care, focused on improving safety and clinical outcomes, developed around women, babies and families based on their needs and decisions, where they have genuine informed choice. 4. Development of the workforce, multidisciplinary training and collaborative working. Source: 7 P a g e

9 2.0 The Case for Change It s time to think differently about the commissioning and provision of maternity and new born care in Lincolnshire. In recent years there has been significant investment in developing and improving local services. Despite this, we know from a number of national reports, local reviews and from listening to the views of women, their partners and families - our local experts, that we are not always getting it right. More can be done to ensure that the model of maternity and new born services in Lincolnshire provides women with meaningful choices, tailored to their individual needs and delivered safely and closer to home. Figure 1 identifies the key drivers for local change: National Policy-Better Births Lincolnshire STP Regulatory reports and benchmarking Joint Strategic Needs Assessment 8 P a g e

10 3.0 The Key Stakeholders The aims of the plan can only be realised when all stakeholders of maternity and new-born care come together and make a commitment to improving choice, personalisation of maternity services and safety of maternity care. As a LMS we need to listen to the needs and expectations of women and their families, alongside the knowledge and experience of professionals. We will seek input from a wider group of stakeholders including lay members, maternity and neonatal network leads, professionals from health and social care settings, educational providers, the voluntary sector and other relevant stakeholders. A diverse LMS membership will provide the platform required to move forward with locally implementation plans built on a well-articulated and endorsed vision developed through systematic stakeholder engagement. Anything less will not elicit the results that are urgently needed in Lincolnshire. The following is a preliminary list of the organisations that have been invited to participate in the development and implementation of the plan. The list will be subject to constant revision to ensure membership is energetic and achieves the desired outcomes. Membership of Lincolnshire LMS Service User Voice Commissioners Providers Others Maternity Voices Health Watch Lincolnshire Children Centre Parent Champions, Facebook and Twitter Groups Lincolnshire East, Lincolnshire West, South West and South Lincolnshire Clinical Commissioning Groups NHS England; Midlands and East (Central Midlands), Specialised Commissioning Local Authority Directors of Public Health, Head of Commissioning for Women s and Children services Local Authority Lincolnshire Partnership Foundation NHS Trust Lincolnshire Community Health Services United Lincolnshire Hospital NHS Trust Lincolnshire County Council East Midlands Ambulance Service Neonatal Operational Delivery Network Primary Care Providers Lincoln University Social Media Local Workforce Action Board Nottingham University De Montfort University 9 P a g e

11 3.1 Commissioning Model for the LMS Commissioning for Effective Service NHS England Feb 2014 Ref No Transformation of health services is essential for a sustainable NHS. The seven themes are shown in the NHSE diagram above and will be the template for the commissioning of Maternity services in the future for the LMS. Foundation Leadership and Co-production Within Lincolnshire we have an established LMS with strong and effective participation and coproduction, an example of co- production is demonstrated in the piloting of the Community Hub model. We are developing ways to hear the voice of the families by establishing Maternity Voices and ensuring the views are clear in all the work. We need to establish our links with the voluntary and community groups across Lincolnshire. Planning Vision and Service design We have developed a strong vision for local service provision with robust communication strategy by using social media and the development of the new Better Births website, linking all involved in the co-production. 10 P a g e

12 We have been listening to the needs of the population and reviewing how current services are performing. We looked at early opportunities for service transformation and following engagement with families will be piloting the Community Hubs in 4 areas of Lincolnshire. The evaluation of this will shape future commissioning of community services Securing Improved outcomes and mechanisms to drive improvement We have a clear vision for delivering safe and effective care by developing a work stream focused on improved outcomes as described in plan. We plan to move services closer to home to make access easier and engage more within our communities, we will take into consideration the impact of service change on the women and their families. Within the work streams we will define what good outcome look like and commission those models 4.0 The Development of the Plan A gap analysis was undertaken at the beginning of the process to fully understand the ambitions set out in Better Births, and the local organisation and delivery of the maternity system. This gap analysis was then used to identify the key areas of priorities for the Local Maternity System, this gap analysis is provided in appendix 1. Alongside this, work began to develop the engagement activity with women and their families to understand their experience of accessing services within Lincolnshire. The LMS have made a commitment to undertaking engagement activity at every stage of the development of this plan to ensure that local services are built around the needs and aspirations of women and their families, as well as staff within Lincolnshire s maternity and new born services. It was anticipated that this would result in the more effective use of services, more personalised care and positive service user and staff experiences. The LMS are fully committed to implementing a full round of communication and engagement at every point of service development to ensure our colleagues, stakeholders and service users are kept up to date with the very latest developments. These will be engaging, entertaining and, crucially, informative using a range of methods such as briefings, s, press releases and face to face engagement. Social media is a critical communication channel, as already evidenced by our outstanding reach. We will commit to communicating all of our key messages through our Better Births Lincolnshire website from October, 2017, and using media outlets to broadcast our messages. 11 P a g e

13 Our approach to communication and engagement with women and their families will be continuously reviewed to ensure its effectiveness and reach. We have also arranged a range of Listening Clinics and engagement activities. We have advertised these using posters on social media and via our key partner organisations. Please see the poster below for the Listening Clinics that took place at ULHT during August P a g e

14 In developing the initial scope for this plan we have engaged with the public and professionals through the following means: Online surveys for both women and families and professionals; Workshops at children s centres and other local venues; Meetings with community midwives and other professionals involved in the commissioning and provision of maternity and neonatal care; Social media including our twitter and facebook channels. In addition to this we have utilised existing sources of information including: Health watch Lincolnshire reports; Patient and family surveys; Listening clinics; CQC reports; NHS Choices; Maternity Voices; Lincolnshire Sustainability and Transformation Plan, Women s and Children s Work stream. 13 P a g e

15 This is what we learnt: What is working well? Postnatal women and their families felt that staff gave the best care possible and were attentive without being overbearing Women and their families thought the maternity units were nice Antenatal appointments were informative and allowed for any questions to be asked Women felt they had received individualised care and support from the staff Women felt assured that staff were around when they needed them and that regular checks and medication rounds for pain relief were offered What could we do better? Women in some rural areas were generally not aware of, or choose not to attend antenatal and parenting classes There is a lack of continuity of care in antenatal clinic settings and in some areas 6-8 week antenatal appointments were generally given between 8-11 weeks There is no or little choice given in terms of birthing location and the majority of women did not recall being offered alternatives and more could be done to promote natural birth Women could not get access to scans at weekends Women feel they are not able to access translation services There was very little support for men, information was all targeted at women Care is not currently centred around women and families and travelling long distances for appointments adds a lot of unnecessary stress and expense Support for women who have pre or post-natal mental illness is limited The views and suggestions gathered through early engagement have been used to develop the model of local Community Hubs as the framework for service delivery and engagement will continue to inform the implementation of the pilot Community Hubs. It will also feed into the Lincoln University Independent Evaluation this is designed to gather views on the pilot Community Hubs including experiences of women and their families, and staff, as well as identifying any health benefits such as smoking cessation and early access into maternity care. Lincoln University will undertake further engagement during the pilot phase to gather views and experiences to understand the impact of the implementation of the community hubs. We plan to engage with all stakeholders using a variety of approaches to shape and inform services at each phase. The table below outlines just some of the ways we have involved stakeholders throughout the project. A full copy of the Communication and Engagement Plan can be found in the appendices (Appendix 3). 14 P a g e

16 Stakeholders identified as high influence, high interest = work together Service users (Lincolnshire and out of county- NLAG, NWAFT, Kings Lynn, Nottinghamshire) Maternity Voices ULHT midwives, obstetricians, paediatricians, neonatal staff LCHS 0-19 services LPFT perinatal mental health teams Village Midwives Independent Midwives and groups Healthwatch Parent groups Pregnant mums Children s Centres around the county Parent Champions National Childbirth Trust (NCT) Women s Institute Lincoln University Senior Management Team across the system: ULHT, LPFT, LCHS, CCGs, EMAS STP Lead & STP PMO NHS England; Midlands and East (Central Midlands) LMS board Primary Care Commissioning Committees Health and Scrutiny Committee LCC LMC Methods of engagement (not exhaustive) Head of Midwifery attends Maternity Voices and member of LMS (Local Maternity System) Attendance at meetings and circulation of documents for feedback Attendance at events, meetings and engagement via social media Member of LMS and Health Visitor champion Member of LMS and engagement via social media Engagement via social media Invited to engage via social media Chair of Maternity Voices and promoting engagement Programme Lead visited a number of groups and more planned Champion established and engaged Full engagement as key part of the Community Hubs and champion established Champion established and part of Maternity Voices Links made Links being explored Member of LMS Engagement of messages and Programme Lead attendance at key organisational meetings including Governing Body Links on Project Board Links established and information shared All plans, updates and reports shared with LMS Board for information and engagement Senior Management and Operational Group share messages Senior Manager links to keep fully informed and engaged Links established and attendance at meetings 15 P a g e

17 We plan to ensure that engagement and consultation continues to drive the development of this plan and as such will use a variety of approaches throughout the plans development and delivery to shape and inform services development at each stage. The diagram below illustrates this model. 5.0 Maternity Voices in Lincolnshire Throughout the development of the Better Births Plan for Lincolnshire there has been a strong emphasis on ensuring that the plan is co designed and co-produced with women and their families. An integral component of this has been the development of the Maternity Voices partnership. The Morecambe Bay Investigation highlighted how crucial it is to have a well-functioning Maternity Service Liaison Committee (MSLC) in place, a forum where senior clinicians of all relevant disciplines can discuss with service user representatives the strengths and weakness of the services. The LMS has been working with partnership agencies to support the transition and development of the MSLC in Lincolnshire. In June 2017 the former United Lincolnshire Hospital Trust MSLC became Maternity Voices Partnership (MVP) and held its first meeting away from the hospital setting in a central Lincolnshire Children Centre location. The aim of the group is to ensure that women, their partners and families are able to give feedback or become members of the group. The group plans to meet bi-monthly, across the county and present a feedback report into the LMS, the feedback will then shape the work of the group Setting an annual work plan Engage with the community Connect with seldom heard groups Identify and action quick wins that make a difference to parents Use social media Adopt walking the patch 16 P a g e Use online surveys Parent champion working within Children centres, and voluntary agencies i.e. Homestart, will explore any issue identified within the feedback. Then by means of social media the group will cascade message and findings to the wider community.

18 6.0 Background to the Lincolnshire Local Maternity System 6.1 Maternal Health, pregnancy and the first few weeks of life Lincolnshire is the fourth largest county in England covering 6,959 km2 with the fourth most dispersed population. The population density is low at 150 people / km2; there are only six less densely populated counties in England. Large areas of land in the county are used for agriculture and the main employers in the county are in agricultural, food processing, road haulage, logistics industries and the NHS. The road network in Lincolnshire is poorly developed, comprising mainly of single carriageway A and B roads with less than 30 miles of dual carriageway in the whole county which impacts on the population s ability to access services including healthcare. The population of Lincolnshire is approximately , which is broken down to the following population and age profiles. Area Boston South Holland Boston and South Holland East Lindsey Lincoln West Lindsey Lincoln and West Lindsey North Kesteven South Kesteven North and South Kesteven Lincolnshire Total Population 0-19 Population 0-5 Population 6-19 Population 66,902 15,148 5,154 9,994 91,214 19,396 6,054 13, ,116 34,544 11,208 23, ,887 26,564 7,816 18,748 97,065 22,352 7,000 15,352 92,812 20,264 5,861 14, ,877 42,616 12,861 29, ,876 24,356 7,180 17, ,909 31,578 9,369 22, ,785 55,934 16,549 39, , ,658 48, ,224 There are also a number of holiday resorts on the coast, the largest being Skegness with a population of approximately 25,000. This inevitably leads to seasonal variation in the population density and diversity. In addition to this, differences in smaller geographical areas reveal quite high levels of need compared to the rest of the population, particularly along the East coast. Access to care is a particular problem for these communities who may also be at financial disadvantage. Bringing care closer to home is likely to reduce the impact of such inequalities in a noticeable way. 17 P a g e

19 The map below shows the number of Lincolnshire women that gave birth in 2015/16 and their place of birth: Key Navy: Residency of Mothers Turquoise: Place of Birth Across the 4 Lincolnshire CCGs there were 7783 births women who gave birth, with 5448 of these births taking place at United Lincolnshire Hospitals NHS Trust, 3278 at Lincoln County Hospital and 1948 at Pilgrim Hospital in Boston. 222 women chose to give birth at home. The table below illustrates births by hospital trust and area in 2015/16 and highlights the broader choice of birth setting particularly for women who live in east and south of Lincolnshire. Northern *North West Anglia United Lincolnshire Lincolnshire and CCG Area NHS Foundation Hospitals NHS Trust Goole NHS Trust Foundation Trust East Lincolnshire 74.2% 0.5% 23.6% West Lincolnshire 94.3% 0.0% 3.6% South Lincolnshire West 71.4% 10.7% 0.0% South Lincolnshire 29.0% 60.4% 0.1% *(Formerly Peterborough and Stamford Hospitals NHS Trust) 18 P a g e

20 Population Population predictions of women aged years show a stable or a slight fall in the number of women considered to be of child birthing age within all four CCG areas in Lincolnshire (projected up to 2034). This is against an increasing population projection in general, which is represented in the following graph. 50,000 45, based Subnational Population Projections, females aged (CCG) % 40,000 35, % 30,000 25,000 20, % 1.2% 15,000 10,000 5,000 0 NHS Lincolnshire East CCG NHS Lincolnshire West CCG NHS South West Lincolnshire CCG NHS South Lincolnshire CCG 6.2 Demographics Demographic information on ethnicity of mothers illustrates that the percentage of deliveries to mothers from Black and Minority Ethnic (BME) Groups is significantly lower than the average for England with south Lincolnshire having the lowest percentage of births to mothers from Black and Minority Ethnic (BME) Groups. 19 P a g e

21 Multiple births in Lincolnshire is just below the national average for most of Lincolnshire but West Lincolnshire sees a notably higher rate of multiple births from the national average. Likewise caesarean section rates are lower in most of Lincolnshire than England as a whole but South Lincolnshire s rate is higher. Caesarean sections are often required for a number of maternal and infant reasons. By their very nature (i.e. they are used when there are complications) they are likely to be associated with an increased risk of problems. 48% of people in Lincolnshire live in rural areas, compared to a national average of 18% and Skegness and Mablethorpe are in the top 10% of most deprived areas in the country and consequently, a notable proportion of women in these areas are reliant on public transport. This presents specific issues for some women accessing maternity care in rural Lincolnshire: 20 P a g e

22 Long travel time of more than 60 minutes Public transport can be infrequent Women may have to travel as much as 3 hours by public transport Shortest journey time other than living in Lincoln or Boston is 30 minutes by car Pilgrim site to Lincoln site is just over one hour, according to Google Maps Blue light ambulance could do this trip without stops/traffic delays in 60 minutes This does not include the time delays involved from call time to arrival time for ambulance to arrive at pick up point. The diagram below illustrates travel times to current maternity services. Children and young people under the age of 20 years make up 21.7% of the population of Lincolnshire. 15.8% of the population are aged 0-14, compared with a national average in England of 17.3%. 11.0% of school children are from a minority ethnic group. 21 P a g e

23 The number and proportion of children across the four CCGs is illustrated in the table below (based on mid 2014 population figures from ONS for 0-15 year olds): CCG Area Total Number of Children Proportion of Children East Lincolnshire 37, % West Lincolnshire 39, % South West Lincolnshire 21, % South Lincolnshire 26, % Lincolnshire 124,300 17% Across Lincolnshire there are several areas that have a higher density of children. The highest densities of children are concentrated predominantly in the urban areas of Gainsborough, Lincoln and surrounding neighbourhoods. There are pockets of high-density areas of children in Bourne, Stamford and Boston with the east coast having a much lower density areas. The health and wellbeing of children in Lincolnshire is mixed compared with the England average. The chart below gives an overview of how children's health and wellbeing in Lincolnshire compares with the rest of England. This is based upon 2016 data. 22 P a g e

24 Within Lincolnshire background levels of health and wellbeing are variable between local areas and communities. Where underlying health is poor, this is more likely to result in higher levels of need for health care and poorer pregnancy outcomes. The social situation in which children are conceived even before they are born affects their life chances and health and wellbeing across the life course. Maternity care is a golden opportunity to reach almost all of the population at this crucial stage, maximising health improvement through prevention and targeted care for those in greatest need. The countywide level of child poverty is better overall than the England average of 20.1%, with 18.1% of children aged under 16 year s old living in poverty in However, this rises to 23.3% in Lincoln and 23.9% in East Lindsey. We know that income deprivation alone can affect a child's life chances. The rate of family homelessness is better than the England average, although 454 families in Lincolnshire containing children or a pregnant woman were homeless in 2014/15. Infant and child mortality rates are similar to the England average. Infant mortality was highest in Boston of all the District areas over the periods at 5.3 per 1,000 live births, although not significantly higher than the England average of 4.0 in 2016 there were 17 reported still births. This represents a decrease from 20 in 2015 and 27 in Risk Factors for infant mortality include: Deprivation: overall deprivation, measured by the Index of Multiple Deprivation (IMD) in 2015, shows that Lincolnshire ranked 92nd overall (where 1st is the most deprived). However, Districts are varied, with Lincoln ranking 62nd for overall deprivation, and 34th for Income Deprivation Affecting Children Index (IDACI) Low birth weight: Lincolnshire figures are better than the national average for babies born at full term who have a low birth weight (under 2.5kg). When all live births are taken into account, Lincolnshire East and South West are most likely to have a baby born at low birth weight. Smoking at the time of delivery: despite the rate dropping year on year in Lincolnshire, smoking during pregnancy has remained higher than the national rate. Maternity services records show that 21.5% of Lincolnshire women were smoking at their first booking appointment with this falling to 14.1% at delivery. This is still above the national average of 10.6%. Smoking during pregnancy is highest overall in the Lincolnshire East CCG area and particularly in the Boston area. Mother s country of birth: whilst births to non-uk parents remain lower than the national average, local public health statistics demonstrate there has been a sharp rise between 2001 and 2015 to over 22%. In Lincolnshire as a whole with the highest percentage rise seen is in South Lincolnshire. Further exploration demonstrates localised increases in South Holland (22.6%) Additionally, in the East of Lincolnshire Boston (35.3%). Maternal age: the teenage pregnancy rate throughout the whole of Lincolnshire is similar to the England average. In 2015/16, 1.1% of women giving birth were teenage which, whilst higher than the national average, represents a decrease from the previous year. The greatest fall in conceptions has been seen in Lincoln, although this is still the district of the county with the highest rates of conception in under 18s. Only Lincoln and Boston are significantly above the national average for teenage pregnancy rates, with Lincoln being the highest at 36 per 1,000. The percentage of births to mothers over the age of 35 years is lower than England at 15.7% compared to 21.1%. Immunisation against flu during pregnancy is highly effective in safeguarding both the health of the mother and her baby. Flu vaccination in pregnancy confers passive immunity to flu to babies in 23 P a g e

25 their first few months of life. The flu vaccine can safely be given at any stage during pregnancy with no evidence of increased risk of adverse pregnancy outcomes in vaccinated women. Pregnant women receiving flu vaccination in Lincolnshire as a whole is higher than the national average with women in South Lincolnshire receiving the highest level of protection. However, in East Lincolnshire the picture is different with the percentage of women receiving flu vaccination being below the national average and below the rest of Lincolnshire. Immunisation against pertussis during pregnancy provides the baby with passive immunity to pertussis infection from birth and offers ongoing protection until the baby can be immunised at 8 weeks. Pertussis vaccination should be offered to pregnant women at 20 weeks gestation, following the anomaly scan. The uptake of pertussis vaccination is high across all areas of Lincolnshire. A new initiative to offer women both flu and pertussis vaccination alongside maternity antenatal services will commence in November Prenatal pertussis vaccine programme coverage (%) in pregnant women, 2016/17 average, Lincolnshire, (CCG) NHS South Lincolnshire CCG NHS South West Lincolnshire CCG NHS Lincolnshire West CCG NHS Lincolnshire East CCG Lincolnshire 74 England P a g e

26 7.0 The Joint Strategic Needs Assessment The Joint Strategic Needs Assessment summarises the local picture for maternal health, pregnancy and the first few weeks of life. The full detail is available at: Strategic-Needs-Assessment.aspx The JSNA concludes that the health of the population in need of maternity care in Lincolnshire as a whole is good compared to the England average. However, more could be done to promote continuity of breastfeeding and maternal mental and physical wellbeing 25 P a g e

27 7.1 Breastfeeding Breastfeeding is important for the long term health and wellbeing of both the mother and the newborn child. For mothers this includes a lower risk of postpartum depression and reduced risk of type 2 diabetes, cardiovascular disease, breast cancer and ovarian cancer and for the new-born child breastfeeding provides better protection from acute infections, otitis media, neonatal enterocolitis and respiratory illness. Research also indicates that for the child breastfeeding also reduces the risk of obesity in later life. In 2013/14 the proportion of women initiating breastfeeding in the first 48 hours after birth, were: In England 74% In the East Midlands 72% In Lincolnshire 75% The importance of dedicated staff in promoting and supporting breastfeeding in Lincolnshire is well recognised. The National Institute for Health and Care Excellence (NICE) recommends the provision of local, easily accessible breastfeeding peer support programmes as part of a multidisciplinary team. Breastfeeding support, information and advice locally is provided primarily through midwives and health visitors at antenatal and post-natal contacts as determined by the Healthy Child Programme and NICE Pathway guidance. A network of breastfeeding support groups (BreastStart) are run at Children's centres and other venues throughout the County and a Breastfeeding app has been developed Breastfeeding is not all about front line service delivery and a key component of the local Infant Feeding Strategy is promoting cultural and social acceptance that this method should be the biological norm by maximising the reach of social and other media and incorporating breastfeeding into all areas of public life through planning colleagues, local businesses, nurseries, children's centres, youth groups and schools to ensure basic information about breastfeeding is understood across all sectors of communities using the MECC (Making Every Contact Count) approach. Complementary to this is the Unicef Baby friendly initiative (BFI). Despite this, in 2015/16 the proportion of infants totally or partially breastfed at 6-8 weeks were: In England 43.2% In Lincolnshire 37.3% Lincolnshire remains the worst in the region for breastfeeding prevalence at 6-8 weeks and this indicates that work still remains to be done to support women to continue with exclusive breastfeeding for the recommended 6 months, and therefore this area will be a key priority for this plan. 26 P a g e

28 8.0 Maternal Mental and Physical Wellbeing Health 8.1 Maternal Mental Health Pregnant women can experience the same mental health problems as the general population but it is particularly important to address them during pregnancy and following childbirth. The mental health of the mother has a far reaching effect on the unborn baby, the wider family and mother s long term health. It is estimated that between 10% and 20% of women are affected by mental health problems at some point during pregnancy or the first year after childbirth. Based on the number of women giving birth each year in Lincolnshire, we would estimate the following numbers of women to suffer a diagnosed mental health problem in the perinatal period: CCG Area Postpartum psychosis Chronic severe mental illness Severe depressive illness Mildmoderate depressive illness and anxiety (lower estimation) Mildmoderate depressive illness and anxiety (higher estimation) Posttraumatic stress disorder in the perinatal period Adjustment disorders and distress in perinatal period (lower estimation) Lincolnshire Adjustment disorders and distress in perinatal period (higher estimation) NHS Lincolnshire East CCG NHS Lincolnshire West CCG NHS South West Lincolnshire CCG NHS Lincolnshire South CCG Our current service model provides support and advice across primary care, maternity, children s, family, and mental health services. All pregnant women aged 16 years and over, or who have given birth within the last year; with a suspected serious mental illness are eligible for an assessment/advice and intervention. Referrals are also accepted for women who are not yet pregnant but have a severe mental health condition and are planning a family. Lincolnshire does not have a Specialist Mother and Baby Unit but we maintain excellent links with our partners in Derby and Nottingham Specialist Mother and Baby Units to ensure facilitate admission when clinically indicated and discharge. 8.2 Maternal Obesity Maternal obesity is an increasing concern for local maternity services; the proportion of adults who are overweight or obese is higher than the England average in Lincolnshire at 69.9%. Lincolnshire benefits from a large network of children centres that support children and families. Early Help Workers deliver a range of evidenced based programmes addressing home conditions, budgeting or parenting to help the family prepare practically and emotionally for the birth, one to one at home or in a group. A pathway of care for women who are overweight and pregnant, Bumps & Beyond is an Antenatal Weight Management Service designed specifically to support pregnant women who have a Body Mass Index (BMI) of 35 or over and are due to have their babies at either Lincoln County Hospital or Pilgrim Hospital, Boston. 27 P a g e

29 8.3 Stop Smoking Services Quit 51 provides the Lincolnshire stop smoking service, that focuses on engaging women to quit smoking around the time of pregnancy, and cessation advise is incorporated into all midwifery contacts. An opt-out approach is taken where all women are seen within 7 days of referral and support is available throughout the pregnancy. 8.4 Domestic Violence and Abuse Almost one in three women who have suffered domestic abuse during their lifetime, report that the first incidence of violence happened whilst they were pregnant. Living in a household with domestic violence is also a risk factor for poor mental health in babies and toddlers. Lincolnshire does have slightly lower levels of reported domestic violence; 14.1 incidents per 1,000 population compared to 16.1 for the East Midlands and 15.6 nationally. Offering adequate support for parents suffering domestic abuse is a good opportunity to prevent further mental health problems within the family. 8.5 Poor Social Support Women who lack social support have been found to be at increased risk of antenatal and postnatal depression. The number of births which were registered by the mother alone may give an indication of the number of mother and babies who lack the support of the father during transition to parenthood. In Lincolnshire in 2014, there were 425 sole registrations (5.5% of all births, which is similar to the England average of 5.4%). 8.6 Parents with a Drug and Alcohol Problems Within Lincolnshire, the number of pregnant women entering treatment services for drug and/or alcohol misuse is low, with year-end figures reducing from 20 in 2014/15 to 9 in 2015/16. When shown as a proportion of all women in treatment, the latest figures throughout 2015/16 show 1.8% of women in treatment were pregnant at the start of treatment, which is lower than the 2.4% seen nationally. This shows a decrease on the 3.9% of women who were pregnant at the start of treatment during 2014/15, when the Lincolnshire rate rose higher than the national average of 2.3%. 8.7 Oral Health The number of children with decayed missing or filled teeth at age 5 is similar to the England average in Lincolnshire. Oral health improvement is embedded throughout children's services from 0 years onwards and targeted at groups with highest risk of poor oral health. The importance of good oral hygiene and taking up access to free dentistry is included in antenatal information for expectant mothers. 28 P a g e

30 9.0 Current Service Configuration In Lincolnshire there is already a broad range of multi-disciplinary universal, targeted and specialist care pathways in place to meet the health needs of women and children from sexual health and preconceptual care to maternity and neonatal care and early year s services. Since October 2016 the Lincolnshire Sustainability and Transformation Partnership has worked with the people of Lincolnshire to ensure that pathways of care for women and children are developed around the needs of our local population so they are fit for the future. The focus to date has been to ensure that women have flexible local pathway and can access specialist services when required, including obstetric services in hospital, and in more specialist centers, perinatal mental health services, fetal medicine, and neonatal and paediatric services if they are needed once the baby is born. For the majority of women in Lincolnshire who have a healthy pregnancy antenatal care is currently managed by the community midwives. Appointments are provided in local clinics, GP surgeries, and children s centers and within the woman s home and there is a need to travel to the hospital for routine scans and consultant appointments. However, some women who are assessed to need more specialised care are booked under consultant care, where appointments are shared between the community midwife and the hospital antenatal clinics held at Lincoln, Boston, Grantham, Gainsborough, Skegness or Spalding. Postnatal care is offered both in the hospital and community setting. Women in Lincolnshire have the choice of giving birth at home or in a consultant-led obstetrics unit, of which there are two; one in Lincoln and one in Boston. Lincolnshire does not currently provide either a co-located or standalone midwife-led unit, which the National Maternity Review 2016 recommends should be available by 2020, however midwifery led care is delivered within the acute settings. There are currently 2 main providers of maternity and new-born care in Lincolnshire. United Lincolnshire Hospitals Trust provides all routine and urgent and emergency antenatal, birth and postnatal care, including homebirths. Lincolnshire Community Health Services (LCHS) provides the Healthy Child Programme for children aged 0-5, including breast feeding and infant nutritional support, screening, immunisation, health and development reviews, supplemented by advice around health, wellbeing and parenting. Moving forward form October 2017 the Health Visiting service will be provided by Lincolnshire County Council. United Lincolnshire Hospitals NHS Trust (ULHT) comprises of 3 main acute hospital sites: Lincoln County Hospital which has approximately 620 beds including 32 antenatal and postnatal beds and 11 delivery suite beds. It provides a full range of acute services including a 24 hour emergency department, intensive care, high dependency, coronary care, maternity and paediatric services. The neonatal unit is classified as a local neonatal unit (LNU) and currently has 15 cots comprising of 1 intensive care, 2 high dependency, 12 special care and an additional 4 transitional car cots on the postnatal ward. Pilgrim Hospital which has approximately 391 beds including 26 antenatal and postnatal beds and 9 delivery suite beds. It provides a 24 hour emergency department, elective surgery, critical care at levels 1, 2 and 3, maternity and paediatric services. The neonatal unit is classified as a Special Care Unit and has 12 cots, 8 for Special Care and 4 for Transitional Care. Grantham and District Hospital has approximately 110 beds and provides 24 hour emergency department (currently 12 hours a day), elective surgery, critical care at levels 1 and 2, medicine and outpatient services. Both antenatal, postnatal and gynaecology outpatient clinics are provided at this site. 29 P a g e

31 Choice in model of care is largely dependent on geography with more choice available in the less rural areas of Lincolnshire. Maternity and new born care in Lincolnshire is provided by a range of different health care professionals including hospital and Community Midwives, GP s, Health Visitors, Advanced Neonatal nurse practitioner, Transitional care nurses, Nursery nurses, Mental Health Practitioner, Sonographers, Physiotherapists and Consultant Obstetricians. Across Lincolnshire there are approximately 7783 women who gave birth in 2016/17 ULHT Maternity Service undertakes approximately 5,400 births per year (3,278 at Lincoln County 1948 at Pilgrim Hospital in Boston and 222 home births). The Trust also provides antenatal and postnatal care for a further 500 women who live on the Lincolnshire borders and choose to give birth at maternity services nearer to their home. The maternity service includes both midwifery and obstetric led care, but at the present time does not offer a Midwifery Led Unit. The graph below identifies the number of births year on year and shows a slight decline in births at Pilgrim Hospital and at Lincoln County Hospital. 30 P a g e

32 10.0 Regional Neonatal Services Neonatal care is a highly intensive environment in which nurses and doctors provide continuous support for very sick babies and their families 24 hours a day. Since 2013, neonatal services have been managed within Operational Delivery Networks. There has been a recent review of neonatal services across England and Wales as it is recognised that there are challenges to delivery of neonatal care which is due to inadequate capacity, staffing difficulties, and uncertainty over the best models of care particularly in the immediate perinatal period. The national maternity review findings outlined how maternity services cannot be considered in isolation and are inextricably linked to neonatal services, which are key in delivering optimal outcomes for babies. The national maternity review highlighted a number of concerns linked to neonatal medical and nursing staffing numbers, staff training, the provision of support staff and cot capacity, and safety and sustainability. The drivers for change across neonatal intensive care services are linked to a combination of the need to start neonatal intensive care in the best place possible to promote survival and morbidity, whilst delivering care for that family as close to home as possible. The challenges for neonatal services relate to a lack of clarity regarding the best models of care, capacity and patient throughput, workforce and safety issues, and the utilisation of transport services to support patient flows. Neonatal services are inextricably linked to Maternity and Obstetric services and form part of an integrated pathway for high quality Maternity, Paediatric and family care. We recognise the importance of collaboration between Maternity, Obstetric and Neonatal services to co-develop pathways of care to ensure the best possible outcomes for mother and baby and to ensure that care is delivered in the appropriate place as close to home as possible. We will work with our Neonatal ODN to ensure that, as part of shared clinical and operational governance, integrated pathways will deliver optimal perinatal and neonatal outcomes. Priority Implementation of ATAIN principles to reduce term admissions Monitoring of and improvement in the administration of prophylactic medicine to optimise outcomes i.e Antenatal Steroids & Antenatal Magnesium Sulphate Development of formal Neonatal Transitional Care in Trusts to reduce separation, improve capacity in neonatal units and improve families and carers experience Optimisation of birthplace for premature infants to support the national ambition through improvements in IUT transfers, protocols and agreements: ensuring women at high risk of extreme premature birth are delivered in a unit designated as the Lead NICU How will we know its improved Reduction of neonatal admissions for Hypoglycaemia Hypothermia Jaundice Respiratory problems Perinatal asphyxia Administration rates meet the National audit criteria of the National Neonatal Audit Programme (NNAP) Neonatal services have robust strategies in place. Improvement of IUT transfers for mothers and babies to the Neonatal ODN NICU, who are safe to transfer, achieved in 100% of such cases 31 P a g e

33 Provide on-going support for Neonatal Outreach services which will result in improved capacity in neonatal services, reduce length of stay and improve family and carers experience. All neonatal units have access to Neonatal Outreach services Reduction in neonatal unit average length of stay. Improved discharge care pathways Support the neonatal ODN in monitoring and ensuring adequate neonatal capacity, within their area of responsibility, which is in line with ODN pathways of care Support the monitoring of neonatal mortality and case reviews resulting in improvements through learning, reducing mortality rates and safety of care assurance Ensure any reconfiguration of maternity and obstetric services is fully aligned to neonatal services Workforce Planning- support the implementation of the National Neonatal Review and the East Midlands Capacity Review Ensure that workforce planning for Neonatal Qualified in Speciality (QIS) training is a high priority for Local Workforce Advisory Boards. Support the work of the Neonatal ODN in developing a standard programme for Neonatal QIS training Transfers out of the neonatal ODN are <5% per annum Average annual occupancy of neonatal inpatient services is 80% Establishment of an ODN mortality review process that reports to the LMS on themes and learning points from case reviews Learning points are shared and implemented across the units within the Neonatal ODN Any strategic change in service redesign includes the Neonatal ODN as a key stakeholder All units have robust strategies in place to work towards the National Neonatal nurse staffing standards; 1:1 in Intensive Care 1:2 in High dependency care 1:4 in Special Care Extent of training need is well understood Commissioned courses meet the standards as prescribed by HEE and provide the number of places which are required All commissioned education providers meet the agreed Neonatal ODN standards 32 P a g e

34 10.1 Lincolnshire s Neonatal services Lincolnshire s Neonatal services improve babies chances of survival and minimise the morbidity associated with being born either premature or at full term and sick. It is a low throughput service in which clinical expertise is a key determinant of the quality of the outcomes for the baby. They provide a family-centred approach to care, defined as involving families in the care of their own children, and helping parents understand their baby s needs. They improve the quality of care by working in partnership with Lincolnshire s Local Maternity System to ensure integrated models of care across the whole of the maternity and children s care pathway. Lincoln County Hospital is designated as a Local Neonatal Unit (LNU) this means that it is for babies needing short-term intensive care with apnoeic attacks that require support, including receiving continuous positive airway pressure (CPAP). Some babies receiving parenteral nutrition (tube feeding) may also need this level of care. Pilgrim Hospital is designated as a Special Care Baby Unit (SCBU) this means that it is for babies who need continuous monitoring of their breathing or heart rate, additional oxygen tube feeding, phototherapy recovery (to treat neonatal jaundice) and convalescence from other care. The graph below shows the total care days at these units by year. The two graphs below show admission to the neonatal unit by gestation and admission by weight with the highest percentage of admissions by gestation being babies over 37 weeks gestation and the highest percentage of admissions by weight being babies over 2500grams 33 P a g e

35 Admission by gestation Admission by weight Nottingham Hospitals NHS Trusts Level 3 Neonatal Intensive Care Unit (NICU) provides care for babies born in Lincolnshire who need respiratory support (ventilation) weighing less than 1,000g, born at less than 28 weeks gestation and needing significant CPAP support and babies with severe respiratory disease who also require surgery may need this level of care too. 34 P a g e

36 11.0 Vision to Reality - The Local Maternity Offer Through surveys, a launch event and social media, stakeholders and service users have been involved in sharing their thoughts on improving maternity care, to influence and develop our local maternity system, to develop a local vision for improved Maternity Services based on the principles of better Births by 28th September 2017 & to ensure Lincolnshire implement the Better Births recommendations by the end of 2020/21. This has included how we will put in place the infrastructure needed to support services working together. Based upon this information the plan for Lincolnshire transformation has been categorised into four themes which are included below: 11.1 Personalised and Safe Models of Care Better Births identifies that maternity care should be personalised to women s needs and those of their baby and family. It is recognised that every woman is different and will be starting from different places; some will be first time mothers, whilst others may have had babies before. Whatever their background and circumstances women should be able to make decisions about their care during pregnancy, during birth and after their baby s birth. In relation to our local maternity system when engaging with women a common theme was that women often did not recollect being offered a choice: I don t remember being offered a choice of where to have my baby To address this gap the local maternity system has been working on developing services that meet the needs of individual women and their families. These services will focus on pre conception support and advice through to antenatal, intrapartum and post-natal services, these range of services are depicted within the concept of the best start for women and children, and focuses on improving the health of the whole population by Making Every Contact Count (MECC). A range of universal and targeted public health interventions will be available to support the best start for women and children from preconception to school age. In Lincolnshire best start universal and targeted interventions will focus on: Planning for pregnancy Teenage pregnancy Healthy weight and nutrition Smoking in pregnancy Drinking alcohol in pregnancy Inter-parental relationships and transition to parenthood Domestic violence and abuse Perinatal and infant mental health Breastfeeding Screening and vaccination 35 P a g e

37 The interventions are being developed to ensure that they are delivered through schools, Children s Centres and other primary and community settings. As part of the preventative health programme, the Lincolnshire s Early Help Offer will identify the need for help for women and their families as soon as problems start to emerge, or when there is a strong likelihood that problems will emerge in the future. It includes universal and targeted services designed to reduce or prevent specific problems from escalating or becoming entrenched. This includes the Healthy Child Programme which provides a framework to support collaborative working and more integrated delivery. The Programme aims to: Help parents develop and sustain a strong bond with child Encourage care that keeps children healthy and safe Protect children from serious disease, through screening and immunisation Reduce childhood obesity by promoting healthy eating and physical activity Identify health issues early, so support can be provided in a timely manner Make sure children are prepared for and supported in all child care, early years and education settings and especially are supported to be ready to learn at two and ready for school by five 1. The Healthy Child Programme presents an invaluable opportunity for the best start for women and families that are in need of additional support and children who are at risk of poor outcomes. The 1 Milestones of normal child development age ~4 years (based on the work of Mary Sheridan From Birth to Five Years) 36 P a g e

38 programme operates across a continuum of provision for children and families to ensure personalised care at different levels of need including Community, Universal, Universal Plus and Universal Partnership Plus. The development of the full service specification has been overseen by the Women s and Children s Delivery Board An Integrated Approach All pregnant women need a certain level of support, but some need more specialised care, and therefore this plan has been developed to ensure that there is an integrated model which supports the delivery of care at the lowest level of complexity, yet has the flexibility and capacity to provide specialised and complex care, quickly, as required. Meaning that most women in Lincolnshire will benefit from midwife-led care, including home births, and birth in collocated and, where it is safe to do so, a stand-alone midwife-led unit or birthing centre. Whilst care will normally be provided as close to home as possible, for some women with very complex needs care will be consultant led. Women living in deeply rural areas of Lincolnshire will need to have different arrangements which will include taking advantage of newer technologies, including telemedicine. Whether midwife led units in Lincolnshire are co-located alongside consultant led units or stand-alone will be subject to further public consultation and consideration of a number of factors including safety, geography, existing service provision and accessibility for women and families. Lincolnshire home birth rate is currently above the national average at 2.45% of all births.it is acknowledged that the demand in Lincolnshire exists for such services and with the development of Better Births locally, for women who access midwife led and assisted pathways of care home births must be promoted and resourced accordingly. In determining the best fit for each women and family to achieve safe and effective care an initial assessment of clinical risk will be carried out to determine whether there is normal-risk, medium-risk (requiring a higher level of oversight) or high-risk (requiring a more intensive level of care, either throughout or at a particular stage of care). This will support the discussion between the women and her midwife and enable an informed choice regarding her preferred pathway of care. Across all risk levels there is the potential need for an increased level of care and the importance of a smooth transfer between pathways of care is recognised. The decision as to the most appropriate location for a woman to give birth will be kept under constant review throughout the pregnancy and evaluated post birth. Regardless of the determined level of risk, all care pathways will support the normalisation of pregnancy and birth. To this end women will be offered choice regarding their preferred pathway of care in line with assessed clinical need and best practice. 37 P a g e

39 12.0 Maternity Safety Plan A Maternity Safety Plan has been developed to improve the outcomes and experiences for women, their babies and their families during their pregnancy, birth and the postnatal period by: Improved patient safety Improved clinical effectiveness Improved experiences for women and their families Staff satisfaction A-EQUIP Implemented and embedded. The quality measures will be reported within the Maternity Dashboard and the evolving Quality Matrix, which will integrate with national tools i.e. Maternity Service Data Set, CQC and Rightcare. Lincolnshire s overarching approach to the maternity safety plan is energised by our partnership with the Maternity and Neonatal Health Safety Collaborative. We are improving clinical practice, reducing unwarranted variation and implementing the Saving Babies Lives Care Bundle to ensure: Sustained reduction in avoidable stillbirths, neonatal and maternal deaths of 20% by 2020 and by 50% by 2030; Implementation of the Saving Babies Lives care bundle. Improved recognition of the unwell women both in the acute and community setting as evidenced by incident reporting; Reduction of term admissions to the Neonatal Unit in line with national average; Reduction in the incidence of post-partum haemorrage(pph); The diagram below the primary drivers of change to achieve these outcome measures: Primary Drivers Outcome Measures Reduction in smoking prevelence of women at time of delivery - Smoking at Time of Delivery (SATD) Recognition and escalation of concerns by women when altered fetal pattern movement identified Regognition of altered fetal monitoring in antenatal/intrapartum care Small for gestational age Sustained reduction in avoidable stillbirths, neonatal and maternal deaths of 20% by 2020 and by 50% by 2030 Compliance with maternity MEWs/sepsis care bungle in practice Multi disciplinary team education and training Relevant evidence based guidelines for use in practice in all clinical areas providing care to the ill women Early recognition of deteriorating women 38 P a g e

40 Early identification and management of respiratory distress syndrome of the newborn Early identification and management of infection of the newborn Early identification and management of hypoglycaemia/thermoregulation of the newborn Early identification and management of jaundice of the newborn Early identification and management of asphyxia of the newborn Prevention and reduction of term admission to the neonatal unity Early identifcation of co-morbidities,assigned to appropriate clinical pathways Training and scenario based learning to be facilitated by the multi disciplinary team Proactive management of the pregnancy and birth pathways to reduce incidence of poor outcomes related to PPH Early identification Improved pathways of care Training and development of staff Reduction in the incidence of post-partum haemorrage(pph) Improved outcomes & management of women with perinatal mental health issues 12.1 Safety Leads and Champions Safety Leads and Champions have been identified to ensure the Maternity Safety Plan becomes owned and embedded by staff, women and their families, The Maternity Service is currently in the process of implementing a new maternity Information Technology (IT) system which will greatly enhance the collection of robust clinical outcome data so that the service can reliably benchmark its patient safety outcome data. A maternity dashboard will provide monthly data including data from the National Maternity Safety Thermometer and the national maternity and staff surveys, and Friends and Family Test to evidence improvements against the outcomes within the safety plan. Lincolnshire Maternity Voices and Lincolnshire Health Watch will also be a source of evidence in relation to users experiences of the service Serious Incident Monitoring and Learning from Serious Incidents The system for reporting incidents follows the NPSA reporting framework across the providers in Lincolnshire. There is a monthly Serious Incident Review Group chaired by the 4 Lincolnshire CCGs where all incidents are critically reviewed against the NPSA criteria and feedback is given to providers, any themes or trends are also discussed at Patient Safety meeting and the bi-monthly Maternity Service Review. 39 P a g e

41 At the present time learning from incidents is shared with staff in a variety of ways including: Governance meetings Safety briefings Newsletters Presentations Team Meetings Feedback reports s Face to face meetings The LMS work-stream, Promoting safe and effective care, will review the communication methods of sharing lessons learnt and plan to have Better Birth safety champions in the work place. It will also work with the Maternity Voices Partnership to ensure the voice of the women and families is heard, by hearing patient stories or case studies to provider wider input and understanding of the family perspective. The LMS will ensure any lessons learnt are implemented system wide and evidenced by follow up audits which can then again be shared system wide. The Promoting safe and effective care group will develop audit programmes in collaboration with providers A-EQUIP: an acronym for Advocating for Education and QUality ImProvement The A-EQUIP model supports a continuous improvement process that aims to build personal and professional resilience of midwives, enhance quality of care for women and babies and support preparedness for appraisal and professional revalidation. The restorative function has been shown to: have a positive impact on the immediate wellbeing of staff, helps staff to feel valued by their employers for investing in them and their wellbeing, influence a significant reduction in stress and burnout, the job satisfaction of staff, improve the retention of staff, reduce stress levels whilst maintaining compassion, improve working relationships and team dynamics, help staff to manage work/life balance more effectively and increase enjoyment and satisfaction related to work (NHS England A Model of Clinical Midwifery Supervision) The A-EQUIP model works for women in three ways: Supporting midwives to advocate for women Providing direct support for women within a restorative approach and Undertaking quality improvement in collaboration with women The Professional Midwifery Advocates (PMA) is a new and fundamental leadership and advocacy role designed to deploy the A-EQUIP model. The role supports staff through a continuous improvement process that aims to build personal and professional resilience, enhance quality of care and support preparedness for professional revalidation. Leadership is an essential part of the PMA role. PMA s show leadership by being self- aware, knowing their own values principles and assumptions and being able to learn from experiences. They are able to manage and organise themselves whilst taking account of the needs and priorities of others. PMA s provide care and support (personally and professionally) to midwives and multidisciplinary teams. 40 P a g e

42 Within Lincolnshire United Lincolnshire Hospitals NHS Trust (ULHT) Maternity Service undertakes approximately 5500 births per year and provides antenatal and postnatal care for a further 500 women, and has a significant rural population with high Eastern European migration. The service has a multi-disciplinary approach to training to develop and maintain standards of leadership, teamwork, communication, clinical skills and a culture of safety. Of the 21 Supervisors of Midwives employed by ULHT, 10 Midwives have decided to become PMA s. All previous Supervisors wishing to undertake the new role of the PMA will have to a short bridging course. Any new midwife wanting to become a PMA will have to a full PMA course which is facilitated at university. More detail of the model is included within Appendix 3 41 P a g e

43 13.0 Strengthening Care Pathways The Local Maternity System care pathway design will be based on the preferences of local women and their families and will be supported by the provision of locally produced information (in a variety of forms), which will describe a suite of choices that are available in Lincolnshire now and in the future. To achieve this there are three care pathways currently under development: Proposed Care Pathway Midwife Led Care Assisted Care Consultant Led Care Risk Pathway Descriptors Level Low Risk Women and community midwives will be partners in care; Care will be led and coordinated by an assigned community midwife working within a multidisciplinary team framework; Most of the care pathway will be delivered in the community and close to home; Woman will have real choice regarding where they choose to birth their baby; Transition of care to another pathway, temporarily or permanently due to an emerging risk or choice will be facilitated by clear protocols for communication, care planning and risk assessment Medium Women and community midwives will be partners in care; risk Care will be led and coordinated jointly by an assigned community midwife working within a multidisciplinary team framework which includes an Obstetrician; Most of the care pathway will be delivered in the community and close to home; Woman will have real choice regarding where they choose to birth their baby; Transition of care to another pathway, temporarily or permanently due to an emerging risk, decreased risk or choice will be facilitated by clear protocols for communication, care planning and risk assessment; Postnatal care will commence in the birth setting and transition to the community on discharge High Risk Women will be partners in care with a named obstetrician working within a multidisciplinary team; Most of the care will be led and coordinated by Obstetric Doctors and midwives from the multidisciplinary team ; Where possible antenatal care will take place in the community Births will usually take place in the hospital setting within an obstetric unit; Transition of care to another pathway, temporarily or permanently due to an decreased risk or choice will be facilitated by clear protocols for communication, care planning and risk assessment; Postnatal care will commence in the birth setting and transition to the community on discharge 42 P a g e

44 In order to ensure the pathway for maternity care is effective the following principles will be explicitly adopted and practiced by maternity care teams: There is a shared explicit practice philosophy that supports, protects and maintains normality; The midwife is the lead professional for healthy women with uncomplicated pregnancies; There is consistent high quality communication with women, with relevant information provided at appropriate times; Discussion with all women is facilitated to enable them to make decisions regarding care and birth preferences, including place of birth and to encourage women to document these preferences in their handheld record; Women are supported to take a central, active role in their own care during pregnancy, labour and the postnatal period; There is recognition of the impact of inequality and social exclusion on health and it is ensured that appropriate information, support and referral are provided to all women based on need Antenatal Care The Antenatal Care Pathway in Lincolnshire will ensure that all pregnant women receive personalised care that is appropriate to their healthcare needs including physical health, social circumstance, lifestyle choices and mental health needs. The pathway will be supported by electronic interoperable maternity records; personal hand held records which interface with digital solutions and access to digital sources of information for women and their families. Locally work is underway to scope the following solutions to personalised and safe care: A library of guidance for registered users of the patient care portal; organised by category so that all leaflets relevant to a certain subject, e.g. diabetes during pregnancy, can be easily accessed; Electronic access to their maternity records; accessible by mobile phone as this is the device which most women currently use and always carry with them, such a facility would also be of benefit to women who move around frequently e.g. wives of RAF personnel which is a feature parts of the Lincolnshire population; Women have asked for a view of their appointments across all services e.g. midwife, health visitor, social worker. There are currently a significant number of appointments missed and this feature could help to reduce non-attendance; Women should ideally be able to cancel and make appointments using the portal to reduce; Cancellation of an appointment may include a reason for the cancellation so that these issues such as access to care be analysed; Cancelling appointments should be possible from a mobile phone; ideally in response to an appointment booking confirmation; some women have indicated that if they do not respond immediately they forget to do so. Solutions to improve uptake of maternal and neonatal screening and vaccinations; Where a woman concerns that the pregnancy is deviating from the normal pathway, the patient portal could provide a good mechanism for them to send a question to a triage midwife; A facility for women to self-refer to maternity services using the patient portal accessible to all women i.e. no need to be a registered user of the portal to self-register; The pathway is designed to be responsive, flexible and timely with women seeing the most appropriate professional at the most appropriate time and in the most appropriate setting, this includes the role of the Midwife, GP, Obstetrician, Sonographer, Health Visitor, Peer support worker 43 P a g e

45 and others clinicians and non-clinicians who contribute to the provision of maternity care. Antenatal maternity services will be integrated across both community and hospital, for booking visits, antenatal care, health and social care professional input and for scans with primary care and community settings being utilised as far as currently possible. Through our engagement activity we have identified that women and families in Lincolnshire are generally not clear about the role of the GP during pregnancy. Whilst Midwives are the lead professional, GPs have a critical role to play around the impact of pregnancy and childbirth on women s general medical and social health and continuing care for women with underlying medical conditions. Midwives and GPs will share information as partners in care, in order to facilitate optimum maternity care provision for women in Lincolnshire. In remote and rural areas, the GPs role in maternity care could be enhanced to ensure appropriate medical input into emerging models of maternity care. Further engagement activities are planned across Lincolnshire to ensure that pregnant women and their families have the information they need to access and book with Midwives early and contribute to further dialogue regarding the role of the GP in future models of care. Some women considered to be low risk at the beginning of pregnancy will require consultation or transfer of care to the wider multidisciplinary team at some point during the antenatal period. The bi-directional transfer of care between professionals and between care pathways should be seamless. At all stages, the need and rationale for consultation with another professional, or the transfer to a different care model, will be discussed with the woman. Some high-risk mothers and babies may be referred to a medical or multidisciplinary team clinic e.g. for diabetes, where an individuated, agreed, multidisciplinary, multispecialty care plan will be agreed in order to ensure that the care is appropriately integrated and structured. Should the mother and baby deteriorate and become critically ill, the mother enters the Care Pathway for the Critically Ill Woman in Obstetrics. In Lincolnshire the Healthy Child Programme provides strong universal support during the antenatal period through an antenatal education programme. A range of postnatal health checks within the child s first year. There will be a strong focus providing more support during the first year of a child's life with a key focus on providing all families with a consistent Health Visitor with whom they can build a trusting relationship. As children and families thrive they will require less support from the Service but will still have effective understand the needs of all prospective parents during the antenatal period and if required provide bespoke interventions so that prospective parents are well prepared for parenthood and coordinate and deliver a countywide antenatal education programme for all Lincolnshire resident prospective parents working alongside Midwifery and early years services to inform prospective parents of key health and development promotion messages and help them prepare for parenthood. A copy of the 0-19 Service Specification is available in the appendices (Appendix 4). Pregnancy should be a happy time for women and their families but for some it can be a stressful and vulnerable experience. Women living with social complexities including learning disabilities or disabilities are far more likely to have difficulty accessing good quality antenatal care that meets their needs.the most significant barriers to accessing antenatal care cited by women with disabilities are inappropriate attitudes, behaviours and communication and lack of disability awareness. In Lincolnshire the antenatal pathway for women with a learning disability/difficulty will ensure: All staff have awareness training and education on Women living with social complexities including learning disabilities in order to provide the responsive support required by community care legislation; Maternity services undertake risk and needs assessment in relation to Women living with social complexities including learning disabilities throughout the pregnancy pathway, taking into account that needs may change over time. 44 P a g e

46 Midwives are alert to behaviours that might indicate that a woman has learning disabilities. This should prompt the use of simplified language, appropriate resources and further screening. A screening tool should be used to aid identification of women with learning disabilities. Adult services can be contacted to provide advice and support, and to undertake further assessment where appropriate. Where a woman has learning disabilities or difficulties a staged booking process will be considered to allow information to be provided in manageable amounts and understanding to be reinforced. Appropriate resources e.g. easy read information leaflets, should be available at these appointments Care will be tailored to the needs of the woman and include more frequent appointments, longer appointment times, home visits and orientation visits to the maternity unit. The woman s birth preference (woman centred passport) should be referred to and discussed further, during an orientation visit to the labour ward. Staff caring for the woman in labour will refer to and implement her birth preference (woman s centred passport/person centred plan) ensuring that communication support needs are met and that continuity of carer is provided. TAC should be informed of the birth. Staff caring for the woman after the birth will refer to and implement her care plan and coordinate parenting support to meet her needs. A longer hospital stay should be considered to facilitate learning and to ensure home support arrangements are in place prior to discharge; Staff will engage with and observe mother and baby interactions to identify any support needs. Where current or anticipated needs are identified, these should be documented and social services informed; Easy read resources and other accessible sources of information e.g. CD/DVD/websites, along with face-to-face information sharing, will be used routinely to support communication with women with learning disabilities. The Well Family Model is a single door primary care NHS-based approach that will provides early intervention to prevent escalation of issues and prevent crises from occurring. The Well Family service will provide a single door for a wide range of support so that users with complex problems don t need to deal with a number of agencies. It will tackle the social problems underpinning medical referrals, offering help at an early stage to prevent more serious problems developing. Key interventions provided by the service include: Advice and information regarding housing, debt, welfare benefits or employment support Counselling for emotional problems including anxiety, depression, bereavement and relationship difficulties Promotion of leisure, social and physical activities and volunteering opportunities Signposting and referral to other services Carer and peer support Evaluation 13.2 Postnatal Care Support Pathway Postnatal care will be provided in different settings and for a different duration dependant on need. For women who give birth in hospitals, the setting for delivery of postnatal care is determined by the type and complexity of the delivery and length of stay. The majority of post-natal care takes place in community settings and the women s homes and is coordinated by the community midwife for the first 10 days minimum, transferring to the Health Visiting Service thereafter. A postnatal check at 6-8 weeks is provided by the local GP services. The current post-natal support pathway is being reviewed to ensure: A personalised postnatal birth plan is in place for all women based on a needs assessment on health, social and environmental factors; 45 P a g e

47 All women have access to their midwife as they require after having had their baby; As a minimum 3 face to face postnatal contacts take place in the most appropriate environment; A smooth transition from midwife to others involved in the post-natal pathway of care including Health Visitor and GP; Women and their babies are protected against vaccine preventable disease, including those babies from high risk groups who require additional vaccinations such as hepatitis B and BCG; New born screening tests are offered in line with UK National Screening Programmes, including new born and infant physical examination, newborn bloodspot screening and new born hearing screening programme; Women are supported through healthy eating and stop smoking initiatives; All women are monitored for signs of post-delivery physical and mental ill health and given advice on warning signs prior to discharge; New parents are given support in adapting to parenthood; Provide post-delivery contraception advice to all women; Promote UNICEF Baby Friendly principles for breast feeding and bonding; Safe sleeping practices are adopted; Through the Healthy Child Programme the Health Visitor will: Undertake health checks at defined intervals to help identify if children are developing within their expected ages and stages of development both emotionally and physically; Provide expert advice and direct high quality interventions to support health concerns according to the needs of the child or family. If applicable, to support access to specific interventions from other more appropriate services. Provide families with effective access and respond to any concerns they may have relating to their child through telephone support and bookable/drop in clinics. Enhance the use of children s centres including- supporting families to engage and participate in activities, work jointly with early years commissioned providers to co-deliver sessions and deliver health clinics;. Support transition to childcare/school for children with health concerns or complex needs; Train and develop volunteer Peer Supporters to build a wide network of support for Lincolnshire families across a range of topics Neonatal Care Pathway Since 2013 neonatal services have been managed by Operational Delivery Networks (ODN). The local ODN is a stakeholder and integral part of the Local Maternity System. A National Neonatal Critical Care Review (The NCC Review) has been undertaken looking at capacity, workforce, pricing, education and models of care. The aim of the NCC Review was to make recommendations that will support the delivery of high quality, safe, sustainable and equitable models of neonatal care across England. The review highlighted a number of concerns linked to neonatal medical and nursing staffing numbers, staff training, the provision of support staff and cot capacity, and safety and sustainability. The review findings outlined how maternity services cannot be considered in isolation and are inextricably linked to neonatal services, which are key to delivering optimal outcomes for babies. The challenges for neonatal services relate to a lack of clarity regarding the best models of care, capacity and patient throughput, workforce and safety issues, and the utilisation of transport services to support patient flows. Neonatal services are inextricably linked to Maternity and Obstetric services and form part of an integrated pathway for high quality Maternity, Paediatric and family care. We recognise the importance of collaboration between Maternity, Obstetric and Neonatal services to co-develop pathways of care to ensure the best possible outcomes for mother and baby and to ensure that care is delivered in the appropriate place as close 46 P a g e

48 to home as possible. We will work with our Neonatal ODN to ensure that, as part of shared clinical and operational governance, integrated pathways will deliver optimal perinatal and neonatal outcomes. The Lincolnshire Local Maternity System will ensure that as this plan is developed and implemented it dovetail s into the learning from the review and is jointly developed and delivered by local neonatal and maternity service providers and their respective commissioners to ensure that: Mortality There is a clear focus on neonatal mortality and as the work progresses through the Neonatal Mortality Group, its findings and recommendations will be incorporated into this transformation plan The LMS will develop effective protocols to ensure that wherever possible, all women <27 weeks are able to give birth in centres with a neonatal intensive care unit (NICU). The LMS will work with the Operational Delivery Networks (ODN) to ensure there are clear guidelines for antenatal transfer in the event of impending delivery < 27 weeks, as part of the shared clinical and operational governance being developed across LMS. The LMS will work with the ODN to ensure at least 85% of all births at weeks of gestation are in a maternity service with an on-site NICU include actions to deliver this in local transformation plans. The LMS will continue to work with key providers to ensure that all neonatal deaths are investigated at a local level using a standardised framework including root cause analysis and reported nationally to support learning. Each Baby Counts (RCOG) investigates local review quality for term babies. The LMS will work with the network to ensure that, following birth at 23 weeks of gestation or more, every death (100%) in the delivery room and neonatal unit is investigated, and that lessons are learned, implemented and shared though maternity Clinical Networks. The LMS will work with the key providers to ensure that an appropriate methodology is adopted when it becomes available, including the Perinatal Mortality Review Tool ( and the Child Death Audit Guidance, both of which will be published by the end of 2017 and in line with the Serious Incident Framework. Neonatal Care Capacity The LMS will work with the ODN to review the capacity and demand data in relation to the neonatal units The LMS will work to ensure that Neonatal services have the capacity to provide all neonatal care for at least 95% of babies who require admission for neonatal intensive care and are born to women booked for delivery in the network (i.e. no more than 5% of babies requiring intensive care born to booked women should be transferred out of network for inappropriate reasons), To ensure that neonatal care services do not operate above the 80 percent occupancy averaged over the year, and To ensure that babies requiring neonatal services receive that care from a unit with the appropriate level of care as close as possible to the family home. 47 P a g e

49 Neonatal Transport Transfers The LMS will review the 2016 data received from the Neonatal Transport Group to: o o o Assess the reasons for babies being transferred because of lack of capacity (space or staff), Review the reasons why babies are transferred for more specialised care, and Establish if any of the babies transferred in the first 3 days should have been born in an intensive care unit in the first place The LMS will ensure that there are systems in place to enable an annual needs assessment, and gap analysis to ensure that adequate transfer capacity plans are in place. Reduction of Term Admissions and ATAIN The LMS will work with providers to review the admissions by gestational age data Ensure that the ATAIN scheme and action plan are implemented and Monitor the levels of term baby admissions in neonatal units Workforce Planning The LMS will review progress against local workforce plans in place to address staffing. Review the outcomes of the QST peer review visits and ensure work is being undertaken to address the risks and concerns identified as part of the local transformation planning. Carry out a capacity review to determine the correct level of cots and their distribution across local maternity systems. 48 P a g e

50 Personalised and Safe Models of Care Priority Areas: The Local Maternity System will: 1. Carry out a baseline assessment of current resources, identifying areas of best practice and gaps in the current service configuration against the aims of the plan. 2. Further develop personalised postnatal pathways of care. 3. Develop a model for listening to local women and families and harness their preferences, as well as involving them in discussions about future service codesign; 4. Develop an engagement platform for ensuring those who have knowledge and experience support local women and families to design services around choice and continuity of care; 5. Develop systematic approaches to inform women and their families of the choices available to them, using all available mechanisms including social media, and bespoke events Care Portal development; 6. Empower and upskill the workforce to provide them with the competencies to support women about the choices that are available locally and to ensure they are able to help women make unbiased shared decisions about their care; 7. Take every opportunity to involve partners at all stages of the maternity pathway; 8. Develop the options available to women regarding their place of birth to improve choice, quality of services and best use of resources 49 P a g e

51 14.0 Continuity of Care and Continuity of Carer Better Births identified that women felt they saw too many midwives and doctors over the course of their pregnancy and the birth, and that they did not always know who they were and what their role was. Continuity of care and continuity of carer have been demonstrated to improve outcomes for women. In our engagement activities within Lincolnshire women identified that they did not always see the same midwife. I don t always get to see the same midwife.and making contact with them can be difficult It is anticipated that by further developing the existing community midwifery service working collaboratively alongside a range of health and social care professionals including GPs, Health Visitor, Community Mental Health Teams, Social Care and Public Health Workers and local third sector and voluntary organisations we will provide woman with integrated care as close to home as possible and support women through all stages of her care continuum. Communication protocols, shared records and accessible information technology will enable decisions about care to be effectively communicated between professionals and others. Moving to a multidisciplinary collaborative and women centred maternal and new born care model in Lincolnshire will require a fundamental change in the way services are currently configured and delivered. Following our engagement with women, their families and local professionals it is proposed that continuity of care and continuity of carer is realised through the development of local community hubs. The picture below illustrates the continuum of care could be supported through this way of working. 50 P a g e

52 In a survey responded to by 247 members of the public and 105 professionals; 82% felt that a community hub model would bring about positive change for families. Maternity Voices is supporting the development and roll out of 4 community hub pilot sites in Skegness, Lincoln, Grantham and Boston. The pilot sites have been chosen because we know from the public health data that they serve communities where women and new born children are more likely to experience poor outcomes and this will ensure that local transformation has an impact on reducing health inequalities. The aim of the pilot would be to engage with adults pre-conception so that families have a seamlessly support services with the long term aim of ensuring that children are school ready, healthy and living in a working household. Alongside the development of the maternity led community hub model, options are being appraised for the future configuration of consultant led care from the two sites of Pilgrim Hospital and Lincoln Hospital. The development of safe and effective new models of care necessitates stability in the prevailing model balanced with a readiness for change. There are two emerging clinical models which are likely to be the best fit moving forward. The LMS Board is working with the Women s and Children s Board to further develop current thinking around the proposed models and the environments within which the teams will operate Defining Continuity of Carer Continuity of carer is fundamental to the model of continuity of care. Women, families and staff have identified that delivering the local pledge for continuity of carer will be challenging but fundamental to realising Better Births in Lincolnshire. The Community Hub model provides the best vehicle for achieving this pledge and a multidisciplinary caseload model provides the best methodology. Initially the multi-disciplinary teams will consist of: Midwives (between 6-8 and a named midwife approach) Early Help Workers Early Years Practitioners; Early Years Specialist teachers Health Visitors We will build an adaptable community facing midwifery service to support the normalisation of the birth process as much as possible and develop the role of the Maternity Support Worker to enable better flexible working strategies to be employed. Much of the care will continue to be provided directly by the midwife, whose expertise lies in the care of women and babies during normal birth and pregnancy. Where obstetric or other medical involvement is necessary, the midwife will maintain responsibility as the lead carer. This will maximises continuity of carer and promotes a positive birth experience for the women. Maternity support workers contribute most when midwives train, manage and supervise them, and they are integral to the maternity care team. This will be considered further within the work streams of the LMS Appendix 5. All pathways of care will lend themselves to the principle of continuity of care and a seamless interface between pathways for mothers and families. To direct women into the right type of care requires midwives to have a visible place in community settings to ensure easy access and where possible become the first point of contact. Women in the assisted care pathway will give birth alongside women in the midwifery led care pathway in comfortable, low tech birth rooms; labour 51 P a g e

53 aids such as birthing balls and pools and complementary therapy will be welcome alongside natural coping strategies. Women in consultant led pathways will give birth in an obstetric unit. Transfer to the obstetric unit will be organised and where possible the same midwife will continue the women s care. It is recommended that a designated space is established within a Specialised Birth Centre, with an appropriate environment and processes to ensure that, as far as possible, the normal risk woman will be provided with a natural childbirth experience. 52 P a g e

54 14.2 Roll out of the Community Hub Pilots The roll out of the community hub pilot will be in three phases: Phase 1 - Fit for Pregnancy: The best outcomes for mother and baby occur when mother is: Not socio-economically disadvantaged In a stable, supportive relationship not experiencing domestic abuse In good physical, mental and emotional health Not smoking, consuming alcohol or misusing illegal substances Managing stress and anxiety. Fit For and During Pregnancy Improving Prevention: Reducing Inequality Alison Burton, Maternity and Early Years Lead, Public Health England Some risk factors facts include: Smoking Smoking during pregnancy causes 2,200 premature births; 5,000 miscarriages and 300 perinatal deaths per year in the UK. Young Parents Young parents are 1/3 likely to breastfeed; 3 times more likely to smoke and 3 times likely to suffer poor mental health. Deprivation Pregnancies in the areas of higher deprivation are 50% more likely to end in stillbirth or neonatal death. Mental Health 20% of mothers develop mental health problems during pregnancy or within a year of giving birth. Key risk factors include: a history of poor mental health; domestic abuse; traumatic childbirth, still birth and infant death; and poor social support. Perinatal mental health, Public Health England The effective prevention pathway will promote: Contraceptive choices Pregnancy testing Improve pre-conception health and care Promote healthy behaviours and reduce risk factors Timely screening and immunisations Improve postnatal care and transition to health visiting/early years Employment support. The majority of these services (such as Addaction, Domestic Abuse support, Quit 51; sexual health services) are already in place or commissioned, but would be offered together from one Hub site. Phase 2 - Antenatal Care: Most of the services above would continue to be offered to those mothers and their partners who become pregnant if an impact was not achieved during the Fit for Pregnancy stage. In addition midwives would offer from the centre: Booking in appointments with a focus on booking before 10 weeks gestation Ongoing antenatal appointments and screening 5 week antenatal programme co-delivered with health visitors and Best Start practitioners 53 P a g e

55 Skype appointments, where necessary, with Obstetrician Future plans would incorporate the use of scans Signposting and introductions to children centre/health visiting services such as peer support groups and feeding support. It may also be possible to offer support for women not wanting to go ahead with pregnancy Phase 3 - Postnatal Care: The services from Phase 1 would continue to be offered where appropriate. In addition postnatal services would be delivered in partnership by: Post-natal checks and classes delivered by Midwives Health visitors health assessments; group delivery; targeted support Locality Early Years teams development assessments; inclusion support; targeted group based interventions; Locality Early Help Workers parenting programmes; one to one targeted interventions in the centres and home The Best Start commissioned contract universal and targeted early years sessions and targeted skills development support for parents. In addition: Safeguarding and support for our most vulnerable families would underpin all the services, with an enhanced offer for targeted families Professional's packs would be provided in each Hub to ensure that all professionals had a clear understanding of each other's roles/offer. The current Parent Champion scheme would be enhanced to develop Maternity Parent Champions Evaluation of the development of the community hubs and their impact on continuity of care and women and their families will be coordinated by Lincoln University School of Health and Social care. Continuity of care and Continuity of Carer Priority Areas The Local Maternity System will: 1. Agree a local aspiration and vision for Continuity of Carer ; 2. Engagement with women and staff, including the use of social media, to identify the needs and preferences of local women; 3. Share learning from pilot sites and other organisations where work is already happening, as well as reflecting on past lessons from previous attempts to introduce caseload working; 4. Adopt a multiagency approach to the creation of Community Hubs; Better Pre and Perinatal Mental Health Services 54 P a g e

56 15.0 Better Pre and Perinatal Mental Health Services For all women the transition to motherhood is an event of huge social and emotional significance and all families must be treated with care, dignity and respect during this time. At least 1 in 10 of all new mothers suffer from mental illness during pregnancy, or in the year after birth, which if untreated can have a devastating impacts on them as individuals and their families. Perinatal mental health conditions are a leading indirect cause of maternal deaths and can have a significant impact on mother and child bonding, which increases the likelihood of the child developing on-going emotional and behavioural problems. Early recognition of difficulties and swift intervention are critical to an effective recovery and a reduction in the escalation of symptoms. In Lincolnshire universal services have an important role in identifying mothers, who are at risk of, or suffering from, mental illness, and facilitating access to specialist support if needed at the earliest opportunity. Early help services for maternal mental health antenatal and postnatal including support for partners are provided in community settings by the midwife, health visitor or GP, healthy lifestyle and support services are accessed via children s centres and more specialist talking therapies usually involve weekly meetings with steps2change staff are part of Lincolnshire s Improving Access to Psychological Therapies (IAPT) programme. Where an individual is assessed as requiring referral for specialist mental health services, their GP can refer to the local Community Mental Health Team or Perinatal Mental Health Team where currently available. Where a woman is acutely ill or experiencing a psychosis, may require admission to an approved mental health centre, following which she can return to the care of the local Community Mental Health Team, and her GP. It is important to note that the biggest risk for mental ill-health in pregnancy or postnatal period is a prior history of mental health difficulties. Regardless as to whether a woman presents to a maternity service with a pre-existing mental health problem, or develops one during this time, it is important that the maternity and mental health services work together to provide the best care possible. The lead carer will play an important role here, and should aim to ensure that continuity of care is maintained. Women at risk of developing or experiencing emotional or mental health difficulties in the perinatal period will be identified, and referred to the specialist mental health service. Lincolnshire Partnership Foundation Trust delivers a robust specialist perinatal service providing prompt identification and treatment of antenatal and postnatal mental health issues. The current service model provides support and advice across primary care, maternity, children s, family, and mental health services. All pregnant women aged 16 years and over, or who have given birth within the last year; with a suspected serious mental illness are eligible for an assessment/advice and intervention. Referrals are also accepted for women who are not yet pregnant but have a severe mental health condition and are planning a family, for pre-conception counselling. The Local Maternity System proposes expanding the service to cover the full Lincolnshire geography.this will ensure an integrated, responsive service for Lincolnshire through enhanced relationships with health and social care delivery partners, ensuring we can be more proactive in the mental health management of women, including those known to mental health services and those at risk. Further development of integrated working with midwifery and new-born services will enable: Delivery of highly skilled psychological interventions directly to women delivered on both an individual and group basis, which will include CBT, IAPT and family work Delivery of psychological interventions by other colleagues through the provision of clinical supervision and consultation Delivery of specialist training to partner organisations, inclusive of Midwifery, Obstetric and Community Midwifery Teams. 55 P a g e

57 Delivery of parent-infant attachment therapy services. Increasing awareness of potential indicators to increase referrals and reduce stigma in the community Provision of a telephone advice line currently introduced a duty system and propose advice line from 1pm-5pm on weekdays. Development of social prescribing support in alignment with existing networks of support services, inclusive of app signposting technologies. An enhanced and responsive specialist multi-disciplinary perinatal service will augment a more inclusive and continuous provision, integrated with maternity and community midwives, health visiting, obstetricians, paediatrics and GPs, to provide much timelier assessment, diagnosis and intervention that is integral to adult mental health services ensuring: women with serious affective disorders are sufficiently informed about the effects of their pregnancy on their condition information and advice is routinely provided about medication and pregnancy data is collected routinely on women whom are pregnant or in the postpartum year; additional training is provided to emergency psychiatric services, (crisis resolution and home treatment and liaison teams), healthcare teams about perinatal mental health; proactive and wide-spread screening and detection by a broader range of health and critical care professionals; high quality, evidence-based psychological interventions; psychologically-informed supervision and training of front-line staff; Introduction of patient and peer forums; additional contact for assessment and treatment to meet demand for services; timely access in times of crisis and urgency, particularly in dispersed rural areas; improved liaison and integrated working across the service throughout the county; improved maternity liaison work; improved skill of staff in psychological interventions. 56 P a g e Better Pre and Perinatal Mental Health Services Priority Areas The Local Maternity System will: 1. Undertake a scoping exercise of current practices, caseloads, and resources. 2. Embed mental health assessments throughout maternity care 3. Establish robust methods of screening and assessment for PMH throughout and after pregnancy 4. Support delivery of the PMH model and link it to the local sustainability and transformational plan 5. Embed and implement the perinatal mental health pathway

58 16.0 Bereavement and Palliative Care Support Work has commenced on the development of comprehensive plans for palliative, end-of-life and bereavement in the perinatal and neonatal phases of care. Under this programme of work, each maternity unit will identify how it can best support the palliative care needs of babies and their families to improve and standardise bereavement care. A Health watch Lincolnshire enter and view visit to United Lincolnshire Hospital Trust maternity sites in March 2016 highlighted that more could be done to support women and their families experiencing the loss of a baby. In line with the national SANDS audit tool, a full review of bereavement services is currently being undertaken to benchmark and identify areas for further development. As part of the review we will give due consideration to incorporating the London Clinical Network tool and other best practice into the way we gather feedback from families following the death of a baby. The specialist children s palliative care team (also known as the PATCH team) is part of United Lincolnshire Hospitals NHS Trust children s community services, covering the county of Lincolnshire. The team is made up of a specialist palliative care nurse (team leader), health care/family support workers and play specialist. The PATCH team is part of the wider team consisting of the community children s nurses, children s Macmillan nurse and the specialist family support team. A new palliative care pathway has been launched which will provide greater continuity of care for women and new born babies who have life limiting conditions. 57 P a g e

59 17.0 Multi Professional Working and Working Across Boundaries Within Lincolnshire there are a number of complex challenges, particularly an expanding ageing population; increasing expectations from patients, users, carers, the wider community; greater pressure to meet growing clinical standards and better outcomes for patients. Financial imbalances across the Lincolnshire economy already make it difficult to deliver services as desired and budgetary pressures will make this increasingly difficult now and in the future. The challenges require joined up approaches to ensure that we work together, with our patients, staff and communities together with wider health care partners, to achieve our ambitions for today, tomorrow and into the future. Our workforce is what will enable us to deliver our future vision and the quality services that we strive for, but we know that there a range of challenges to recruiting and retaining people with the right skills. We need to look at new roles and different ways of working, training and developing our people to meet the on-going challenges. In delivering transformation we face a number of specific workforce challenges, which must be addressed and overcome. Current Establishment of Workforce Profile: To address the difficulties in relation to the levels of temporary workforce within our establishment figures as not only is this an impact on the financial position of the our providers, but there are significant quality implications relating to a workforce profile which relies on a temporary workforce. Employment Costs: Focus on reducing the inflated employment costs of locum medical staff in order to deliver savings and move to more Trust-wide on call arrangements and, create a more sustainable and stable permanent workforce. Staff Age Profile: The Retirement Profile shows major issues to be managed over the next five years in relation to some key clinical post holders, with an increased spike in individuals eligible to take retirement compounded by changes to pension rules. Recruitment and retention of permanent Medical, Nursing and Midwives staff: Of major concern is the difficulty in recruiting and retaining high calibre Medical, Nurses and Midwives staff. A combination of geography, structural configuration of services and past reputational issues both as an employer and a place for care has impacted our ability to recruit and retain the best team. It is recognised that historically it been more challenging to recruit/attract staff to geographically distant sites Clinical skills development and maintenance: Maintaining multiple sites with low levels of activity and small teams on each site not only restricts both skills development and maintenance for experienced staff and training experience for junior staff but also increases professional isolation. As a result, some services are operationally extremely fragile and so we need to build staffing models that ensure clinicians can work in a networked way across multiple sites to maintain clinical contact and expertise. Currently maternity services in Lincolnshire are largely consultant led and structured around the hospital; the model of care now proposed represents a fundamental shift in the philosophy of service provision. This will have a significant impact on local workforce requirements. There is a clear need therefore to scope out the staffing requirement arising from the new model of care, and prepare a workforce plan to incrementally build capacity in the maternity services workforce. Workforce planning will need to go beyond the core requirement of obstetricians and midwives, and apply across the entire multidisciplinary team. Ensuring that mothers and babies in Lincolnshire 58 P a g e

60 have the right staff to meet their needs will require the appropriate use of expert skills of the whole maternity service team with appropriate delegation of responsibilities to qualified support staff. Skill mix changes will need to reflect the needs of local communities, sensitive to equality matters, with access to education and training to ensure that all carers have the necessary competencies. All women in Lincolnshire regardless of location will receive care from a multidisciplinary team led by a midwife whose expertise may include sonographers, obstetricians, neonatologists, maternity support workers, GPs, anaesthetists and fetal medicine consultants. Embedding multi-disciplinary continuous learning and multi-disciplinary training will help to foster a positive culture of shared responsibility for improving maternity and new-born services and ensure a greater capacity for change and innovation. Effective maternity service delivery requires processes to ensure that there will be sufficient staff available at the right time, with the right skills, diversity and flexibility to deliver high quality care for women and babies i.e. appropriate skill mix. In Lincolnshire evidence-based workforce planning tools have been used in line with the National Quality Board guidance Safe, sustainable and productive staffing - An improvement resource for maternity services to model the future scenarios for planning and analysis of the staffing required across all disciplines. This is what we learnt: Right staff Right skills On the whole the current establishment of midwives in Lincolnshire reflects the national trend Doctors, midwives and nurses are more difficult to recruit in the more rural and remote areas of Lincolnshire Non clinical and other support staff are not difficult to recruit in the more rural areas of Lincolnshire The Midwifery Support Worker role needs to be developed to support continuity of care Further consideration will needs to be given to opportunities for further integrating peer support workers and local support groups The interface between community midwifery and the public health nursing services could be further strengthened A review of obstetric anaesthesia staffing would be beneficial Review of neonatal nurse capacity Specialist perinatal mental health support roles need to be equitable across Lincolnshire and available 24 hours a day Training for the maternity team on early identification and management on mental health and learning disabilities needs enhancing Birth debrief and bereavement skills need to be more readily available Expansion of the infant feeding coordinator is required to address the challenges with breastfeeding targets GPs may need additional training to support continued medical management of pregnant women in remote areas depending on model of midwife led care Local implementation of A-EQUIP (Advocating for Education and Quality Improvement) the employer led model of midwifery supervision. 59 P a g e

61 Right place and time Information technology connectivity between professionals providing maternity services is critical to continuity of care Commitment to continuity of care and carer will require expansion of current flexible working arrangements Access to different approaches to care delivery will necessitate role development and expansion across professional boundaries There is a gap in availability of sonographers Continuity of care necessitates continuity of carer. Achieving this will require a review of the way we currently work to provide the service. Workforce models employing Birth rate Plus as the preferred workforce tool are being developed to shape workforce plans that achieve continuity of carer as well as ensuring sufficient and appropriate staffing capacity and capability to ensure safe, high quality and cost-effective care for women and new born at all times. It will also be necessary to analyse the training needs associated with the implementation of the new model of care to ensure that the current and future maternity workforce have the necessary skills and competencies to deliver safe high quality maternity care. Lincolnshire is working with Health Education England Local Workforce Action Board (LWAB) through the Lincolnshire Sustainability and Transformation Partnership to develop an integrated maternity and neonatal workforce planning framework which will incrementally build capacity in the maternity services workforce ensuring that sufficient staff are available at the right time, with the right skills, diversity and flexibility, to deliver high quality care for women and new-born babies in Lincolnshire. This will include developing the Maternity support workers workforce and utilising funding from Health Education England for sonographers if workforce plans indicate that this is required. Central to ensuring continuity of care in rural Lincolnshire through proactive workforce planning is the recognition of the need to ensure newly qualified midwives are representative of the local community, are locally sourced and locally retained and that the continuing professional development of existing midwifes is supported my local educational providers. Nottingham University and De Montfort University Leicester are well established partners in Lincolnshire working closely with United Lincolnshire Hospital Trust to ensure that on average 30 new midwives are recruited annually. In future Lincoln University will play a vital role in the Local Maternity System in bridging the gaps between current skills and competencies and those required in the new models of care. The University School of Health and Social Care already provides undergraduate adult and mental health nursing courses, return to practice courses and a range of post graduate health and care modules. The School of Health and Social Care is working with the Local Maternity System and Nursing and Midwifery Council to establish a Midwifery programme in Lincolnshire. The programme is currently subject to approval from the Nursing Midwifery Council and is a three year midwifery degree programme which is anticipated to commence in September 2018.Throughout the course students will be exposed to caseload holding where they will follow a woman and family through their pregnancy to birth and the postnatal period this reflects the personalisation and continuity of carer recommendations within Better Births. Midwifery students will have access to state of the art clinical skills simulation suite, as well as learning in the academic setting and learning in practice. The University is currently working with maternity care providers in Lincolnshire to see how the suite can support the continued professional development and fitness to practice of experienced local midwives. 60 P a g e

62 The LMS has presented the plan in relation to Better Births to the local workforce action boards, to ensure that there is a clear strategy for Maternity workforce transformation, and this is aligned to the local workforce transformation strategies. The LMS will therefore work in partnership with the local workforce board to: Create a workforce development plan based on robust commissioner intentions and provider plans Work in partnership with universities, other education providers and research and innovation organisations Establish a joined up approach to workforce planning and transformation with local authorities and health and wellbeing boards. Share good practice on workforce solutions Support workforce transformation including the up-skilling of current staff 61 P a g e

63 18.0 Developing Digital and Technological Solutions Alongside this technological solutions are being developed as a key enabler of continuity of carer. The use of the Care Portal is considered key in Lincolnshire to ensuring clear communication and a full understanding of the treatment of women accessing maternity services. Lincolnshire made a number of successful bids for funding through the Primary Care Transformation Fund and Estates and Technology Transformation Fund. The most significant initiative is an integrated care record portal, consisting of 4 modules. Procurement is and implementation planned over the next 3 years, up to The care portal enables health and care organisations (including social care) to share on a read only basis their clinical records for Lincolnshire patients with the view of the data managed through role based access controls. This is being rolled out now. The second phase of the care portal is Personal Community. This module enables patient access to their integrated record via a tablet and mobile friendly website. Detailed scoping is about to commence, with maternity chosen as a priority cohort. As well as enabling the patient to view all or part of their record, the patient module can support proxy access if appropriate. Patients can communicate with care providers via secure messaging, use the portal to and submit forms and questionnaires and see their various appointments on a calendar. The patient module will have a trusted library of information and can be used to target information to a specific cohort or individual, this could be a leaflet, video or suggested app. Individuals can also contribute to their own record via wearable devices for example. It is planned to have a limited cohort using the patient portal by end of March A future phase of the portal is Care Community, the Care Planning module of the Care Portal. This supports the production and sharing of care plans across the health and care community, supporting patients and carers to play an active part in their care and enabling health and care workers from multiple organisations to contribute to care plans will support the provision of integrated care for patients. This module will support improved multi-agency patient management. The use of Skype communications i.e. to a named obstetrician is seen a key solution to ensure that women in the most rural and remote areas can be cared for close to home. Accurate, consistent data collection will enable us to measure outcomes for every women and new born in Lincolnshire so that we can understand where progress is being made and where more needs to be done. Good data will enable us to compare and benchmark their performance, highlighting opportunities for improvement and help teams to develop innovative solutions to the challenges we face in Lincolnshire. Establishing a multidisciplinary collaborative and women centred maternal and new born care model has the potential to address local variations in recruitment in rural and remote areas. Having the option of working in a collaborative multidisciplinary team may make the provision of maternity care more appealing to newly qualified midwives and other health care professionals and encourage those who have left the professions to return to practice. 62 P a g e

64 Multi professional working and working across boundaries Priority Areas The Local Maternity System will: 1. Define the roles and skills that are needed to achieve the local vision 2. Scope out the multi-professional staffing requirement arising from the new model of care, and prepare a workforce plan to build capacity and a training needs; 3. Undertake a baseline assessment local education and training needs and standardisation multidisciplinary learning across the LMS, to include joint learning forums across the network, as well as the review of and learning from adverse events 4. Establish an IT system-wide solution to facilitate more co-operative working across organisations and across primary and secondary care by means of the Care Portal 63 P a g e

65 19.0 Financial Case for Change 19.1 Introduction The health care system in Lincolnshire is challenged from a financial perspective, with an increasing financial gap appearing across the health care system in Llncolnshire if this increasing gap is not addressed In relation to maternity services the financial case for change has focused on redesigning maternity services to make them clinically and financially sustainable. The proposal is to invest in the estate to allow more activity to be managed through midwifery led pathways of care, providing care in the community and closer to home. Currently within Lincolnshire there are only about 6% deliveries which are coded as midwifery-led. The financial case for change builds upon strengthening our community and midwifery pathways, and modernising our approach to caring for women and their families. In most services, national tariffs already reflect the differences in the cost of services. However, there is no price difference between consultant and midwifery led activity in the current coding of tariff activity. Hence, using a tariff for transacting maternity would leave commissioners with the same costs even if providers lower their cost base. To properly reflect the proposed service model, the health community would need to: create a service delivery model which released medical input required for maternity in order to reduce costs for providers agree an approach that enables the financial flow to support the ongoing transformation of maternity services in Lincolnshire. 64 P a g e

66 19.2 Proposal In the new service delivery model, costs of estate will increase due to the investment in co-located midwifery-led units. The new models of service would need to reduce costs by at least this level. Currently only about 500 deliveries per year are midwifery-led, about 6% of the total. It is proposed to increase this percentage to approximately 50% over 3 years. This would support 3,000 women into community and midwifery led care pathways Assumptions Costs of the Estate: New investment in estate will attract capital charges for interest repayments and depreciation. 1m investment with 15 year life would lead to annual costs of around 100k per annum. Refurbishing two units is considered sufficient to manage 3,000 additional midwifery led births. More modelling work will be needed to confirm these assumptions Efficiency Savings: The current costings for tariff prices do not allocate costs to activity in enough detail to automatically describe the savings between consultant led and midwifery led activity. In the national tariff the costs are the same for both. More work needs to be done on individual patient pathways in the two scenarios to create a greater degree of clarity of impact. This business case assumes that around 5% of costs ( 240) could be avoided for some patients by providing management through community and midwifery led pathways Cost impact The costs and savings from the proposal are outlined in Table 1 below. The capital costs would immediately increase the costs of the service. Increasing the proportion of midwifery led care will produce additional savings opportunities. At the end of the 3 year transition there would be 0.5m annual savings. Note that this very simple model makes no assumptions on growth. It is also important to note that the savings would be in medical staff time. This becomes an opportunity cost either to perform other activity or reduce staff numbers. The scope for actually reducing staff numbers in the medical will be restricted by many factors including clinical minimum staffing numbers. 65 P a g e

67 Table 1: costs by year Total maternity costs Base Year 1 Year 2 Year 3 k k k k Deliveries 17,787 17,787 17,787 17,787 Ante natal and post natal costs 17,784 17,784 17,784 17,784 35,571 35,571 35,571 35,571 Costs of refurbished estate Savings (240) (480) (720) Net impact 200 (40) (280) (520) Revised total spend 35,771 35,531 35,291 35,051 Other factors Variation in maternity activity may make it difficult to maximise use of staff resources for the new units. Patient choice of location and birth plan will also affect activity. New changes to clinical protocols could change activity flows. Conclusions Shifting activity from consultant led to midwifery and community led pathways has the potential to release staff resources, save money and provide a clinical sustainable service delivery model. More work needs to be done to establish the proposed changes in practices and the financial impact that this will have on staff resources needed. However, there is potential for a recurrent saving of 0.5m. This could be cash releasing, or could release staff time to manage more activity. Assumptions Table 1: delivery costs and activity from 2016/17 for Lincolnshire CCGs 2016/17 delivery activity Midwifery Consultant Total Average Total led led price cost k k Normal Delivery 378 2,004 2, ,912 Normal Delivery with Epidural or Induction 60 1,864 1, ,728 Assisted Delivery ,235 Caesarean , ,912 Total 452 6,588 7,040 17,787 Table 2: ante natal and post-natal activity and cost from 2016/17 for Lincolnshire CCGs 66 P a g e

68 Activity Cost Average k Ante natal 10,937 15,287 1,398 Post natal 9,073 2, Total 20,010 17,784 Table 3: estimated pathway costs for a maternity episode Standard pathway costs Averages Estimated savings at 5% Ante natal 1, /17 average Post natal phase /17 average Normal or Assisted delivery with CC > 0 3,120 Total cost estimate 4, Subject to validation Table 4: capital charge estimates k Capital costs 1,000 Depreciation year life Interest 30 6%, 500k average balance Estimated capital charge Investment of Maternity Transformation Funding The LMS has received 77k investment from the national programme. In 2017/2018 the plan for investment of this funding is the following areas A transformation office has been established, the PMO office has the following staffing structure and costs Resource Costs Total Band 8A programme lead x2 51,800 x Band 5 Project support officer x1 28, Website Development 7000 Stakeholder Event 500 Media/Publicity Material 2000 Support for Maternity Voices 5000 Total FYI P a g e

69 20.0 Delivering the Plan - The Enablers Delivery Work Streams The implementation plan will address actions that can be initiated and implemented within a short timeframe while working towards the achievement of the longer term vision. A copy of the Plan detailing short-term and long-term goals can be found in the appendix Driving Change Governance and Accountability This plan outlines a radical new model of maternity care in Lincolnshire which requires strong and effective clinical leadership to realise the significant change in the way we deliver care to women and their families. Only then can we create and sustain an equitable model of safe personalised women centred care across Lincolnshire. At local level, we will ensure leadership at all levels of our organisations. We need to empower the whole workforce to take a lead in identifying opportunities to improve, to develop a women centred culture and to feel responsible for improving the care they provide. As part of the Workforce, Training and MDT workstream there will be a focus on strengthening the existing leadership within the system - the Dalton Review (2014) points out, leadership is key to change. Strong and capable leadership is key to driving transformational change and often involves taking bold decisions. More support is needed for leaders to develop large-scale change management, strategic and commercial skills and the ability to lead in a networked or group structure are becoming more important. Principles of Leadership, coaching and development, will be identified across the system via the work stream, proposals will be developed and shared via the LMS for confirm and challenge prior to implementation. (NHS Leadership 2014). Realising the vision for maternity services outlined in this plan will be challenging, particularly in light of the current economic and resource constraints and the plan will therefore be implemented alongside the Lincolnshire STP with oversight from the Health and Wellbeing Board. This plan cannot be successfully delivered without the right resource, effective relationships and collaborative working arrangements across the Lincolnshire health and care system. We have employed a programme management approach to developing and delivering the plan and have appointed a programme office which currently includes two Maternity Transformation Programme Managers and a Project Support Officer. This resource has been reviewed by the LMS and a further Maternity Transformation Programme Managers is about to be sourced. All posts are seconded from within the local system to ensure the expertise is retained in the long term to invigorate their areas of practice and continue to contribute to the social movement driving change in Lincolnshire. We will seek support from the local Maternity Clinical Networks and neonatal network to act as a local quality improvement advisers and conduit for sharing learning arising from national (and international) best practice. It will be led locally and monitored through the Lincolnshire Maternity System Board (formally Lincolnshire Maternity Transformation Programme Board). The Board will lead this work, through representatives from partner organisation who are empowered to discuss, agree and implement the transformation required across maternity services. 68 P a g e

70 The board is responsible for: Developing and overseeing the local implementation plan for the recommendations arising from the national maternity review Overseeing progress against agreed deliverables / work plans of the work programmes Receiving audits and review relating to midwifery or maternity care and ensuring that any actions / recommendations relevant to the local maternity system are actions Managing the critical dependences of the project / programme Establishing sub-groups in key areas as required Reviewing the adequacy and effectiveness of: systems of risk and control, relating to agreed objectives and programmes of work Seeking assurance that agreed objectives are being met Approving key documentation in relation to maternity Disseminating information to appropriate stakeholders internally and externally Progress on the implementation of the plan will dovetail into the existing governance and performance dialogue and the NHS Rightcare Commissioning for Value Focus Resource Pack will be embedded into performance monitoring and evaluation of the plan. Lincolnshire Maternity System Board will report to both the Sustainability and Transformation Partnership (STP) executive and also reports to the Women s and Children s Delivery Board. This will ensure alignment of the local maternity transformation plan and the wider STP with the Local Maternity System (LMS) Board having strategic responsibility for leading the maternity work stream working alongside STP enablers. Lincolnshire Maternity System Board will seek to bring together existing providers and other key stakeholders to work as a collaborative alliance on achieving a defined set of outcomes and performance indicators which can be written into a single maternity specification for an integrated model of care in Lincolnshire. To ensure strategic alignment and continuity the Senior Responsible Officer (SRO) for the Lincolnshire Maternity System Board will be connected into the governance of the STP. 69 P a g e

71 20.1 The Governance Framework The governance framework for the Lincolnshire Maternity System Board is illustrated below: Regional maternity programme board DCO Maternity programme board Joint Delivery Board Sustainability and Transformation Executive Board East Midlands Clinical Network (LMS Delivery Support) Women and Children s Delivery Board Lincolnshire Maternity System (LMS) Board Lincolnshire LMS Alliance Agreement Provider contract Provider contract Provider contract Provider contract As a Local Maternity System we will use a range of quality metrics to measure, analyse and demonstrate progress with delivery against our strategic priorities. A LMC Quality Dashboard is currently under development and a list of metrics to be included can be found in the Appendices (Appendix 6). 70 P a g e

72 Lincolnshire Better Births Gap Analysis Appendix 1 1 Personalised care centred on the woman, her baby and her family based around their needs and their decisions where they have genuine choice informed by unbiased information LMS Workstream: Continuity of Carer and Personalisation No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? 1.1 Every woman should develop a personalised care plan, with their midwife pregnancy progresses and after the birth. and other health professionals, which sets out her decisions about her A health assessment is undertaken and care plan developed at 12 week care, reflects her wider health needs and is kept up to date as her booking. Maternity survey E-referral data Maternity Services Data Set 1.2 Unbiased information should be made available to all women to help them make their decisions and develop their care plan drawing on the latest evidence, and assessment of their individual needs, and what services are available locally. This should be through their digital maternity tool. Plan for midwives to have broader range of digital technology to enable this to happen. Maternity survey and NIB monitoring 1.3 Women should be able to choose the provider of their antenatal, intrapartum and postnatal care and be in control of exercising those choices through their own NHS Personal Maternity Care Budget. Awaiting pilot outcomes in order to understand the impact of the maternity care budgets. Maternity survey, e-referral data and CCG Assessment 1.4 Women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit after full discussion of the benefits and risks associated with each option. Lincolnshire does not currently offer women the choice of giving birth in a Midwifery Led Unit and so are looking to establish co-located birthing centres as part of the transformation programme Currently there is work being undertaken to analyse the options for co-location Maternity survey, e-referral data and CCG Assessment STP configuration 2 Continuity of carer, to ensure safe care based on a relationship of mutual trust and respect in line with the woman s decisions LMS Workstream: Continuity of Carer and Personalisation No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? 2.1 Every woman should have a midwife, who is part of a small team of 4 to 6 midwives based in the community who know the women and family, and can provide continuity throughout the pregnancy, birth and postnatally. Midwives are currently operating in teams larger than this and over larger footprints so there is a need to reconfiguration to enable the establishment of these neighbourhood midwifery teams Maternity survey 2.2 Each team of midwives should have an identified obstetrician who can get to know and understand their services and can advise on issues as appropriate. This will also be addressed through the work undertaken above (2.1). Staff feedback 2.3 Community hubs should enable them to access care in the community from their midwife and from a range of other services, particularly for antenatal and postnatal care. Looking to map community teams around children s centres, subject to IT and space requirements being met. CCG assessment 2.4 The woman s midwife should liaise closely with obstetric, neonatal and other services ensuring that they get the care they need and that it is joined up with the care they are receiving in the community. This is already an integral component of care. Maternity survey, Local Maternity System governance 71 P a g e

73 3 Safer care, with professionals working together across boundaries to ensure rapid referral, and access to the right care in the right place; leadership for a safety culture within and across organisations; and investigation, honesty and learning when things go wrong LMS Workstream: Promoting Safe and Effective Care No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? 3.1 Provider organisation boards should designate a board member as the board level lead for maternity services. The Board should routinely monitor information about quality, including safety and take necessary action to improve quality. Michelle Rhodes Director of Nursing is the designated board member CQC Inspections 3.2 Boards should promote a culture of learning and CQC continuous improvement to maximise quality and outcomes from their services, including multi-professional training. CQC should consider these issues during inspections. Multi-professional training takes place but this should be extended and developed for improvement CQC Inspections 3.3 There should be rapid referral protocols in place between professionals and across organisation to ensure that the woman and he baby can access more specialist care when they need it. it Rapid referral protocols are in place (fetal medicine, social care) Local maternity system governance 3.4 Teams should collect data on the quality and outcomes of their services routinely, to measure their own performance and to benchmark against others to improve the quality and outcomes of their services. We use the maternity dashboard and this is aligned to the Clinical Network regionally. Regional clinical network monitoring, CQC inspections 3.5 There should be a national standardised investigation process when things go wrong, to get to the bottom of what went wrong and why and how future services can be improved as a consequence. Set nationally. DH / NHS Improvement / HCISB Monitoring 3.6 There is already an expectation of openness and honesty between professionals and families, which should be supported by a rapid redress and resolution scheme, encouraging rapid learning and to ensure that families receive the help they need quickly. New duty of candour meetings. We involve patients in complaints procedures. DH implementation 4 Better postnatal and perinatal mental health care, to address the historic underfunding and provision in these two vital area, which can have a significant impact on the life chances and wellbeing of the woman, baby and family LMS Workstream: Perinatal Mental Health No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? There should be significant investment in perinatal mental health services** in the community and in specialist care. Postnatal care must be resourced appropriately. Women should have access to a midwife as they require after having had their baby. Lincolnshire has a perinatal team that meets regularly but no specialist mental health midwives. Ideally we would have 2 FTEs investment to meet this requirement. Our outcomes for postnatal care are currently below the European average. Ensure that we are following NICE guidance for the best care. CCG Assessment Framework, Mental Health Minimum Dataset (MHMDS), MCMDS STP configuration Maternity survey, MCMDS 4.3 Maternity services should ensure smooth transition between midwife and obstetric and neonatal care, and when appropriate to ongoing care in the community from their GP and health visitor. This is in place. Maternity survey 4.4 A dedicated review of neonatal services should be taken forward in light of the findings of this review. NHS England NHS England reporting ** Perinatal mental health services care for women during pregnancy and in the first year after birth 72 P a g e

74 5 Multi-professional working, breaking down barriers between midwives obstetricians and other professional to deliver safe and personalised care for women and their babies LMS Workstream: Workforce, Training & MDT No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? 5.1 Those who work together should train together. The Nursing and Midwifery Council and the Royal College of Obstetricians and Gynaecologists should review education to ensure that it promotes multi-professionalism and that there are shared elements where practical and sensible. Awaiting outcome of NMC/RCOG review. NMC and RCOG reporting 5.2 Multi-professional training should be a standard part of professionals continuous professional development, both in routine situations in emergencies. Local multi professional skills training in place, further developments to be identified HEE reporting CQC inspection Board reporting 5.3 Use of electronic maternity records should be rolled out nationally, to support sharing of data and information between professionals, organisation sand with the woman. Commissioners and providers should invest in the right software, equipment and infrastructure to collect data and share information. Medway in place Digital Maturity Self-Assessment will cover electronic records generally 5.4 A nationally agreed set of indicators should be developed to help local maternity systems to track, benchmark and improve the quality of maternity services. This should include the possible development of PROMS/PREMS measures for maternity. To be developed at a national level NHS England reporting 5.5 Multi-professional peer review of services should be available to support and spread learning. Providers should actively seek out this support to help them improve, and they must release their staff to be part of these reviews. CQC should consider the issue as part of inspections. National body recommendation RCM and RCOG reporting CQC Inspection 6 Working across boundaries to provide and commission maternity services to support personalisation, safety and choice, with access to specialist care whenever needed LMS Workstream: Workforce, Training & MDT No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? 6.1 Providers and commissioners should come together in local maternity systems covering populations of 500,000 to 1.5 million, with shared standards and protocols agreed by all. This is already happening in Lincolnshire. Analysis of Lincolnshire border systems being undertaken CCG Assessment 6.2 Professionals, providers and commissioners should come together on a large geographical area through Clinical Networks *** coterminous for both maternity and neonatal services, to share information, best practice and learning, to provide support and to advise about the commissioning of specialist services which support local maternity systems. NHS England and Networks NHS England assurance of Clinical Networks *** Formerly Strategic Clinical Networks 6.3 Commissioners should take greater responsibility for outcomes, by commissioning against clear outcome measures, empowering providers to make service improvements and monitoring progress regularly Maternity transformation board being established key metrics for outcome measures being developed CCG Assessment 6.4 NHS England should seek volunteer localities to act as early adopter sites. Looking at this area NHS England reporting 73 P a g e

75 7 A payment system that fairly and adequately compensates providers for delivering high quality care to all woman, whilst supporting commissioners to commission for personalisation, safety and choice LMS Workstream: Finance & Commissioning No Recommendation / Action Lincolnshire Current Self-Assessment How Will We Know? The payment system for maternity services should be reformed. In particular, it should take into account: The different cost structures different services have, i.e.: a large proportion of the costs of obstetric units are fixed because they need to be available 24 hours a day, seven days a week regardless of the volume. 7/1 The need to ensure that the money follows the woman and her baby as afar as possible, so at to ensure woe men s choices drive the flow of money, whilst supporting organisations to work together. Looking at this area NHS England and NHS Improvement reporting The need to incentivise the delivery of high quality and efficient care for all women, regardless of where they live of their health needs. The challenges of providing sustainable services in curtain remote and rural areas.. 74 P a g e

76 Professional Midwifery Advocate Role: United Lincolnshire NHS Trust Implementation Plan Appendix 2 Background to the Professional Midwifery Advocate Role (PMA) The Morecambe Bay Investigation highlighted weaknesses in the current system of midwifery regulation that failed to identify inadequate care. Following this investigation, the NMC commissioned the King s Fund to undertake an independent review of midwifery regulation. The findings of the King s Fund review (2015) made the recommendation that the supervision and regulation of Midwives should be separated and the NMC as the regulator should be in direct control of all regulatory activity. The main conclusion of the King s Fund (2015) was that the peer investigation model, a key function of the statutory framework, was not impartial, and led to confusion about processes of clinical governance. This additional investigatory process was not present in other health professions. The NMC agreed with the King s Fund recommendation in January 2015 and commenced proceedings to secure legislative change. The Department of Health consulted on the proposed changes to the legislative framework governing the NMC, the Nursing and Midwifery Order 2001 (NMO). The proposed changes to the Order would: 75 P a g e remove the additional tier of regulation relating specifically to Midwives by removing provisions on the statutory Supervision of Midwives remove the Midwifery Committee as a statutory committee of the NMC make a number of changes to improve the efficiency and effectiveness of the NMC s fitness to practice processes. The Section 60 Order was approved by Privy Council on the 8 February 2017 and the Order came into force on the 31 March Although Midwifery Supervision has been removed from statute, these legislative changes do not mean an end to supervision, only to its statutory components. The developmental and supportive nature of supervision is important to the Midwifery profession and for outcomes to women and babies. The culture of developmental and supportive supervision will continue in the updated A-EQUIP: an acronym for Advocating for Education and QUality ImProvement model. Prior to the removal of Midwifery Supervision from statute, United Lincolnshire Hospitals NHS Trust employed 21 Supervisors of Midwives. Within their role, the supervisors of Midwives provided: A 24 hour on call service Annual reviews for all Midwives Undertaking reviews of incidents and undertaking investigations as necessary Provided support to women and their families when they chose to birth outside of Trust and national guidance Debriefing service for women and their families (Birth Afterthoughts)

77 Debriefing of Midwives who had been involved in traumatic events/incidents Providing support for Midwives going through investigative processes Contributed to and wrote trust guidelines Highlighted areas of practice concern or good practice through audit Annual report to the Local Supervising Authority. Developing the A-EQUIP Model The Task Force agreed that the new model should be: Consistent standards developed nationally, delivered locally with education and training Strategic response to national initiatives and strategies such as the quality and safety aspects of Five Year Forward View (NHSE 2014), the DH Mandate (DH 2015)/recommendations from Better Births the National Maternity Review (DH 2016b), registrant revalidation requirements (NMC 2015a) and Leading Change Adding Value (NHSE 2016) with a focus on reducing unwarranted variation. Integrated employer led model incorporated into local governance arrangements. (Gillman and Lloyd 2015) Clinical Supervision (Restorative) Restorative Clinical Supervision (RCS) involves the creation of thinking space, supporting the practitioner to physically and mentally slow down, through a process of discussion, reflective conversation, supportive challenge and open and honest feed-back. RCS restores thinking capacity, enabling the professional to understand and process thoughts which free them to contemplate different perspectives, and inform their decision making (Pettit and Stephen 2015). This approach has been found to reduce stress and has had a positive impact on physical and emotional well-being, job satisfaction and relationships with colleagues as shown below: 76 P a g e

78 Monitoring, evaluation and control (Normative) This element focuses on supporting individuals to develop their ability and effectiveness in their clinical role, whilst facilitating restoration through validation of the Midwife s clinical actions or through discussion of any consequences resulting from clinical errors. The benefits of the normative function include: Promotion of personal and professional accountability Awareness of self-development Involvement in service improvement Support to the delivery of a high standard of ethical, safe and effective care Enhancements to performance. Personal action for quality improvement A Midwife s personal action(s) to improve the quality of care for women and babies, involves ensuring that the right thing takes place, within the right context at the right time to improve quality of care. Promoting the safety of those who use maternity services is of particular importance. Personal action for quality improvement is a function that aims to ensure that through staff development, action to improve quality of care becomes an intrinsic part of everyone s job, every day, in all parts of the system. Education and development (formative) This function of the model aims to focus on the development of knowledge and skills through education and can inform appraisal, revalidation and leadership development. The Role of the PMA The PMA is a new and fundamental leadership and advocacy role designed to deploy the A-EQUIP model. The role supports staff through a continuous improvement process that 77 P a g e

79 aims to build personal and professional resilience, enhance quality of care and support preparedness for professional revalidation. Leadership is an essential part of the PMA role. PMA s show leadership by being selfaware, knowing their own values principles and assumptions and being able to learn from experiences. They are able to manage and organise themselves whilst taking account of the needs and priorities of others. PMA s provide care and support (personally and professionally) to midwives and multi-disciplinary teams. How A-EQUIP and the PMA role works for women The A-EQUIP model works for women in three ways: Advocating for women Providing direct support for women within a restorative approach Undertaking quality improvement in collaboration with women. Implementing the A-EQUIP Model into United Lincolnshire NHS Trust United Lincolnshire Hospitals NHS Trust (ULHT) Maternity Service undertakes approximately 5500 births per year and provides antenatal and postnatal care for a further 500 women, and has a significant rural population with high Eastern European migration. The service has a multi-disciplinary approach to training to develop and maintain standards of leadership, teamwork, communication, clinical skills and a culture of safety. The fundamental, underpinning values of the role of the PMA align with the Maternal and Neonatal Health and Safety Collaborative. The aims of the Health and Safety Collaborative is to reduce the rates of maternal deaths, stillbirths, neonatal deaths and brain injuries that occur during or soon after birth by 20% by 2020 and 50% by 2030, to ensure England is one of the safest places in the world to have a baby. This ambition is part of a wider 78 P a g e

80 government aim to reduce all avoidable harm by 50% and save 6,000 lives by It will form a key part of the work of the patient safety campaign; Sign up to Safety. Better Births, Improving outcomes of maternity services in England (2016) highlights the need for multi-professional working, breaking down barriers between midwives, obstetricians and other health professionals to deliver world-class safe, personalised care for women and their babies. As part of the ambition to halve maternal and perinatal mortality and intrapartum brain injuries, the Department of Health has identified a training fund for NHS maternity services to be administered through Health Education England (HEE). ULHT submitted a bid to the HEE and successfully received funding for maternity safety training. The Competencies for the PMA bridging module/shortened education programme are aligned with the five Care Quality Commission (2013) Key Lines of Enquiry. These five areas address the key priorities of every service, determine quality and identify risks. 1. Safety and quality improvement 2. Effective 3. Caring 4. Responsive 5. Well-led Of the 21 Supervisors of Midwives employed by ULHT, 10 Midwives have decided to become PMA s. All previous Supervisors wishing to undertake the new role of the PMA will have to a short bridging course. Any new midwife wanting to become a PMA will have to a full PMA course which is facilitated at university. PMA The Way Forward Plan at ULHT 31 st March rd July 2017 On Call Support The Supervisors of Midwives that were in post prior to the 31 st March 2017 are continuing to provide a 24 hour on call support service. This on call service is being maintained to ensure the safety of the units whilst a manager on call rota is being developed. The manager on call rota will go live on the 7 th August The A-EQUIP model is being introduced and discussed on the mandatory Midwives study day programme 2017/18 3 rd July 2017 November 2017 A Midwifery Advocate (MA) will be accessible Monday to Friday, to 17.00, for telephone advice and support, for women and their families and Midwives. A MA will be available 3 times per week, 9-12 covering Lincoln, Boston and Grantham maternity units. The MA will be available to offer appointments or drop in sessions. 79 P a g e

81 Within the 3 days, the MA will be involved in supporting the Golden Hour. This will involve: o Attending ward areas o 15 Steps is the ward tidy? o Is the ward welcoming? o Do staff smile and introduce themselves? o Are staff wearing the correct uniforms? o Are staff bare below the elbow? o Safety o Caring o Well led o Documentation Cardio Toco Graph (CTG) guideline compliance. MA s will hold monthly meetings and invite the Head of Midwifery and Nursing Women & Children (HOM/N) to attend. Provide a written report to the HOM/N quarterly. To attend and support the Sustainability and Transformation Plan (STP) Annual report to the: Trust Board Speciality Governance Business Unit Governance Attendance at the Trust Board meeting to introduce the A-EQUIP model and the role of the PMA. Produce a proforma to analyse trends in accessing MA support. Birth Afterthoughts service will continue, as this service is accessed regularly by women and their families. Some of the past Supervisors of Midwives have expressed their desire to continue in this role. Arrange to meet Midwifery Managers and Matron s to introduce the A-EQUIP model and the role of the PMA. Recruitment of further PMA s. Consider the role of a full time PMA. Angela Crosby / Louise Hugo June P a g e

82 Maternity Transformation Programme Communications and Engagement Plan 2017 Appendix 3 Background The National Maternity review Better Births report was commissioned in March 2015 by NHS England on behalf of the national organisations that had authored the NHS Five Year Forward View. It considered how maternity services needed to change to meet the needs of the population and set out a clear vision for safe and efficient models of maternity care, including safer care, joined up across disciplines, reflecting women s choices and offering continuity of care along the pathway. The report sets out 28 recommendations for Local Maternity Systems to implement, under the following 7 themes: Introduction This communications and engagement plan will outline the engagement to be undertaken within each of the 7 themes above. It is an evolving document and will initially focus on the first phase of engagement required with staff to inform them of what has been undertaken so far, engage them in the Better Births for Lincolnshire programme and to secure their involvement moving forwards. This plan will be updated with further details of the subsequent engagement phases described above once scoped Happened so far: Development of Local Maternity Systems (LMS) The review asked commissioners and providers to work together across areas as local maternity systems, with the aim of ensuring women, their babies and their families have equitable access to the services they choose and need, as close to home as possible. 81 P a g e

83 In response to this, the Lincolnshire Local Maternity System Group was established in September 2016, as recommended by the National Maternity Review, to ensure the delivery of these recommendations. By September 2017, Lincolnshire need to establish a shared vision and plan to implement the recommendations by the end of 2020/21. Community Hubs The Better Births Programme says the NHS needs to organise its services around women and families. Community hubs should be identified to help every women access services she needs, with Obstetric units providing care if she needs more specialised services. We have engaged with the public and professionals about the development of our Community Hubs through the following means: An online survey for both women and families and professionals A workshop attended by approximately 25 children s centre staff A workshop on 29th March attended by professionals and users of services Various other meetings with community midwives Which showed us: 247 responses from the public and 105 from professionals 87% of those surveyed believe that a community hub will bring positive change Half of professionals and one third of the public have some concerns about community hubs 51 members of staff that d the survey were interested in being more proactively involved in the shaping of future services All communications and engagement activities will be documented in the activity log at the back of this document. Our commitment to robust communications and engagement Section14Z2 requires CCGs to involve users in the development and consideration of proposals for changes in the commissioning arrangements We will ensure our engagement is: clear and concise meaningful and purposeful informative proportionate targeted with approaches that suit audiences needs Engagement approach throughout the project We are committed to undertaking engagement at every point of the project to ensure the systems and processes developed are built around the needs and aspirations of the service users and staff. This will result in more effective use of services, more personalised care and positive service user and staff experiences. The first phase of engagement will underpin the engagement required for each of the 7 sections of the Better Births for Lincolnshire Programme and enable key stakeholder involvement in the initial scoping of the project and subsequent support and involvement moving forward. 82 P a g e

84 Stakeholders should be identified at each stage and given appropriate opportunities for involvement with clear evidence of how their views have shaped each phase and shaped decision making. The following diagram outlines the phased approach to engagement and consultation and the purposes of this. An Equality Impact Assessment will also be undertaken to assess the potential impact on the nine protected characteristics covered under the Equality Act 2010 and engagement focussed with these groups as well as the population as a whole. Communications approach throughout the project We are fully committed to implementing a full round of communication at every point of the programme to ensure our colleagues, stakeholders and service users are kept up to date with the very latest developments. These will be engaging, entertaining and, crucially, informative using a range of methods such as briefings, s and press releases etc. Moreover, we will fully utilise the power of social media through our Facebook and Twitter channels predominantly. We are committed to communicating all messages through our Better Births Lincolnshire website from October, 2017, and using the media outlets to broadcast our messages to as big an audience as we can. This will result in more effective engagement events, more unity across the county in terms of reaching the same goal together and making colleagues, stakeholders and our patients feel a part of the project. 83 P a g e

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