The Local Supervising Authority Midwifery Officer s Annual Report April 2014 March 2015 Barbara Kuypers LSA Midwifery Officer Midlands and East (West) 1
Contents Introduction 3 The Nursing & Midwifery Council 3 The Midwives Rules & Standards 3 NHS England Local Supervising Authorities 3 3 The Midlands and East Profile The North and West Midlands Profile National Agenda s impacting on Maternity Services 4 6 9 The Ombudsmen s Report 9 The King s and Kirkup Reports 10 NHS England Review of Maternity Services 10 NMC - Re-validation 11 The NHS Mandate for Pregnancy Women and Personalised Care 12 The LSA Office 2014-2015 13 West Midlands Local Supervising Authority Annual Report 2014-2015 Process Prior to the Publication and Presentation of the Report Findings 15 Appointments, Resignations, Removals and Recruitment 16 LSA methods of communication with Contact & Supervisors of Midwives 21 Role and function of Supervision of Midwives 23 Examples of effective Supervision (Survey) Examples of Excellent Supervision of Midwives How women and service users have been involved with business of the LSA Evidence of engagement with Higher Education Institutions 30 Developing Trends Affecting Midwifery Practice in the LSA 31 Workforce 33 Workforce and Clinical Activity 37 Clinical Activity & Trends Perinatal and Maternal Mortality West Midlands LSA Audit for 2015-2015 Reports of Supervisory Investigations Undertaken During the Year Complaints regarding the discharge of the Supervisory Function Midlands and East Region Priorities for 2015-2016 Acknowledgement & Thanks 54 Appendices 24 28 29 40 48 49 50 52 53 Appendix 1 Appendix 2 3 Year Trends for West Midlands (Previous West Midlands Trusts) Self Assessment Against the Midwives Rules & Standards (LSA Standards only) 2
Introduction Nursing and Midwifery Council The Nursing and Midwifery Council was established under the Nursing and Midwifery Order 2001 as the body responsible for regulating the practice of both these professions. Articles 42 and 43 of the Order make provision for the practice of midwives to be supervised. The purpose of supervision is to protect the public and to support the enhancement and development of best midwifery practice. The local bodies responsible for the discharge of these functions are the Local Supervising Authorities (LSAs). The Midwives Rules and Standards (2012) This report enables the LSA to meet the statutory requirement of the NMC Midwives Rules and Standards Rule 13. (2012). The NMC has requested for this 2014-15 Reporting Year that the LSA s send their respective information via a Portal to the Mott McDonald Website and so this report is a narrative report written specially for the key partners and stakeholders of the Midlands and East (West) LSA. NHS England As of 1 st April 2015, the Regional LSA was split into Midlands and East, East and West. For Midlands and East (West), four Trusts previously with East Midlands were integrated as part of the North Midlands locality. These included: Nottingham Derby Chesterfield Sherwood.Forest Local Supervising Authorities The Local Supervising Authority (LSA) is responsible for ensuring that the statutory function for the supervision of midwives and midwifery practice is carried out to a satisfactory level, for all midwives working within its boundaries. The Midlands and East Regional Office of NHS England took over this function in April 2013 and continues with this function. The LSAMO s for Midlands and East meet regularly with the Director of Nursing and the wider Nursing Quality Team for the Region in order to keep updated with regard to the continued developments within NHS England. On receipt of the LSA Annuals Reports the NMC carry out an analysis of the information which is publicised annually: The most recent, Supervision, support and safety. Analysis of the 2013/14 LSA annual reports to the NMC can be downloaded from www.nmc-uk.org 3
Midlands and East Profile April 2015 NHS England Reconfiguration From April 2015, NHS England was reconfigured to four Regions: North of England Midlands and East of England South of England and London Figure 1: The four NHS Regions from April 2015 4
Midlands and East The previous eight Area Teams across Midlands and East were re-aligned into four localities. North Midlands: Derbyshire and Nottinghamshire & Shropshire and Staffordshire West Midlands: Central Midlands: East of England: Birmingham and the Black Country & Arden, Herefordshire and Worcester. Leicestershire and Lincolnshire & Hertfordshire and South Midlands East Anglia & Essex Figure 2: The four re-aligned localities across Midlands and East This report covers the period from 1st April 2014 to 31 st March 2015 and will discuss both midwifery and supervision of midwives activities within the respective Trusts and Universities that provide clinical care and education activities for maternity services in Midlands and East (West). 5
The North and West Midland Regions Hospital Trusts providing Maternity Services This report describes the maternity provision of services across the North Midlands and West Midlands NHS Trusts. North Midlands There are seven Trusts that provide maternity services within this locality. Nottingham has the largest obstetric facility working across two sites within the city. North Midlands NHS Trust merged with the previous Mid-Staffordshire Trust and all obstetric services re-located to the hospital at Stoke on Trent in January 2015 leaving a Midwifery Led Birthing Centre at Stafford. The Obstetric Unit at the Shrewsbury and Telford NHS Trust relocated from Shrewsbury to Telford in March 2015. Shrewsbury then remained with the Free Standing Birthing Unit, one of five within the Trust. West Midlands There are eleven Trusts providing maternity services within this locality. The largest Trust is the Heart of England with over 10,000 births across 3 sites, Birmingham and Sutton Coldfield and Solihull Midwifery Led Unit. Both, Walsall and Wolverhampton have also experienced an impact on their activity following the closure of the Maternity Service at Stafford with many women south of Stafford booking with Black Country Units. A number of Services consolidated their provision of Midwifery Led facilities having benefited from an allocation of funds from the Department of Health. Coventry, Walsall and Wolverhampton all increase the births occurring through their midwifery led environments. Worcester being the most recent Trust to complete its service redesign opened the Meadow Birthing Centre on the 13 th April 2015. Figure 3: The Meadow Birthing Centre Name Tree Maternity Provision in North and West Midlands 6
Trusts Obstetric Site Midwifery Led Units North Midlands Burton Burton 1 stand-alone at Lichfield Chesterfield Chesterfield Integrated Derby Derby alongside Nottingham Nottingham 2 alongside North Midlands Stoke on Trent 1 alongside & 1 at Stafford Sherwood Forest Sherwood Integrated Shrewsbury and Telford Telford 1 on Telford Site and 4 Free- Standing West Midlands Birmingham Women s Edgbaston 1 alongside City City Site Coventry Coventry 1 alongside Dudley Dudley 1 alongside Heart of England Birmingham and Sutton Coldfield Nuneaton Nuneaton Integrated Walsall Walsall 1 standalone Warwick Warwick Integrated Wolverhampton Wolverhampton 1 alongside 1 alongside and 1 standalone at Smethwick 1 alongside and 1 standalone at Solihull Worcester Worcester and Redditch 1 alongside at Worcester Wye Valley Hereford Integrated Table 1: Current Service Provision and Midwifery Led Units 7
Acute Trusts Providing Maternity Services 4. Birmingham Women s Healthcare NHS FT 5. Burton Hospitals NHS FT 8. Chesterfield Royal Hospital NHS FT 9. The Dudley Group NHS FT 10. Derby Hospitals NHS FT 12. George Eliot Hospital 13. Heart of England NHS FT 20. University Hospital of North Midlands (County Hospital Site) 24. Nottingham University Hospital NHS Trust 31. Royal Wolverhampton Hospital NHS Trust 32. Sandwell & West Birmingham Hospitals NHS Trust 33. Sherwood Forest Hospitals NHS FT 34. Shrewsbury & Telford Hospitals NHS Trust 38. University Hospital of Coventry & Warwickshire NHS Trust 39. University Hospital of North Staffordshire (Royal Hospital Site) 41. Walsall Healthcare NHS Trust 42. Warwick Hospital NHS FT 45. Worcestershire Acute Hospitals NHS Trust 46. Wye Valley NHS Trust Figure 4: Map of Trusts providing Maternity Services across Midlands and East (West) (Courtesy Health Education England) 8
National Agenda s impacting on Maternity Services The Ombudsmen s Report In response to the Parliamentary Health Service Ombudsmen s Report (PHSO) into the events at the University Hospitals of Morecambe Bay NHS Foundation Trust (published in 2013), the Nursing and Midwifery Council (NMC) accepted, based on the findings in the Ombudsman's report, the recommendations that that the framework for midwifery regulation and the structure for investigation and regulation needed an urgent review. The Ombudsmen set out two principles that should apply to a future model for midwifery. That midwifery supervision and regulation should be separated That the NMC should be in direct control of regulatory activity. She outlined her concerns and concluded: I am deeply concerned that the regulations allow potential muddling of the supervisory and regulatory roles of even the possibility of a perceived conflict of interest. Dame Julie Mellor: PHSO The LSA conducts an annual Self-Assessment Review for all Trusts with regard to the specific supervisory recommendations from the NMC Morecambe Bay Hospitals NHS Trust Review (2012) so that the LSA can benchmark progress and sustaining of the expected standards. All Trusts within West Midlands are monitored annually with regard to their compliance with these recommended standards. Figure 5: The 2013, Ombudsmen Report 9
The King s Fund Report 2015 The NMC as a result commissioned the Kings Fund to carry out a Review of the function of Supervision of Midwives and to consider making recommendations around public protection, proportionality and public confidence in the regulatory model. This report concluded in December 2014 and proposed that: The NMC as a health care professional regulator should have direct responsibility and accountability solely for the core functions of regulation. The legislation pertaining to the NMC should be revised to reflect this. This means that the additional layer of regulation currently in place for midwives and extended role for the NMC over statutory supervision should end. The Report in turn was presented to the Midwifery Committee at the NMC and also to the NMC Council in which both bodies accepted the recommendations. A plan will be put in place to facilitate this work but it is anticipated that the statutory function of Supervision Midwives will cease by the end of March 2017. The Kirkup Inquiry The English government had also launched its own investigation in to the events which had occurred at Morecambe Bay NHS Trust and this (Kirkup) Inquiry was published in March 2015. This Report again made recommendations to the NMC to proceed without delay regarding the recommendations of the King s Fund Report. Announcing the Report s findings Dr Bill Kirkup said: All health care everywhere includes the possibility of error. The great majority of NHS staff know this and work hard to avoid it. They should not be blamed or criticised when errors occur despite their efforts. But in return, all of us who work for the NHS owe the public a duty to be open and honest when things go wrong and most of all to those affected, and to learn from what has happened. This is the contract that was broken at Morecambe Bay. NHS England Review of Maternity Services Finally, both the Kirkup Inquiry and NHS England 5 Year Plan concurred with each other and recommended that there should be a National Review of Maternity (and Paediatric) Services. The report should make recommendations regarding the provision of such services in rural and isolated or difficult to recruit to areas. Baroness Julia Cumberlege was announced to lead the Review which will report in December 2015. 10
Re-validation From April 2016, the NMC will implement the process of re-validation for all registrants as a mechanism to re-register in their respective professions. All nurses and midwives are currently required to renew their registration every three years. Revalidation will strengthen the renewal process by introducing new requirements that focus on: up-to-date practice and professional development reflection on the professional standards of practice and behaviour as set out in the Code, and engagement in professional discussions with other registered nurses or midwives. Revalidation is about promoting good practice across the whole population of nurses and midwives. Revalidation will give greater confidence to the public, employers and fellow professionals that nurses and midwives are up to date with their practice. The purpose of revalidation is to improve public protection by making sure that nurses and midwives continue to be fit to practise throughout their career. Nurses and midwives should stay up to date in their professional practice. Revalidation provides nurses and midwives with the opportunity to reflect on their practice against the standards in the Code and so demonstrate that they are living these standards. Figure 6: The model of Re-validation to be introduced from April 2016 11
The NHS Mandate for Pregnant Women & achieving Personalised Care The NHS England also made a commitment for women attending for NHS care and these include to: Offer women the greatest possible choice of providers Ensure every woman has a named midwife who will make sure she has personalised, one to one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who had maternal health concerns. Reduce the incident of and impact of postnatal depression through earlier diagnosis and better intervention and support. Recommendation of Services via Friends and Family test. Health Education England (HEE) as part of its own mandate is working to support the multi-disciplinary workforce in achieving these and facilitated 5 consultative Events during the Spring of 2014 to explore the long term vision for maternity care up to 2022 and to consider the academic requirements needed to be put in place by the Higher Education Institutions to assist services reach their visions. The Report of this work will be published later in 2015. Fig 7: The Personalised Maternity Care Project (HEE) 2014 12
The 2014-2015 Supervisory Year Business Continuity & LSA Office Administration: The LSA Office is part of the Nursing and Midwifery Directorate of NHS England Midlands and East (West). The West Midlands LSA Team comprises: 1 wte: LSA Midwifery Officer Barbara Kuypers 1 wte: LSA Administrator Lisa Wilkes 0.6wte LSA Project Midwife Ann Kingscott The role of the LSA Project Midwife was permanently agreed to be part of the LSA establishment and December 2013. The role has been pivotal in supporting the LSAMO during the Audit Cycle, advising Supervisors of Midwives undertaking Supervisory Investigations and also taking the lead in facilitating a the LSA Events Calendar The role of the LSA Administrator has also encompassed supporting the LSA Audit Calendar, assisting in the preparation for the PoSoM Selection processes, LSA Web communications and preparing the LSA Surveys for each respective Trust as well as across the LSA for both East Midlands and East of England. (From April 2015, LSA Midwife Jane Turnock and LSA Administrator Pam Swift from the Est Midlands LSA Office worked across both the Midlands and East Region. LSA Database: The LSA Data-base was commissioned for the West Midlands in 2008. Use and engagement with the database has improved year on year. The LSA Database is now integral to the business of the LSA and training for new Supervisors of Midwives occurs biannually on the LSA Preceptorship days and is also part of the final day of the POSOM Programme. These sessions are facilitated by the LSA administrator Lisa Wilkes. The West Midlands LSA uses the database: To Upload ITPs For archive of Supervisory Reviews For archive of PREP Evidence For Notification of Maternal Deaths For Notification of Maternity Unit Suspensions of Service For Collation of Workforce and Clinical Statistics The West Midlands LSA has never used the LSA Database as a vehicle to be notified of Supervisory Investigations by respective Trusts or to archive Supervisory Investigations. 13
LSA Website: Requests were made by the Supervisors of Midwives for access to a West Midlands LSA Website and work was put in place to look at the design and content for such a facility. Midwives and Supervisors contribute to what items they would want to locate from the site to assist them in their role. The website is managed by the LSA administrator Lisa Wilkes. The site www.lsa.westmidlands.nhs.uk provides the following services. Home Page with key link information Contact Us and Introduction to the LSA Team and Office locality LSA Events Calendar which provides study day information and enables bookings via the website An extensive publications and documents library which includes Power Point Presentations which the Trusts can access themselves Links to the LSA Database Links to key West Midlands Trusts and National organisations such as the NMC and RCM Link to PoSoM Ballots Electronic Surveys and Data archive for Trusts Additionally the site is used to host: Electronic Surveys for LSA Audits Electronic Surveys for adhoc Trusts Reviews The LSA Audit for 2009-2010 and 2012-13 involved an Electronic Survey which was split in to two parts: One for access by midwives and the other for Supervisors of Midwives. As the surveys were accessed via the LSA website, this increased the exposure to the site and has raised the profile and work of the LSA. Additionally, for those Trusts that commission Reviews of Services, the Electronic Survey is part of the methodology by which midwives can express their views anonymously. The survey questions are usually bespoke to the Trust and have specific additions around the working culture and practices of the midwives working environment and so have greatly increased the numbers of midwives that would otherwise not have access to the Review team. Twitter The West Midlands LSA in 2013 also opened a Twitter Account @LSAWestMidlands 14
The West Midlands LSA Annual Report 2014-2015 Process prior to Publication and Presentation of the Report Findings An Executive Summary of this Report was provided and approved by the Midlands and East Regional Board for July 2015. For the Supervisory Year 2014-15 the NMC has requested all LSA s to submit their Annual Reports via a Portal Route with Mott McDonald who now hold the contract for the collation of LSA information on both a quarterly and annual basis. The West Midlands LSA has following consultation with Directors of Nursing, Heads of Midwifery, Lead Midwives for Education and Contact Supervisor of Midwives decided to continue with a narrative report which will detail the background, context and clinical outcomes across the maternity units that submit data to the LSA. This report with a letter of introduction will then be disseminated in electronic format to all: Acute Trusts, Clinical Commissioning Groups Lead Midwives for Education and respective Universities Course Leaders for the Preparation of Supervisors of Midwives Programme. The Perinatal Institute Finally the report will be placed on the West Midlands Local Supervising Authority Web Site www.lsa.westmidlands.nhs.uk. There is a link to the National LSAMO s Forum Web site at www.lsamoforumuk.scot.nhs.uk and also to the Birmingham City University Moodle Website which provides curriculum details for the Preparation of Supervisors of Midwives Programme at www.bcu.uk.org The content therefore should meet with the wider expectations of key stakeholders such as providers, commissioner s educationalists and users of maternity services. The report holds additional clinical activity information and workforce trends and these tabulates can be found integral to the report and as appendices. The contextual narrative and information regarding clinical outcomes and workforce data, is intended to be utilised and resourced by all readers to assist in furnishing in-house reports, reviews and support curriculum activities in universities. Finally, the document should assist in assuring the public that the framework of supervision of midwives does protect mothers and babies by ensuring excellence and best practice amongst midwife practitioners. The electronic submissions to the Trusts will as always occurs, be accompanied by a series of Power Point Slides that can be used for internal purposes either to support ongoing business cases as well as increasing awareness with regard to Supervision of Midwives and the function it provides for the safety and well being of women and their babies. 15
Supervisor of Midwives appointments, resignations, removals & recruitment. 2012 2013 2013-14 2014-15 Number of Supervisor of Midwives 234 255 260 ITP s received throughout year via LSA database 3388 3507 3531 New Appointments 12 22 11 Resignations or Retirements 11 13 21 Sabbaticals 4 6 1 Removals 0 0 0 Ratio of Midwives to SoMs across LSA 14 15 15 Table 2: Demonstrates the number of designated Supervisors of Midwives on 31 st March 2015 with comparators against a three year trend. (Previous West Midlands Only). Recruitment Strategy and Ratios. Although the pro-rata ratio indicates within the LSA and within most Trusts the standards of one Supervisor having a caseload of no more than fifteen midwives appears to be met. In reality this is not often the case with many supervisors carrying caseloads of over 20 midwives. In this instance, it is often due to newly appointed supervisors carrying lesser caseloads whilst they are establishing themselves to the role or midwives exercising their choice to remain with Supervisors who then continue to carry larger caseloads than necessary. In some circumstances, the LSAMO has indicated to the respective Trusts where the aspect of caseload selection could be more actively managed and so asked for an internal ballot in order to create some equity amongst the supervisory teams. The ratio of midwives to Supervisor of Midwives is additionally monitored monthly by the regional Director of Nursing. Trusts that carry a pro-rata ratio of over 1:20 have been invited to proceed with an interim contingency plan asking retired Supervisors to rejoin the team for the 2013/14, supervisory year, this also includes a Supervisor retired from a different Trust in the LSA. Here some Supervisors still carry a caseload of nearly 30, the Head of Midwifery commit to 2 days a month each for the respective supervisors in order for them to carry out their function. Each Trust has a Supervisor of Midwives notice board so that staff can be notified of supervisory business and be alerted to future ballots. Supervisors also discuss with midwives during their annual reviews if they feel them appropriate for the role if they would consider placing themselves forward. 16
POSOM Selection Panels The Preparation of Supervisors of Midwives Programme (POSOM) is hosted with Birmingham City University for West Midlands. There are opportunities for up to 32 midwives to take up the programme once they have been through their nominations and ballot as required by the Standards for Preparation of Supervisors of Midwives (NMC2014) within their Trusts. Once there are submissions for the programme by the Trusts, a series of selection panels are held during the spring and autumn of each year. This enables the LSAMO and the Programme Leader to meet and advise the nominees regarding the requirements of the programme. Joining the LSAMO and Programme Leader on the Selection panels is a Supervisor of Midwives, a Head of Midwifery and a Lay Representative thereby meeting the NMC standard. The panels have evolved from each applicant making individual presentations and interview discussion to a group session whereby applicants present to each other, thereby encouraging debate amongst the group. The selection panels have been very successful and are very informative in demonstrating how well prepared the candidates are for their future studies. Birmingham City University also hosted its first Masters Degree cohort in September 2011 and have continued with students at master s level within each annual cohort. The Preparation of Supervisors of Midwives Programme (PoSoM) Each of the students undertaking the programme has a supervisor of midwives as a mentor. Similarly to the sign off mentor for pre-registration student midwives, they are invited for a half day workshop in order to refresh their knowledge of the curriculum and introduce them to the website if they have not mentored a student supervisor for a while. The students, during the programme present a case study that demonstrates their learning and either the LSAMO or a Link Supervisor attends these sessions along with the mentor for the student supervisor. This forms part of the course assessment requirements With the introduction of the LSA Database and LSA website, the LSA Administrator also has a teaching session scheduled within the timetable of the programme. Each day of the programme is evaluated and this feedback allows the lecturing team to implement any changes or additions are made to the programme as required. The Birmingham City University Moodle Website provides curriculum details for the Preparation of Supervisors of Midwives Programme at www.bcu.uk.org. This website and E-Learning methodology has been presented at various midwifery conferences and has always been very well evaluated. The LSAMO attends the selection panels, teaches during the introduction week and also attends the student assignments. 17
Appointment to the Role. Once qualified, the NMC are informed by the course leader and on final approval by the respective Trust Supervisory Team, midwives are then appointed formally by the LSA. Preceptorship for newly appointed Supervisor of Midwives All newly appointed Supervisors of Midwives are invited back to meet with the LSAMO at six months or a year post appointment. Each year, the LSA facilitates 2 Pre-ceptorship workshops for newly appointed Supervisors of Midwives. The agenda includes a workshop on conducting a supervisory investigation and re-introduction to the LSA website and database, a session lead by the LSA Administrator. Topics of discussion include: Mentorship support from peer supervisory colleagues Shadowing supervisory investigations Shadowing supervisory annual reviews Taking up their own caseload of supervisees Contributions to policy reviews within their Trust. (CQC etc) Issues brought to their attention during on calls or during shifts Mediation or problem solving The day evaluates very well giving assurance to the Supervisors of Midwives as they consolidate and mature in their role. Remuneration for the role of Supervisor of Midwives Following raising the profile of Supervision across West Midlands by the LSA, all Supervisors of Midwives from all of the West Midlands Trust providing maternity services now receive a remuneration package, this also included midwives not employed directly by the services such as midwives working in education for instance. However, the issue of remuneration and the size of the individual caseloads for Supervisors of Midwives is not indicative of individual or group performance in their role. Of stronger significance is the model of engagement that supervisors have with the management team and in particular with the Head of Midwifery and how inter-grated the philosophy of supervision is with the service ambitions and governance framework of the Trust in general. 18
Supervisor of Midwives and Midwives Ratio s TRUSTS Supervisor Head Count Midwives Head Count RATIO 2013 RATIO 2014 RATIO 2015 North Midlands Burton 13 152 12.5 12.0 14.0 Chesterfield 6 129 14 22.0 22.0 Derby 16 269 17 20.0 18.0 Nottingham 23 523 15 23.0 22.7 North Staffordshire 24 348 14.2 12.2 14.5 Sherwood Forest 9 146 16 16.1 16.2 Shropshire & Telford 19 308 16.3 14.5 16.2 Total 110 1875 15.6 17.8 17.04 TRUSTS Supervisor Head Count Midwives Head Count RATIO 2013 RATIO 2014 RATIO 2015 West Midlands Birmingham Women s 20 414 17.05 18.0 20.7 City 19 277 14.05 12.6 14.5 Coventry 19 289 12.8 13.2 15.2 Dudley 16 189 12.0 10.29 11.8 Heart of England 29 523 17.03 17.6 18.0 Nuneaton 6 99 10.0 16.0 16.5 Walsall 11 197 20.0 14.2 17.9 Warwick 12 150 14.1 15.4 12.5 Wolverhampton 17 226 8.95 9.3 13.3 Worcester & Redditch 18 315 16.8 16.9 17.5 Wye Valley 10 127 13.7 11.1 12.7 Total 177 2806 14.4 15 15.8 GRAND TOTAL 287 4681 14.8 17.0 16.3 Table 3: Demonstrates the ratio of Midwives per Supervisor with each Trust, and the ratio for the whole LSA. In addition provides numbers of midwives with Universities and the West Midlands Perinatal Institute. 19
Continuous Professional Development and Maintaining Supervisory PREP All Supervisors of Midwives must maintain their own Supervisory PREP requirements of six hours each supervisory year. The LSA Office facilitates a calendar of study days and events hosted throughout the sector. Attendance is noted to ensure that each Supervisor of Midwives meets this standard annually. Each Supervisor of Midwives is additionally asked to submit a supervisory activities form annually to the LSA and this also asks for evidence of PREP compliance which is then confirmed with the LSA s own attendance lists. The West Midlands LSA Events Calendar: The LSA Events Calendar is reviewed annually in discussion with Heads of Midwifery, Contact Supervisors of Midwives and Lead Midwives for Education. All events are evaluated and these help to devise future themes. The total funding for the LSA Events Calendar is approximately 60,000 and this pays for venue, catering and publication costs. All of the events on the calendar are free to the delegates. There are key elements to the Events Calendar and include: Bond Solon Events These study days are very popular and attended by Supervisors and Midwives who wish to improve their statement and report writing skills. Study days are also provided discussing Accountability and this is particularly useful for midwives who need to improve their insight around their responsibility to women and to their role whilst working in a multiprofessional team. Conducting a Supervisory Investigation The Events Calendar hosts a series of 1 day workshops across the year, but also during 2014-15, the LSA facilitated a day workshop at each Trust so that every Supervisor of Midwives appointed within the LSA could access this day. This has been important in raising the standards of investigation and also in meeting the requirements of Rule 10 of the Midwives Rules and Standards 2012. Home Birth and Midwifery Led Unit Study Days The LSA began hosting this event as Maternity Services were successful in winning their bids with the Department of Health in order to enhance their birthing facilities for midwifery led environments. Speakers are invited from across England so that various models of care and successful projects can be explored. The births in MLU s across the West Midlands now amount to 12% of all births occurring in the region. 20
New Supervisors of Midwives Review Workshop This event is hosted twice a year and is a follow up day for new Supervisor of Midwives who have been appointed in the previous 12 months. The day enables discussions which explore their experiences as they consolidate in their role and gives advice and guidance with regard: Managing a caseload of Supervisees Conducting the Annual Review Debriefing midwives following untoward events Proceeding with a Supervisory Investigation Challenging poor practice Supporting women with birth choices Supporting midwives attending complex births at home Each Study Day is evaluated and here below are some of the comments and feedback to the LSA. Excellent, all my expectations were met Bond Solon Event Statement & Report Writing Excellent Fascinating to hear different approaches across the Region Midwifery Led Unit Event Excellent Day. Full of productive and relevant information. Great overview of Kings Fund Report New Supervisors Review Workshop Future study events for 2015-2016 will include workshops on Re-validation and also how to support midwifery practice in the future once statutory Supervision is not in place. 21
LSA methods of communication with Contact & Supervisor of Midwives For formal business the LSA holds four meetings annually with Link and Contact Supervisor of Midwives. Lead Midwives for Education are also invited to these meetings as well as the current POSOM students. Heads of Midwifery can also attend if they wish as the meeting is not exclusive. The standard agenda items include: Welcome Minutes of the previous meeting. Matters Arising -to be addressed within the Agenda Education POSOM Cohorts and future Selection Panels Induction Day for new Supervisors of Midwives Events Calendar Independent Midwives Event General Update LSA Project Midwife Serious Untoward Incidents Investigations Update Practice Forums Supervisory Investigation Workshops LSA Business Audit Calendar and methodology Database and Website Monthly and Annual Statistics Future of the LSA within NHS England NMC - Midwives Rules and Standards 2012 DoH - CNO Vision and 6Cs NHS Mandate for Pregnant Women Francis Inquiry Kirkup Inquiry (Morecambe Bay) Any Other Business Maternal Death Events Maternity Unit Closures Personalised Maternity Care Round Table The Contacts then cascade information back to their respective supervisory team at their monthly meetings. The LSA would also send out the minutes of these meetings by Email and indicate if these are to be disseminated on to the whole supervisory team. The LSA has contact details for all Supervisor of Midwives and most contact with the LSA office is either by telephone or email. 22
Dissemination of Information and access to the LSA Midwifery Officer Information from the LSA is shared via a number of mechanisms. Face to face group and individual meetings with: Contact Supervisor of Midwives Heads of Midwifery Lead Midwives for Education PoSoM students and their mentors Directors of Nursing from provider and commissioning Trusts Additionally, all Supervisor of Midwives would have an opportunity to meet with the LSAMO during their Annual LSA Audits and during Educational Events which are often used as further forum to share information. Information is also shared via the LSA website www.lsa.westmidlands.nhs.uk which provides links to various other stakeholder organisations and to PowerPoint Presentations introducing topics presented from the Events Calendar and also new items such the findings of the Kings Fund Report and the Kirkup Inquiry. Many Supervisors are in frequent touch with the LSA Office for various reasons as indicated below. Supervisors Survey: Slide 3 Ensuring consistency with regard to how the supervisory function works The supervisory function is facilitated via a portfolio of activities. Midwives rules and standards 23
Role and Function of Supervision of Midwives The new Midwives Rules and Standards (2012) describe in Rule 12 how the practice of midwives is supervised. Supervisors of Midwives supervise midwives by: Receiving Intention to Practise forms and submitting to the LSA Providing 24 hour access for midwives to a Supervisor of Midwives Providing 24 hour access for women to a Supervisor of Midwives Providing opportunities for midwives to have their Annual Supervisory Review To agree development plans to support a midwives experience and growth in competency To investigate supervisory investigations following critical incidents or evidence or poor practice by a midwife To put in place a developmental support programme, or if required a Supervised Practice Programme To provide strategic leadership for excellent clinical practice in order to ensure the public are safeguarded and protected. Details of how midwives are provided with continuous access to a supervisor of midwives All units are aware of the requirement to provide 24 hour access to a supervisor of midwives for both midwives and for women. All services within West Midlands now provide an on-call rota which is accessed either via the maternity wards or the hospital switchboards. During the practice year, the LSA undertook concurrent audits of access to a supervisor of midwives to ensure that women who wanted to speak to a Supervisor or midwives requiring advice in emergencies, particularly at sites away from the main unit, are not left waiting for advice or guidance beyond 15 30 minutes. During the LSA Audit visits to the Trusts, no complaints or indicators of concerns were made by midwives regarding access when meeting with the audit team. Most midwives contact their Named Supervisor of Midwives either by email or by telephone as each respective midwife would have had a letter from their Named Supervisor of Midwives explaining the best way to contact them. Many midwives use this direct mechanism and would only sue the switchboard during an emergency when the midwife themselves are away from the hospital. During the 2013 LSA Survey, 75% of midwives considered their Named Supervisor of Midwives to be very accessible followed by 20% who felt they were somewhat available. No midwives indicated that their Named Supervisor of any Supervisor was not available to them in an emergency. 24
Midwives Survey: Slide 2 Midwives Survey: Slide 3 25
Details of how the practice of midwives is supervised The Annual Review There has been a growing philosophy of a pro-active model of supervision across West Midlands. The Annual Reviews usually include discussions around practice ambitions, debrief following complex cases, self audit of records, meeting of PREP requirements, clarifying issues around duty of care and achieving competence and confidence in all aspects of practice. Although most supervisors meet with their midwives one to one, there are additional opportunities such as group supervision which appear to be increasingly taken up. With time, midwives feel more confident to bring evidence to their Reviews to demonstrate how their practice is evolving. The Supervisors also encourage midwives to archive their PREP evidence in electronic portfolios and to vary their evidence by using teaching tools such as those hosted by the Royal College of Midwives, ifolio and ilearn. All of the West Midlands Supervisors now archive the Annual Reviews on the LSA Database. At the time of the Mott McDonald Review during the Spring of 2015, The LSA assessed how many midwives had undertaken their Annual Review and had the Review archived on the LSA Database. Over 97% were found to be meeting this standard. The remaining 3% were newly qualified midwives who had only recently taken up new posts with their employers. Although many of these had met with their Named Supervisors of Midwives as part of their induction, these meetings were not regarded to be Annual Reviews. Midwives Survey: Slide 5 26
Midwives experience of Supervision of Midwives The 3 leading descriptors by midwives of the work of Supervisors of Midwives included: Supportive Advocate Advisory Other supporting descriptions included, leading, guiding and pro-active. For some midwives, Supervision enables a mechanism and safe haven following a serious incident when the midwife may have a protected period of time to reflect and recover her practice if this is required. Very few midwives consider Supervision as a punitive tool and this is demonstrated throughout the survey results. Midwives Survey: Slide 6 27
Evidence about how the LSA has improved care to women and enhanced and supported the practice of midwives. The LSA in West Midlands works to support both women, midwives and supervisors of midwives by using a variety of methodologies which include; The LSA Annual Audit The LSA Events Calendar The LSA Survey Presentation of Case Reviews at PosoM and Practice Forums. The LSA has also supported facilitation of new information and innovations acting as a conduit for both national and regional stakeholders. A key objective outlined by the NHS Mandate for Pregnant Women includes the supporting of choice for women. This includes choice of hospital and choice of place of birth. This can on occasion require the Supervisors of Midwives to act in order to enable informed choices for both women and the midwives providing care. Supervisors Survey: Slide 7 28
Examples of Excellent Supervision of Midwives Supporting women who make Home Birth choices with complex births. There has been a significant emphasis within West Midlands for Supervisory Teams to support women who make the choice of birthing at home whom also have complex medical or obstetric histories. In most instances, an obstetrician would be made aware and increasingly are making referral for the mother and partner to meet with a Supervisor of Midwives and their Named Community Midwife to discuss how their home birth would be supported. Care and Escalation Plans are then mutually agreed and shared throughout the respective unit and with the West Midlands Ambulance Trust. Cases have included: Home Birth Twins Home Birth after previous Caesarean Section Home Birth after loss of confidence in hospital provision Home Birth without active monitoring Home Birth chosen with complex family and social structures Listening Service for women following difficult birth experiences. All Trusts have a provision in which many of the Supervisors provide a de-brief or listening service for women (with their partners or any other friend or family member), who have had difficult or complex births. Usually referral occurs following the post-natal discharge or when women re-book with the service with a subsequent pregnancy. Appointments can be made to meet women at home or at the hospital. On occasion, walk-throughs have been arranged for women who had brief admission to intensive care units and do not recall the episode of care but need resolution with regard to their experience. Information with regard to Listening Services are placed on posters throughout the units and placed in discharger letters. For some Trust s, the facility has impacted and reduced the numbers of complaints that the service received. LSA Practice Forums The LSA also as part of its Events Calendar holds two Practice Forum Events each year and are facilitated by the LSA Link Supervisor for Education, Toni Martin. It is expected that each Trust nominate a Supervisor to present a case in which Supervision has been pivotal in supporting midwives in their practice and supporting women with their choices. They are excellent opportunities for Supervisors to exchange their views and discuss their experiences around managing extra-ordinary cases. The feedback from these events is always excellent. 29
How women and service users have been involved in monitoring supervision of midwives and assisting with LSAMO with the annual audits and other LSA business. Training Workshop The West Midlands LSA Midwifery Officer welcomes the role of mothers, fathers and lay user groups in the work of the LSA function. Requests are made to all Trusts to forward names and contact details of members of the public who would like to participate in LSA activities. Those that express interest are invited to attend an annual workshop in to explore and decide how they could be involved in the business of the LSA and to prepare them for their involvement in LSA business. Audit Visits The LSA Audit Cycle as defined in Rule 13 of the Midwives Rules and Standards (2012) has as a best standard, the inclusion of parents or lay representative as a member of the audit team.. The inclusion of a Lay Auditor is dependent on the Audit Theme and due to the nature of the Audit Process during 2014-2015 regarding Enhancing standards of Supervisory investigations a lay auditor was not included in this years process. POSOM Selection Panels A lay member is also invited as a participant to the selection panels for midwives nominated and balloted to undertake a Preparation of Supervisors of Midwives Programme. All of the selection days held during the 2014-2015 supervisory year had a lay or user representative as part of the panel. Opportunities to shadow within Maternity Services A number of the user representatives involved with the LSA have suggested time working alongside midwives with in the region. One placed her request with a local Trust and had an opportunity of working alongside midwives as a doula for a week. She found this highly beneficial and spoke about her experience at the Annual LSA Conference Event Conference and Speaking events Parents, doulas and user representatives have been invited as speakers and as members of the audience to various LSA and workforce deanery maternity study events. LSA Supervisory Service Reviews Two lay users have been a member of the visiting team involved in LSA Review of services. One of the Lay Members has participated as external advisor during an Appeals Process and her comments were pivotal to the LSA response. 30
Evidence of engagement with higher education institutions in relation to supervisory input in to midwifery education. There are six universities that provide midwifery education in West Midlands. These are: Keele Mid-Staffordshire Wolverhampton Birmingham City Coventry Worcester Communication and Liaison gaining and exchanging information The LSAMO meets with the Lead Midwives for Education (LME) as part of the Links & Contact meeting which occurs four times a year. The LMEs have standing items on the main agenda. This enables the issues of education to be integral to the business of supervision that are discussed during these meetings. This allows for cross fertilization of ideas and theories assisting in increasing the opportunities for further development within the Trusts with regards to how supervision and the clinical environments for student learning are enhanced. Pre-registration Midwifery Training All six Universities provide three year direct entry midwifery training with three providing the 18 month pre-registration education. Each supervisory group has a named supervisor of midwives that assists in curriculum planning with each university. This may require them for instance, to attend interviews in order to select students for the pre-registration programmes. In addition, to ensure and assist in the allocation of a supervisor of midwives to each student cohort is provided with detailed information regarding access to local and education supervisors; this may include having a named supervisor, in order to provide supervisory support and contact during the midwifery training. Supervisors of Midwives are also invited to attend Fitness to Practise Panels at respective universities in the event of students failing to meet course requirements. In this way the LSA is kept informed of students who do not complete the programme. All of the supervisory teams are encouraged to have student midwifery education as a standing item in their supervisory meetings. Assuring the Learning Environments for Student Midwives Various methodologies are used to enable an avenue for students to discuss concerns they may have regard the quality and safety of their learning environments. They may discuss issues of concern with the Trust University Tutor or with their Named Midwife for their respective cohort. Many of the Trusts have protected sessions for student midwives to meet with Supervisors of Midwives in which they can debrief from any experiences that they have found challenging. Issues of concern can then be escalated to the Head of Midwifery and the Lead Midwife for Education or directly to the LSA although this has never actually occurred. 31
Developing trends affecting midwifery practice within the LSA This section of the report describes trends around workforce issues and also clinical activities and outcomes. The following tables denote Trusts and those services that have a portfolio of site and service provision. The data-sets have been collated either via the LSA Database or via the Data Sets submitted to the LSA Website and validated by Contact Supervisors of Midwives and also the Heads of Midwifery at each Trust. The Head of Midwifery role Midwives who hold Head of Midwifery roles often have combined responsibilities with other posts within NHS Trusts. Some Heads have responsibilities for Gynaecology, Neonatal and Children s Services. This is not an unusual portfolio for heads of the profession. Some of the heads also hold General or Business Manager responsibilities or a Clinical Director function in which they also hold the business component for the physician workforce. Additional coresponsibilities include, Breast Surgery and Oncology Services. All but one of the Heads of Midwifery has been trained as a Supervisor of Midwives and work alongside their respective teams during their activities and strategic planning. Specialist Roles This spectrum of skills development and expertise that is being established across the sector also provides challenges for Supervisors of Midwives in giving advice and guidance to midwives who are developing expert and autonomous skills. Increasingly, Supervisors are bringing similar types of practitioners together and facilitating group supervision sessions as part of their methodologies that enable midwives to access their Named Supervisor of Midwives. Of note are the numbers of midwives involved in Sonography, with one Trust for example with all ultra-sound appointments being carried out by midwives. There are increasing numbers of midwives having undertaken the programme for Neonatal Examination that practice in this role in at least one shift each week as part of a rota. 3 Year Trend: Maternity Services continue to evaluate the workforce requirements for their services often commissioning a Birth-rate Plus Review to provide data to equip services to forward plan their establishment requirements according to the dependency trends within their populations. Increasingly there is evidence of women with complex medical care needs requiring early obstetric support in their pregnancies and as a consequence maternity services targeting midwife specialist posts in order to provide additional support for such women. In addition, nurses are increasingly appointed to lead areas such as high dependency care suites as well as caesarean section post surgical care. 32
Workforce Prospective retirement patterns In the West Midlands 1325 midwives (29%) are over 50 and could take retirement in the next 5 years. 530 midwives (11.6%) have chosen to work beyond 55 despite being eligible to retire. Most likely these midwives are working part time. It will be useful to monitor the take up of retirement and resumption of part time hours in this age group. Given the changes around NHS Pensions and deferred retirement age, it is anticipated that the over 55 age group will continue to grow. It is recognised that this will retain within the NHS an increased number of midwives who are experienced in their practice, however, it is also likely that this age group of midwives will move to part time working and may have difficulty working extended 12 hour shifts. Midwives who experience deteriorating health and fitness may have prolonged periods of illness which again impact on service provision. Age Number of Midwives Percentage of Total Under 21 0 0.0% 21 to 25 325 7.1% 26 to 30 480 10.5% 31 to 35 533 11.7% 36 to 40 533 11.7% 41 to 45 583 12.8% 46 to 50 790 17.3% 51 to 55 795 17.4% 56 to 60 397 8.7% 61 to 65 108 2.4% Over 65 25 0.5% Total 4569 100% Table 4: Age Profile 33
TRUSTS FUNDED SMP W.T.E. FUNDED 8D W.T.E. FUNDED 8C W.T.E. FUNDED 8B W.T.E. FUNDED 8A W.T.E. FUNDED 7 W.T.E. TOTAL WTE North Midlands Burton 0.00 0.00 1.00 0.00 2.00 1.20 19.20 Chesterfield 0.00 0.00 1.00 0.00 1.00 6.40 8.40 Derby 0.00 0.00 1.00 0.00 2.00 7.85 10.85 Nottingham 1.00 0.00 0.00 0.00 4.00 6.00 11.00 North Midlands 0.00 0.00 1.00 2.00 3.00 4.00 10.00 Sherwood Forest 0.00 0.00 0.00 1.00 3.00 5.52 9.52 Shropshire & Telford 0.00 0.00 1.00 1.00 4.00 21.37 27.37 Total 1.00 0.00 5.00 5.00 19.00 52.34 96.34 TRUSTS FUNDED SMP W.T.E. FUNDED 8D W.T.E. FUNDED 8C W.T.E. FUNDED 8B W.T.E. FUNDED 8A W.T.E. FUNDED 7 W.T.E. TOTAL WTE West Midlands Birmingham Women s 0.00 0.00 1.00 0.00 5.00 0.00 6.00 City 0.00 1.00 0.00 0.00 2.00 0.00 3.00 Coventry 0.00 0.00 1.00 0.00 4.00 4.00 9.00 Dudley 2.00 0.00 0.00 0.00 1.00 2.00 5.00 Heart of England 0.00 1.00 0.00 3.00 10.00 10.34 24.34 Nuneaton 0.00 0.00 1.00 0.00 1.00 0.00 2.00 Walsall 0.00 0.00 1.00 0.00 3.00 7.80 11.80 Warwick 0.00 0.00 1.00 0.00 2.00 4.80 18.49 Wolverhampton 0.00 0.00 0.00 1.00 2.00 6.70 9.70 Worcester & Redditch 0.00 0.00 1.00 1.00 3.00 0.60 5.60 Wye Valley 0.00 0.00 1.00 0.00 3.00 6.06 10.06 Total 2.00 2.00 7.00 5.00 36.00 42.30 104.99 Grand Total 8.43 2.00 12.00 13.00 55.00 150.70 201.33 Table 5: Demonstrates the number of midwives working in managerial or specialist roles Bands 7-9 34
TRUSTS MIDWIVES W.T.E North Midlands NURSES WTE HCA/MCA WTE Burton 113.53 0.00 30.99 Chesterfield 97.31 0.00 20.57 Derby 187.46 0.00 61.75 Nottingham 378.50 0.00 99.82 North Midlands 225.86 5.40 61.55 Sherwood Forest 110.63 0.00 32.74 Shropshire & Telford 171.32 0.00 87.57 Total 1284.61 5.40 394.99 TRUSTS Birmingham Women s City Coventry Dudley Heart of England Nuneaton Walsall Warwick Wolverhampton Worcester & Redditch Wye Valley MIDWIVES W.T.E West Midlands NURSES WTE HCA/MCA WTE 286.96 0.00 68.00 219.17 0.00 47.38 186.46 0.00 50.90 150.66 0.00 53.47 362.52 2.84 122.86 74.55 1.00 16.57 149.60 4.44 40.70 94.20 0.00 23.80 138.87 4.40 50.62 211.98 0.00 56.97 69.13 0.00 14.29 Total 1944.1 12.68 545.56 Grand Total 3228.71 18.08 939.43 Table 6: Demonstrates the total staff of midwives, nurses and non-qualified staff working in Maternity services giving direct care to women and babies. 35
TRUSTS CONS BAND 7 MW North Midlands BAND 6 MW BAND 5 MW Burton 0.00 16.20 86.86 10.29 Chesterfield 0.00 7.00 79.41 10.90 Derby 0.00 17.35 170.11 0.00 Nottingham 0.00 45.20 275.48 57.82 North Midlands 0.00 29.20 184.06 12.60 Sherwood Forest 0.00 16.00 88.42 6.21 Shropshire & Telford 0.00 27.45 130.47 13.40 Total 0.00 158.40 1014.81 111.22 TRUSTS CONS West Midlands BAND 7 MW BAND 6 MW BAND 5 MW Birmingham Women s 3.00 53.36 191.96 32.64 City 1.00 48.39 146.37 23.41 Coventry 0.00 42.00 144.46 0.00 Dudley 0.00 26.93 103.55 20.18 Heart of England 0.00 68.68 293.84 0.00 Nuneaton 0.00 11.80 58.75 4.00 Walsall 0.00 13.60 107.00 29.00 Warwick 0.00 15.49 67.71 11.00 Wolverhampton 0.00 21.57 117.30 0.00 Worcester & Redditch 0.00 36.39 172.99 2.60 Wye Valley 0.00 6.10 63.03 0.00 Total 4.00 344.31 1466.96 122.83 Grand Total 4.00 480.71 2481.77 234.07 Table 7: Funded numbers of WTE midwifery posts working in clinical practice 36
TRUSTS Workforce and Clinical Activity *MIDWIVES WTE FUNDED ESTABLISHMENT North Midlands CRUDE RATIO OF DELIVERIES BIRTHS TO WTE MIDWIVES 2014-15 2015 Burton 113.53 3650 32.1 Chesterfield 97.31 2793 28.7 Derby 187.46 6225 33.2 Nottingham 378.50 9755 25.7 North Midlands 225.86 7332 32.1 Sherwood Forest 110.63 3429 30.9 Shropshire & Telford 171.32 4653 27.1 Total 1284.61 37837 29.3 TRUSTS *MIDWIVES WTE FUNDED ESTABLISHMENT West Midlands CRUDE RATIO OF DELIVERIES BIRTHS TO WTE MIDWIVES 2014-15 2015 Birmingham Women s 286.96 8154 28.3 City 219.17 5595 25.5 Coventry 186.46 6107 32.7 Dudley 150.66 4324 28.7 Heart of England 362.52 9846 27.1 Nuneaton 74.55 1932 25.9 Walsall 149.60 4687 31.3 Warwick 94.20 2625 27.3 Wolverhampton 138.87 4121 29.6 Worcester & Redditch 211.98 5676 27.0 Wye Valley 69.13 1727 24.9 Total 1944.10 54794 27.47 Grand Total 3228.71 92631 28.6 * This excludes Midwifery Management Teams and Midwives working in Neonatal Units Table 8: Demonstrates the numbers of births in West Midlands against the numbers of WTE Midwives appointed to the Trusts. This then indicates the ratio of births to midwives for respective Trusts. 37
TRUSTS 2012-2013 2013-2014 2014-2015 North Midlands Burton 3623 3354 3650 Chesterfield 3068 2755 2793 Derby 5886 5891 6225 Nottingham 10319 9838 9755 North Midlands 5840 5885 7332 Sherwood Forest 3474 3252 3429 Shropshire & Telford 5154 5012 4653 Total 37364 35987 37837 TRUSTS 2012-2013 2013-2014 2014-2015 West Midlands Birmingham Women s 8218 8264 8154 City 6026 5514 5595 Coventry 6031 5913 6107 Dudley 4784 4545 4324 Heart of England 10785 10390 9846 Nuneaton 2361 2015 1932 Walsall 4678 4672 4687 Warwick 2926 2723 2625 Wolverhampton 3967 4129 4121 Worcester & Redditch 6185 5927 5676 Wye Valley 2007 1835 1727 Total 57968 55927 54794 Grand Total 95332 91914 92631 Table 9: Demonstrates Births over a 3 year trend from 2012 2015. 38
TRUSTS 2012-2013 2013-2014 2014-2015 North Midlands Burton 30.2 28.0 32.1 Chesterfield 33.9 20.5 28.7 Derby 31.4 22.4 33.2 Nottingham 30.3 21.2 25.7 North Midlands 30.8 29.3 32.1 Sherwood Forest 30.4 23.0 30.9 Shropshire & Telford 28.6 24.6 27.1 Total 20.6 20.3 29.3 TRUSTS 2012-2013 2013-2014 2014-2015 West Midlands Birmingham Women s 31.8 30.5 28.3 City 29.6 24.4 25.5 Coventry 32.1 29.6 32.7 Dudley 36.9 36.7 28.7 Heart of England 29.7 29.7 27.1 Nuneaton 32.0 33.1 25.9 Walsall 32.7 34.1 31.3 Warwick 31.9 30.3 27.3 Wolverhampton 30.2 33.0 29.6 Worcester & Redditch 31.6 30.7 27.0 Wye Valley 28.8 28.2 24.9 Total 27.1 20.3 27.47 Grand Total 20.7 19.5 28.7 Table 10: Table to demonstrate birth to midwife ratio over 3 year trend (Crude) 39
Clinical Activity and Trends Clinical Trends: Due to the reconfiguration of Trusts within the sector, such as the closure of Mid- Staffs to obstetrics and the re-location of the obstetric site from Shrewsbury to Telford, there has been some adjustment across the LSA with regards to the clinical picture and where women are choosing to have their babies. For instance, the births increased within the previous West Midlands region by over 2000 from 71,921 in 2013/14 to 74,134. The investments in Midwifery Led Units and Birthing Centre has increased the numbers of babies born in such facilitates. The Induction rates have increased from 25% to 27% over the latter 2 years of data. The caesarean section rates vary considerably across the LSA although respective Trusts remain consistent for instance Shrewsbury and Telford remain the lowest C/S rate of 16% whilst Walsall and Wye Valley remain at 29%. Once the reconfigured Trusts settle with a full year of data, a more realistic picture will emerge and hopefully see an increase again in the normal birth outcomes and reduced numbers of inductions. Home Births. Towns in rural areas without MLU facilities continue to the have the greater numbers of home births with Hereford having the largest percentage of births occurring at home. The average Home birth rate across the sector sits at just over 1%, most likely due to the increased capacity of the Midwifery Led Units. Some Trusts have set up Home Birth Teams to ensure this provision remains a viable choice for women. There was a continued number of women who had births without the aid of an obstetrician or a midwife (BBA) in attendance, these births occurring either at home or in transit to hospital. Complex births at home. There continues to be numbers of women who choose to deliver at home with pregnancies that would normally be under the care of the obstetric teams. This may include women who are expecting twins, or who have had previous caesarean sections, or have been prone to post-partum haemorrhages or require additional pharmaceutical support. In these cases, supervisor of midwives visit the family and full supervisory care plans are discussed and shared with the on call midwifery teams. These care plans seek to provide guidance to both parents and to practitioners with regard to how the framework of Supervision of Midwives seeks to support midwives as they in turn are provided care to women in circumstances that is outside of the midwives usual sphere of practice and expertise. Midwifery Led Units The Birth Place Study published in 2012 indicated that Midwifery Led Units were safe locations and environments for women to labour and birth, particularly for multi-gravid women with successful normal or instrumental births for their first labours. Across West Midlands there has been an increase of Midwifery Led Units opening and this will result in a continued uplift in births occurring in such facilities. 40
TRUSTS TOTAL HOSPITAL MLU BBAS HOME North Midlands Burton 3650 3341 270 24 15 Chesterfield 2793 2740 0 18 35 Derby 6225 5029 1068 33 95 Nottingham 9755 9235 347 69 104 North Midlands 7332 5747 1438 8 49 Sherwood Forest 3429 3248 0 27 154 Shropshire & Telford 4653 3795 757 19 82 Total 37837 33135 3880 198 534 TRUSTS TOTAL HOSPITAL MLU BBAS HOME West Midlands Birmingham Women s 8154 7963 1310 42 143 City 5595 5497 1235 71 20 Coventry 6107 5325 670 63 49 Dudley 4324 3396 873 27 28 Heart of England 9846 8252 1422 139 33 Nuneaton 1932 1854 0 33 45 Walsall 4687 4389 271 22 5 Warwick 2625 2569 0 24 32 Wolverhampton 4121 4070 696 38 13 Worcester & Redditch 5676 5568 0 37 71 Wye Valley 1727 1658 0 26 43 Total 54794 47258 6477 522 482 Grand Total 92631 84242 10357 720 1016 Table 11: Demonstrates the Confinements by place of birth during 2014-2015 TRUSTS TOTAL BIRTHS BIRTHS PER M/W NORMAL DELIVERIES % of total 41
Number % of Births North Midlands Burton 3650 32.1 2015 60.3 Chesterfield 2793 28.7 1821 65.2 Derby 6225 33.2 3419 56.08 Nottingham 9755 25.7 6121 62.75 North Midlands 7332 32.1 3796 52.21 Sherwood Forest 3429 30.9 2294 66.90 Shropshire & Telford 4653 27.1 3314 71.21 Total 37837 29.3 22780 60.3% TRUSTS TOTAL BIRTHS BIRTHS PER M/W NORMAL DELIVERIES % of total Number % of Births West Midlands Birmingham Women s 8154 28.3 4616 55.9 City 5595 25.5 3590 64.1 Coventry 6107 32.7 4043 66.2 Dudley 4324 28.7 2886 64.8 Heart of England 9846 27.1 6302 63.3 Nuneaton 1932 25.9 1276 66.0 Walsall 4687 31.3 3281 70.0 Warwick 2625 27.3 1522 57.9 Wolverhampton 4121 29.6 2547 61.8 Worcester & Redditch 5676 27.0 3536 61.6 Wye Valley 1727 24.9 888 51.4 Total 54794 27.47 34487 58.8% Grand Total 92631 28.7 34487 59.4% Table 12: Demonstrates the normal birth rates at each Trust 42
TRUSTS TOTAL BIRTHS CAESAREAN SECTIONS Emergency Elective Total % of births North Midlands Burton 3650 488 283 771 21.1% Chesterfield 2793 391 262 653 23.4% Derby 6225 978 717 1695 27.8% Nottingham 9755 1298 857 2155 22.0% North Midlands 7332 1054 729 1783 24.3% Sherwood Forest 3429 398 338 736 21.4% Shropshire & Telford 4653 385 381 766 16.4% Total 37837 4992 3567 8559 22.6 TRUSTS TOTAL BIRTHS CAESAREAN SECTIONS Emergency Elective Total % of births West Midlands Birmingham Women s 8154 1365 925 2290 24.7% City 5595 918 464 1382 24.7% Coventry 6107 788 670 1458 23.8% Dudley 4324 675 503 1178 27.4% Heart of England 9846 1459 1291 2873 27.6% Nuneaton 1932 213 211 424 21.9% Walsall 4687 889 514 1403 29.9% Warwick 2625 420 335 755 28.7% Wolverhampton 4121 665 487 1152 23.9% Worcester & Redditch 5676 760 833 1593 28.0% Wye Valley 1727 275 214 489 29.2% Total 54794 8427 6447 14997 25.6% Grand Total 92631 13419 10014 23556 24.4% Tables 13: Demonstrates Elective and Emergency Caesarean Section Rates 43
Trusts Total Births Forceps Ventouse Vg Breech North Midlands Burton 3650 173 307 34 Chesterfield 2793 134 156 13 Derby 6225 469 419 37 Nottingham 9755 656 772 389 North Midlands 7332 373 463 28 Sherwood Forest 3429 196 196 0 Shropshire & Telford 4653 281 256 37 Total 37837 2282 2569 538 Trusts Total Births Forceps Ventouse Vg Breech West Midlands Birmingham Women s 8154 733 558 56 City 5595 356 205 21 Coventry 6107 422 280 31 Dudley 4324 227 132 12 Heart of England 9846 534 563 50 Nuneaton 1932 117 93 13 Walsall 4687 278 175 16 Warwick 2625 191 164 8 Wolverhampton 4121 204 200 18 Worcester & Redditch 5676 474 201 10 Wye Valley 1727 93 176 3 Total 54794 3629 2747 238 Grand Total 92631 5311 5316 776 Table 14: Instrumental Deliveries and Vaginal Breech Births 44
TRUSTS TOTAL BIRTHS INDUCTIONS NUMBER % OF TOTAL BIRTHS North Midlands Burton 3650 875 23.9% Chesterfield 2793 642 23.0% Derby 6225 1526 25.0% Nottingham 9755 0 00.0% North Midlands 7332 2350 32.0% Sherwood Forest 3429 1003 29.25% Shropshire & Telford 4653 1357 29.16% Total 37837 7753 20.5% TRUSTS TOTAL BIRTHS INDUCTIONS NUMBER % OF TOTAL BIRTHS West Midlands Birmingham Women s 8154 2592 27.4% City 5595 1148 20.5% Coventry 6107 1688 27.6% Dudley 4324 1400 32.3% Heart of England 9846 2807 26.9% Nuneaton 1932 532 27.5% Walsall 4687 1542 32.9% Warwick 2625 387 14.7% Wolverhampton 4121 1356 28.1% Worcester & Redditch 5676 1681 29.6% Wye Valley 1727 385 22.2% Total 54794 15518 26.4% Grand Total 92631 23271 24.1% Table 15: Demonstrates rates of Induction 45
TRUSTS TOTAL BIRTHS AT BIRTH % North Midlands Burton 3650 Na Chesterfield 2793 2205 78.9% Derby 6225 4426 71.1% Nottingham 9755 6314 64.7% North Midlands 7332 2201 30.3% Sherwood Forest 3429 2057 59.9% Shropshire & Telford 4653 3313 71.1% Total 37837 20516 54.3% TRUSTS TOTAL BIRTHS AT BIRTH % West Midlands Birmingham Women s 8154 5108 54.0% City 5595 3636 53.2% Coventry 6107 4834 79.1% Dudley 4324 2549 58.9% Heart of England 9846 5884 56.5% Nuneaton 1932 1161 60.0% Walsall 4687 1785 38.08% Warwick 2625 1899 72.3% Wolverhampton 4121 2629 54.5% Worcester & Redditch 5676 4058 71.4% Wye Valley 1727 1224 70.8% Total 54794 34767 59.3% Grand Total 92631 55283 57.3% Table 16: Demonstrates numbers of mothers who choose to breastfeed at birth. TRUSTS TOTAL BIRTHS (WOMEN DELIVERED) TOTAL BABIES BORN BABIES BORN ALIVE STILL BIRTHS INTRA- PARTRUM STILLBIRTHS (DURING LABOUR) 46
North Midlands Burton 3341 3352 3344 8 0 Chesterfield 2793 2827 2817 10 0 Derby 6008 6097 6071 26 0 Nottingham 9755 9894 9843 51 2 North Midlands 7271 7350 7313 36 1 Sherwood Forest 3381 3429 3413 11 0 Shropshire & Telford 4505 4654 4629 25 1 TOTAL 37054 37603 37430 167 4 TRUSTS TOTAL BIRTHS (WOMEN DELIVERED) TOTAL BABIES BORN BABIES BORN ALIVE STILL BIRTHS INTRA- PARTRUM STILLBIRTHS (DURING LABOUR) West Midlands Birmingham Women s 8148 8266 8227 39 0 City 5595 5599 5556 43 1 Coventry 6107 6212 6171 41 4 Dudley 4388 4452 4435 17 0 Heart of England 9846 9946 9895 51 0 Nuneaton 1932 1932 1928 4 0 Walsall 4624 4678 4655 23 2 Warwick 2597 2625 2615 10 0 Wolverhampton 4121 4188 4162 26 2 Worcester & Redditch 5676 5774 5751 23 0 Wye Valley 1727 1759 1748 11 0 Total 54761 55431 55143 288 9 Grand Total 91770 93034 92573 455 13 Table 17: Demonstrates the outcomes for babies born in West Midlands Perinatal and Maternal Mortality 47
Perinatal Mortality The Primary Care Trusts in the West Midlands previously had commissioned the West Midlands Perinatal Institute to carry out work in order to improve the perinatal mortality rates in the sector. The Institute strived to be a centre of excellence in audit, research, education and training, with the primary focus on understanding the causes and developing strategies for the prevention of perinatal compromise. The West Midlands Clinical Commissioning Groups however decided not to continue with this provision and decided to process their perinatal data with MBRRACE The Institute now functions as a Social Enterprise as a non profit organisation and can be located via www.perinatal.nhs.uk Maternal Death Events during 2014-2015 During the period April 2014 to March 2015 there were 6 maternal deaths notified by the Trusts via the LSA database. Of these 1 was a Direct Maternal Death and this case was reviewed by a Supervisor of Midwives. The 5 Indirect deaths were also fully reviewed by a Supervisor of Midwives as appropriate. The supervisory response to maternal deaths was noticeably improved this year with rapid notification and detailed investigation of care. Maternal Morbidity The LSA is informed about women who have non-elective admissions to intensive care units who have required a period of full ventilation as part of their recovery and is an indicator of the increasing number of women with complex care needs entering the services. The national Maternity Critical Care Working Group produced their guidance report on ensuring equity of access for the care of critically ill pregnant or recently pregnant women in July 2011 in order to raise the profile of this particular care group. West Midlands LSA Audit for 2014-2015 Improving the interface between Incident reporting and LSA Investigations 48
With the publication and application of the revised Midwives Rules and Standards (2012) it was decided for the LSA Audit for 2014-15 that every Trust should have a Workshop Day to ensure that every Supervisor of Midwives understood and was able to act on Rule 10 with regard to escalating incidents and applying the LSA Decision Toolkit and proceeding to a full Supervisory Investigation. The Project Midwife has a key role in collating information around the serious untoward incidents for maternity and new-born reported to the commissioners and interfacing these with any Local Supervising Authority Investigations. The role advises and supports supervisory investigating officers and identifies key learning objectives for future practice programmes. The post holder was pivotal in facilitating workshops to support each supervisory team with respective Trusts to apply and meet Rule 10 of the revised Midwives Rules and Standards (2012). This guidance was supplemented West Midlands LSA in the form of additional templates to use during investigations, setting up supervised practice programmes and locality based investigation workshops for all Supervisors of Midwives. All of this work is facilitated by the Project Midwife and the investigation methodology and standard of report writing has greatly improved as a consequence. An investigation database has also been set up to record more fully all investigations undertaken on behalf of the LSA. This database was established in November 2008 but retrospective data to April 2008 was also included to allow an improved tracking and monitoring of investigations. Key Maternity Criteria for reporting of Serious Incidents Maternal Deaths Intra-uterine deaths were omissions of care have been identified Intra-partum deaths after 37 weeks Unexpected Neonatal Deaths Non-elective maternal admissions to Intensive Care Units Admissions to Neonatal Unit were omissions of care have been identified Serious Drug Errors Surgical Operative Errors Loss or mis-labelling of Cytology or Histology Samples. (etc) Reports on all Local Supervisory Investigations undertaken during the year. 49
The LSAMO is informed of all Serious Incidents (SUI s) through the reporting by the Area Teams via the STEIS process. Any SUI notified to the Trust Board, CCG, or Area Team may require a supervisory investigation (NMC 2012). The LSAMO and Clinical Safety teams work together to review and follow up Maternity SUI s which ensures that recommendations for practice are implemented. A total of 200 maternity related SUI s have been received in this reporting year as indicated by the STEIS Reporting Criteria. Following an untoward event or the recognition of circumstances indicating lack of competence, irrespective of any clinical outcome, a Supervisor of Midwives, independent of any management investigation, should as soon as possible undertake a full supervisory investigation of untoward incidents or circumstances (NMC 2012). This is to ensure that practice has been safe and woman centred. Maternity Services Intrapartum Deaths Intra- Uterine Deaths Direct Maternal Death Mothers admitted to ITU for ventilation Term babies admitted to NICU (Unexpected) Unexpected Neonatal Death Total 6 5 52 4 25 94 18 204 Table 18: Category of Untoward Events Local Supervisory investigations during 2014-2015 Any incidents that require Supervisory Investigation are notified to the LSA via a notification process which informs the LSA that an investigation has been instigated. This notification then begins the audit process for each investigation by which each are monitored and quality assured by the LSA. Local Supervising Authorities (LSA s) appoint Supervisors of Midwives to monitor, on behalf of the authority, the practice of midwives against the standards set by the Nursing & Midwifery Council with the aim of ensuring safe practice for protection of the public (NMC 2007). The Supervisors of Midwives (SOMs) role includes supporting midwives to develop and improve their practice and to investigate any issues which question a midwife s fitness to practice. Supervisory investigations are carried out on behalf of the LSA by SOMs using NMC guidance. From April 2014 to end of March 2015 there were 52 investigations undertaken by Supervisors of Midwives on behalf of the West Midlands LSA. These investigations arose from practice concerns within the Acute Trusts across the West Midlands. Some Trusts request an external Supervisor of Midwives to carry out the investigation but in all circumstances, a Supervisor from the employing Trust was participant to the investigation both to support with administrative purposes and to effectively mentored. Most usual criteria for Supervisory Investigations Regulation: Failure to comply with PREP requirements 50
Operating and working outside of usual sphere of practice and competency Clinical: Colleagues: Failure to recognise abnormal progression of labour Failure to recognise abnormal CTG or signs of fetal distress Failure to act Failure to refer to appropriate physician Failure to document and record appropriately Failure to administrate correctly and record medicines Failure to provide a safe environment for practice Failure to check equipment required for safe and effective care Failure to support students or newly qualified colleagues Outcomes and Recommendations Of the 54 investigations (there was generally more than one midwife involved in an incident), there were 59 recommendations of local action which constituted working through practice issues with a named Supervisor of Midwives and 12 recommendations of an LSA Practice Programme under the new rules (2012). Appeals There were 3 appeals by midwives who were recommended to undertake a Local Action or an LSA Practice Programme following Supervisory Investigation. Each appeal was reviewed by Supervisor of Midwives from within West Midlands who were not associated with their employing Trusts. In each instance the Supervisory Investigation findings were approved and the Appeals not upheld. LSA Practice Programmes. Of the 12 LSA Practice Programmes recommended by the LSA, 9 were successful with the midwives progressing well after completion. One midwife who had resigned from her employing Trusts successfully undertook her programmes at another Trusts who had offered a clinical placement. Referrals to the NMC Fitness to Practice department In total, 3 midwives from the West Midlands LSA were reported to the NMC: A Midwife who did not feel well enough to complete an LSA Practice Programme. On referral to the NMC she successfully pursued a Voluntary Removal from the Register. A Midwife who following long term sickness decided she could not complete an LSA Practice Programme and successfully pursued a Voluntary Removal from the Register. A midwife who although undertook an LSA Practice Programme, continued to generate errors and so failed the Programme. On referral to the NMC she pursued a Voluntary Removal from the Register. NMC Referrals and FTP Hearings 51
During 2014-2015, the West Midlands LSA had 5 cases heard at the NMC Fitness to Practice Services. Of these 5 referrals, 3 remained suspended from the register and 2 were struck off. Details of the numbers of complaints regard the discharge of the supervisory function There were two complaints received with regarding the LSA function during the 2014-2015 Supervisory Year. The complaints related to: A midwife who did not wish to subject herself to Supervisory Investigation which occurred in 2013. She wrote to NHS England for review of the objectives of the Investigation. A family who wished for a review of a Supervisory Investigation in relation to the birth of their daughter in 2009. Where there is a complaint against a particular Supervisor of Midwives, to the LSA, a Link supervisor of midwives would be approached to complete the investigation on behalf of the LSA. In the event of a complaint against the LSA function or the LSAMO, this would be directed to the Chief Nurse, Jane Cumming for NHS England. The LSA website provides a direct link and guidance to midwives or the public who wish to make a complaint about a Supervisor of Midwives or the LSAMO via www.lsa.westmidlands.nhs.uk Midlands and East Region LSA priorities for the 2015 2016 Supervisory Year. 52
Working across the Midlands and East Sector Since the merging of the three SHA s into the NHS Midlands and East SHA Cluster the LSAMO s have been working more closely together to enhance equity and consistency of supervisory practice across the three LSA s. This has worked particularly well in terms of benchmarking practice and ensuring systems such as investigation data are comparable across the cluster. The sharing of processes and ideas has enhanced varying aspects of the function and has allowed sharing of educational opportunities for supervisors. Regular meetings between the LSAMO s and the Nurse Director has provided professional support and increased information sharing. This will continue through 2015-16. The priorities identified for the LSA for the year 2015-2016 will be: Work to facilitate the requirements of the LSA for Midlands and East according to Midwives Rules and Standards (2012) and to work across all provider, commissioner and academic stakeholders in this regard. To support the National and Regional institutions and local respective Trusts in the transition of Supervision of Midwives from its statutory function to its dissolution recognising this may not occur until April 2017. To enable this by the mechanism of Trust Audits and exploring the scope of work around managing the transition from statutory supervision to mandated NHS England Model, working towards the implementation of re-validation, and benchmarking for instance against the Kirkup Inquiry Recommendations (2015). To continue in supporting Supervisors of Midwives meet their developmental needs and PREP requirements by providing Education Workshop and Events across the regional LSA. To support Supervisors of Midwives with any LSA Supervisory Investigations and to facilitate and monitor any consequent recommendations of Local Actions or LSA Practice Programmes. To support and contribute to national agenda s such as the National Review of Maternity Services (Cumberlege 2015) and the Proposed Mandated Model to replace Supervision of Midwives (Foster 2015) due to be issued from the Department of Health in July 2015. Acknowledgement and Thanks In preparing this report, thanks should be given to: 53
All Heads of Midwifery and Contact Supervisors for validation of the workforce and clinical trends data Link Supervisors: Toni Martin, Ann Kingscott and Carmel McCalmont Lisa Wilkes - LSA Administrator for personal support, website and data-collation Sylvia Knight, NHS England, Midlands and East for Project and Events Calendar Funding Ruth May Director of Nursing for NHS England, Midlands and East Region. Advisors and Critical Readers: Lisa Wilkes Toni Martin Ann Kingscott Carmel McCalmont Jane Haslam Lynne Wigens LSA Administrator Programme Leader, Worcester University BsC Midwifery LSA Midwife Midlands and East (West) Head of Midwifery Coventry Head of Midwifery - Derby Chief Nurse Midlands and East. Barbara Kuypers Local Supervising Authority Midwifery Officer Midlands and East (West) Annual Report 2014-2015 www.lsa.westmidlands.nhs.uk Appendix 1: 3 Year Trends for West Midlands (Previous West Midlands Trusts) Birth Locations. 54
Year Total Hospital MLU BBA Home 2012-2013 74580 67230 8756 537 651 2013-2014 71921 65682 9238 548 645 2014-2015 70429 63990 8942 573 628 Normal Deliveries Rates. YEAR TOTAL BIRTHS BIRTHS PER M/W NORMAL DELIVERIES % OF BIRTHS 2012-2013 74580 32.8 46639 62.58% 2013-2014 71921 28.8 44187 61.44% 2014-2015 70429 30.1 43612 58.8% Other Vaginal Births Other Modes of Delivery TOTAL 12-13 Total Births Forceps Ventouse Vg Breech 74580 4536 3963 355 TOTAL 13-14 71921 4476 3842 320 TOTAL 14-15 70429 4456 3773 337 Inductions 55
Totals Total Births Inductions % of Total Births TOTAL 12 13 74580 4178 20.65% TOTAL 13 14 71921 17863 24.84% TOTAL 14-15 70429 20100 27.1% Mode of Delivery Other Modes of Delivery Total Births Total C/S Rate Water Labours Water Births VBAC Labours VBAC Births TOTAL 12-13 74580 25.04% 2523 2314 2380 2251 TOTAL 13-14 71921 25.50% 3168 3055 2189 2434 TOTAL 14-15 70429 24.7% 3645 2880 2002 1655 Women choosing to Breast Feed at Birth Totals Total Births At Birth % of Total Births TOTAL 12-13 74580 46719 62.6% TOTAL 13-14 71921 48711 67.7% TOTAL 14-15 70429 40281 54.3% 56