Number: WAG10-11163 A Strategic Vision for Maternity Services in Wales - Draft Strategy Document Consultation January 2011
Crown Copyright 2011 ISBN978 0 7504 5962 4 F6261011
Foreword The purpose of this document is to set out the Welsh Assembly Government s vision and strategy for maternity care in Wales for the future. This offers an opportunity to review what has been achieved and what remains to be done in terms of meeting the standards set in 2005 by the National Service Framework (NSF) for Children, Young People and Maternity Services. The document reflects the Welsh Assembly Government s commitment to the principles of the UN Convention on the Rights of the Child. The standards themselves need to be reconsidered in the light of the changes in recent years, including the recent NHS reforms, the 5 year Service, Workforce and Financial Strategic Framework and new approaches to staffing and developments in technology. It is also a chance to reposition maternity services within the broader setting of creating a better, more sustainable Wales, where government policies can work together more effectively to promote well-being in partnership with people across the country. This document will not repeat what has already been issued by the Assembly Government in other policy documents, such as the National Service Framework for Children, Young People and Maternity Service (WAG 2005). Rather it is a high level strategic statement of expectations, setting out the framework within which services should develop. It sets out the principles and expectations to guide Local Health Boards, which are responsible for planning and securing maternity services in different areas of Wales, in creating services that meet the needs of people in the 21 st century. Edwina Hart, MBE, OStJ, AM Minister for Health and Social Services
1. Introduction And Vision For Maternity Services In Wales It is well understood that the foundations for health and well-being start in pregnancy. From heart disease to obesity, educational achievement and economic status, the months before and the years immediately after birth are crucial to the life chances of the mother, her child and her family. The health and happiness of future generations can be enhanced through the provision of world class maternity services. 1.1 Vision The Welsh Assembly Government s vision for maternity services in Wales is a service that promotes pregnancy and childbirth as an event of social and emotional significance. For every mother wherever they live and whatever their circumstances, pregnancy and childbirth will be a safe and healthy experience and one that she can describe as satisfying. This should particularly be the case for someone becoming a mother for the first time, so that she, her partner and family begin parenting feeling confident, capable and well supported in giving their child a secure start in life. 1.2 Expectations for improvement Across Wales there must be safe, sustainable and high quality services. Women will have a range of high quality choices of care, from midwife to consultant led services, in a range of settings that include home, hospital, or midwife-led birth centres. The needs of the mother and family will be at the centre of maternity care. Maternity services in Wales will aim to be among the best anywhere. Wales will employ highly trained staff, encourage a learning environment that supports research and development and use of the best evidence, with constant monitoring for quality and safety of provision. To achieve this, Welsh Assembly Government intends to develop an outcomesbased approach to planning and monitoring maternity services, focussing on measuring against what women and their families want from their maternity care. 1
2. Public Health Context Chief Medical Officer for Wales Annual Report 2009 states that: the health and wellbeing of the people of Wales is improving overall, although there remain significant challenges to be addressed. (WAG 20101). Improvements in health over the last century mean that people are living longer. However, the nature of health and health threats has changed; in the mid 19 th century 4 in 5 deaths were before age 65. Today more that 4 in 5 deaths are after age 65. Life expectancy is increasing and now stands at 77 years for men and 81.4 years for women. Most people can expect to spend at least three-quarters of their lives in good health and in Wales, death rates from all causes, is declining in line with similar trends in the rest of Europe. Despite the overall improved health and life expectancy of the population, not everyone has gained equally and there remain significant and persistent health inequalities. The population of Wales faces significant health challenges, a complex legacy of an industrial past and economic and social deprivation. Wales has health outcomes that are poorer than its peers and a severe chronic disease burden. The NHS also faces an obesity time bomb, and continued high rates of smoking and drinking. Already 57 per cent of the Welsh population is overweight or obese. The cost of treatment will increase further if we cannot reverse the trend (WAG 20101). 2.1 Births and Deaths Local authority population projections for Wales published in May 2010 (WAG 20102) project that, between mid-2008 and mid-2023, there will be an increase in their overall population. Five local authorities are projected to see increases of 10 per cent or more between mid-2008 and mid-2023. In 2007/08, there were 13 local authorities in Wales who had more births than deaths. The birth rate in Wales has risen year on year in the last five years. It is projected that between 2008/09 and 2022/23, birth numbers will be highest in Cardiff, Swansea and Rhondda Cynon Taf. This is a reflection of the fact that these are the largest local authorities in Wales. Birth numbers in Swansea are projected to increase from 2,700 in 2008/09 to 3,100 in 2022/23, while birth levels in Cardiff are projected to increase from 4,600 in 2008/09 to 5,900 in 2022/23. These growths in birth numbers are mainly a result of an increase in the population of women of fertility age, which is likely to be caused by a high in-migration of women of this age group. Cardiff in particular is projected to see a high net in-migration of women aged 15-49, at around 1,500 each year. Birth numbers are projected to be lowest in the Isle of Anglesey, Ceredigion and Merthyr Tydfil, at around 700 to 800 births from 2008/09 to 2022/23. Birth levels in Ceredigion are projected to remain fairly constant, while birth levels are projected to decline between 2012/13 and 2022/23 in the Isle of Anglesey and Merthyr Tydfil. This decrease in the number of births is a result of a decrease in the number of women of fertility age in these local authorities. 2
2.2 Maternal Mortality The Centre for Maternal and Child Enquires (CMACE) report that whilst maternal deaths are rare (14 per 100,000 in the UK), women who live in the poorest circumstances are up to seven times more likely to die than women from other demographic groups. The report found that women who died were in poorer overall health and less likely to be in regular contact with maternity services and also reflect the poor general health status of pregnant refugees and asylum seekers. More than half of the women who died were either overweight or obese and more than 15% were extremely obese. Key recommendations from the report stressed the importance of: Pre-pregnancy counselling and support for women with pre-existing serious medical or mental health problems such as epilepsy, diabetes and obesity (BMI > 30). Access to antenatal services which must be accessible and welcoming to women. Women should have had their first visit to the antenatal clinic after the first 12 completed weeks of pregnancy. Medical history and clinical assessment of overall health of migrant women being recorded. Doctors should be particularly sensitive toward women from countries where genital mutilation is practised and provide appropriate care for them. Inequalities in health and wellbeing between areas and social groups are proving extremely resistant to policies which seek to narrow the gaps (WAG 2010 1 ). The significant public health challenges are described in the following sections. 2.3 Perinatal Mortality Perinatal, stillbirth, neonatal and infant mortality rates in Wales have remained static in recent years, following a gradual reduction over the previous 10 years (All Wales Perinatal Survey 2008). Preterm birth is the largest cause of death, following live birth and once again, studies have found an association between poor outcome and life style and behaviour factors such as young maternal age, smoking and alcohol use as well as access to antenatal care. 2.4 Challenges for Maternity Services in Wales Pregnancy is a powerful motivator for change and a time when women and their partners, often for the first time, make positive lifestyle changes and choices in order to provide the optimal conditions to ensure the health and wellbeing of their unborn baby. This is particularly important, not just in the context of the pregnancy, but also because we know that when women make these changes, they significantly influence the lifestyle choices of their children and wider family. Pregnancy therefore presents a golden opportunity to impact on the health and wellbeing of individuals and communities. 3
The health of children is influenced by what happens throughout pregnancy and even before, so it is vitally important that efforts to ensure that mother and child are safe and healthy need to start well before the birth. 2.5 Obesity Obesity in pregnancy is associated with an increased risk of a number of pregnancy-related complications and adverse outcomes and the babies of obese women have an increased risk of perinatal mortality compared with the general maternity population in the UK. In addition neonatal unit admissions (within 24 hours of birth) correlate directly with maternal obesity. Given that obesity is more common in areas of high social deprivation (CMACE 2010) it is no surprise that Wales has the highest overall prevalence of maternal obesity in the UK (Fig 1). Fig. 1: Prevalence of maternal obesity by UK nations and Crown Dependencies 2.6 Smoking The Centre for Disease Control (CDC 2010) identified that women who smoke before pregnancy have a 30% chance of being infertile and are more likely to experience delay in conception. Those women who smoke during pregnancy are about twice as likely to experience premature rupture of membranes and placental abruption during pregnancy. Babies born to women who smoke are 30% more likely to be born prematurely, are more likely to be born with low birth weight (less than 2500 grams), weigh an average of 200 grams less than babies born to mothers who do not smoke, and are 1.4 to 3 times more likely to die of Sudden Infant Death Syndrome (SID). 4
Smoking is the largest single cause of avoidable ill health and early death in Wales. Adults in more deprived areas (as defined by the Welsh Index of Multiple Deprivation) are more likely to smoke than those in less deprived areas (Fig 2 on following page). Wales also has the highest rate of smoking throughout pregnancy. 37% of mothers smoke at some stage during pregnancy or the year before it. 22% continue to smoke throughout pregnancy. Mothers in Wales are more likely to smoke and less likely to give up than in other UK countries. There are higher levels of smoking before or during pregnancy amongst mothers in routine and manual occupations, and among those under 20. These mothers were also less likely to give up before or during pregnancy (Ash 2010). Fig. 2: Smoking prevalence rates by Local Health Board in 2008 Welsh Health Survey 2008) 2.7 Alcohol Drinking during pregnancy can result in Fetal Alcohol Syndrome (FAS). This disorder leads to lifelong intellectual and behavioural problems for the child. 5
According to the Department of Health Hospital Episode Statistics the number of cases of FAS in England was 95 in 2000-01, 90 in 2001-02 and 128 in 2002-03. In Scotland, there were four cases of FAS in 2000, five in 2001, four in 2002, two in 2003 and ten cases in 2004. This equated to 0.21 per 1,000 live births in 2004. There are currently no data available for the incidence of FAS in Northern Ireland or Wales. In the USA, the incidence of FAS is reported to be between 0.5 and 2 per 1,000 live births. Fig. 3: Drinking behaviour before and during pregnancy by country The reported worldwide incidence of FAS is 0.97 cases per 1,000. It is important to note, however, that this estimate is based almost entirely on data from the USA. FAS, although not a common condition, is nevertheless regarded as the leading known cause of non-genetic intellectual disability in the Western world. Key findings from the UK Infant feeding survey 2005 are: Over half (54%) of mothers drank alcohol during pregnancy. However, among mothers who drank during pregnancy consumption levels were low. Only eight per cent of all mothers drank more than two units of alcohol per week on average. Almost three-quarters of mothers (73%) who drank during pregnancy received advice about drinking, with midwives being the most common source. 2.8 Teenage Conception The 2006 Health Behaviour in School-aged Children Study showing that Wales had one of the highest proportions of 15 year olds in the 34 European and North American participating countries reporting having had sexual intercourse, at 41% of girls and 30% of boys. Encouragingly, the latest update on the Child Poverty Milestones (WAG 20103) suggests a reduction in inequality between the most deprived fifth of Wales and the middle deprived fifth in relation to underage conceptions. Despite the latest figures 6
for 2008 showing teenage conception rates to be 13% lower than they were in 1999, recent progress has been slow. (See Fig 4 for 1992-2008 trends) Concep tion rate 14 12 10 8 6 4 2 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Fig 4: Under 16s conception rates, Wales 1992-2008 Rate per 1,000 female residents aged 13-15. (Source: Office for National Statistics) 2.9 Breastfeeding Breastfeeding gives babies protection from disease and infections and breastfed babies are less likely to develop asthma, eczema and diabetes. There are advantages for the mother too, as a breastfeeding mother is less likely to develop ovarian and pre-menopausal breast cancer. The Infant Feeding Survey in 2005 shows that Wales lags behind other parts of the UK in sustaining breastfeeding through infancy, but rates of breastfeeding at birth rose in 2008 compared with previous years. Figure 5 highlights the variation in breastfeeding initiation around Wales, with more deprived areas of the Welsh Valley s having the lowest initiation; initiation rates across Wales was 57% in 2008. 7
Fig. 5: Babies breastfed at birth in 2008 Breastfeeding rates for Wales were available for the first time from this survey and showed an initial incidence rate of 67%. This was less than in England (78%) and Scotland (70%) but more than in Northern Ireland (63%). In 2005, 48% of all mothers in the United Kingdom were breastfeeding at six weeks, while 25% were still breastfeeding at six months. In Wales 37% of mothers were breastfeeding at six weeks and 18% at six months, lower proportions than in England (50%, 26%) or Scotland (44%, 24%) but higher than in Northern Ireland (32%, 14%). In 2005, 38% of all mothers in Wales were breastfeeding exclusively at one week, while 15% were feeding exclusively at six weeks. This compared to 45% of all mothers in the United Kingdom breastfeeding exclusively at one week, and 21% feeding exclusively at six weeks. At six months the proportion of mothers who were breastfeeding exclusively in all UK countries was negligible (<1%). (NB. Incidence 8
refers to all babies who were breastfed initially; prevalence refers to the proportion of babies who were wholly or partially breastfed at specific ages.) 2.10 Birth Interventions Of the 34,876 live births to Welsh residents in 2009, 3.7% took place at home (Fig 6 overleaf). Caesarean section rates rose from 23% in 1999-00 to 27% in 2008-09; this is more than 10% above the 15% rate determined by The World Health Organisation (WHO). 1,291 131 17 Hospital Home Other Not stated place 33,437 Total live births:34,876 Fig. 6: Live births to Welsh residents by place of birth, 2009 Figure 7 below indicates the number and type of interventions during the year 2008-9, ie out of 31,769 births there were 15,804 without intervention (49.7%). The interventions include: caesarean section (emergency and elective), ventouse (vacuum), forceps and intervention for breech presentation. Caesarean section is the most common intervention. 9
117 1,830 1,906 19 Unassisted 3,758 4,688 19,451 Emergency caesarean sections Elective caesarean sections Ventouse Forceps Breech Total deliveries: 31,769 Deliveries without intervention: 15,804 Inductions:6,198 Other deliveries Fig. 7: Deliveries in hospitals in Wales by method of delivery, 2008-09 The high levels of induction of labour described in Figure 8 below, coupled with other interventions such as ventouse and forceps birth can all impact negatively on the birth experience and can lead to similar morbidity issues as described above. 25% 20% 15% 10% 5% 0% 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 Surgical Induction Other Induction Fig. 8 Induced deliveries, Wales 2003-04 to 2008-09 Source: Patient Episode Data Wales 10
Figure 9 below shows the percentage of instrumental deliveries by forceps or vacuum (ventouse) over a ten year period 1999-00 to 2008-09. This indicates a steady rise in use since 2003-04. 14% 12% 10% 8% 6% 4% 2% 0% 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 Forceps delivery Vacuum delivery Fig: 9: Instrumental deliveries, Wales 1999-00 to 2008-09 Source: Patient Episode Data Wales 11
3. Workforce Context 3.1 Introduction The vision for maternity services in Wales is to enhance the health and happiness of future generations, through the provision of world class maternity services. As part of the Five Year Workforce, Service and Financial Strategic Framework, workforce modernisation is recognised as a key requirement to deliver appropriate and sustainable services for the future. The workforce transformation agenda recognises the importance of empowering the front line to lead change and deliver high quality care. Any change however will be underpinned by the NHS Shared Values that have been agreed by WAG, the service and staff organisations. The values require: Putting quality and safety above all else: providing high value evidence based care for our patients at all times Integrating improvement into everyday working and eliminating harm, variation and waste Focusing on prevention, health improvement and inequality as key to sustainable development, wellness and wellbeing for future generations of the people of Wales Working in true partnerships with partner organisations and with our staff Investing in our staff through training and development enabling them to influence decisions and providing them with the tools, systems and environment to work safely and effectively The challenges facing NHS Wales, including maternity services, are numerous with many factors converging that require urgent work to modernise, redevelop and balance front line hospital, community and primary care services and staffing. Maternity policy is focusing on increasing health care delivered closer to home. This will be achieved through integrated working across health and social care with greater involvement of women in decisions about their health and health care, as well as more public accountability and engagement of communities in the design and delivery of services. The 5 Year Workforce and OD Strategic Framework develops coherent local, regional and all-wales service, workforce and financial plans for the next 5 years. Delivering workforce change to empower the front line and modernise the workforce is a key component of this work. 12
3.2 Strategic Direction and Intent Key Workforce Priorities The diagram below sets out the strategic workforce priorities for NHS Wales in support of the delivery of the 5 Year Strategic Framework. Citizen Centred Collaboration and Partnership Working Enabled Through To Deliver OD and Culture Change Rebalanced Workforce Appropriate and Affordable Workforce Workforce Sustainability The three key priorities a Re-balanced Workforce, an Appropriate and Affordable Workforce and securing Workforce Sustainability - will only be achieved through strong local management and partnership working, supported and underpinned by cultural change and visionary leadership which fully empowers and engages all NHS staff. Planning and providing local services, getting these right on a daily basis, is a key responsibility for Local Health Boards. This should be undertaken in collaboration with key stakeholders within local communities. Maternity Service Liaison Committees will remain positioned to draw these key stakeholders together and involve service users. For maternity services women and their families must remain central in all decision making. 13
3.3 Culture Change Maternity services will require significant change; effective clinical leadership is crucial to secure this. Leaders need to communicate a compelling vision, generate followership and provide support and personal advocacy to lead others towards the future. To support this it will be essential to develop clinical leadership programmes to support leaders within maternity services. An All Wales Clinical Leadership Development Strategy is being developed with a tiered approach to the local delivery of a nationally agreed curriculum for high volume multidisciplinary training. Dynamic, clear leadership, together with the key staff identified below, is essential for effective working in all places of birth. While the type of leadership will vary according to the birth setting, in addition to senior management (head of midwifery services, clinical director, general manager), each acute birth setting should have a labour ward manager, lead consultant obstetrician, one or more consultant midwives for intrapartum care and midwife shift coordinators. These key professionals are needed to address the quality aspects of service delivery, including guideline development, setting and monitoring of standards, and other organisational issues. 3.4 Re-balanced Workforce As maternity care will be increasingly delivered in homes and community settings the workforce will need to change to reflect these demands. This will necessitate a review of staff roles to ensure that staff are appropriately trained and skilled. It will be for local determination to identify which roles will best suit the service. Reviewing the place of care will provide the opportunity for skill mix to be reviewed across all members of the health care team. This must result in the right member of the team delivering care, for example appropriately trained support workers could deliver components of the public health agenda. Core maternity services are delivered 24/7, while antenatal clinics and some parent education are delivered Monday Friday 9-5. Services should be focused on users needs and this may have an impact on workforce requirements which will need to be considered locally. In units with medical consultants a highly skilled multi-professional team will be needed to deliver a high quality service. There is increasing evidence of the need for the continuous presence of fully trained and experienced obstetricians in high-risk delivery suites. A predominantly consultant-delivered service is planned in these units. Whilst midwives are required to support women across all care settings rebalancing the workforce will ensure that their skills and expertise are utilised most effectively. Traditionally, the consultant has worked in isolation but the focus of the role now needs to move to team working, with the consultant leading a multidisciplinary approach to ensure that health provision is woman-centred and appropriate. In order to ensure quality of care for women of all ages, the role of the consultant must evolve. Redefining both the opportunities in training and the consultant role is essential to ensure the fully trained and fulfilled workforce necessary to deliver the 14
care that women deserve. We expect fewer doctors in middle grade training posts in obstetrics and gynaecology in the future. 3.5 Appropriate and Affordable Workforce Local Health Boards will need to consider how they will plan for the staffing and skill mix levels needed to reflect the local model of care, case mix, the needs of women and their families and service design. Rebalancing the workforce ensures that the most appropriate member of the team delivers the right care and impacts on the cost of the health care team. Service redesign may provide an opportunity for staff costs as skill mix and competencies are reviewed. For Local Health Boards facing the challenge of rurality, regionalised patterns of working might need to be developed with medical and other skilled staff based in larger units with rotation out to smaller units offering less than 24 hour care. These issues and related medical career issues are being addressed through the work of the Rural Health Group. 3.6 Midwifery Workforce The All Wales data for the midwifery workforce indicates that 10.7% are aged 55 years and above so will potentially retire within the next 10 years, signifying a relatively youthful workforce. It is anticipated that the number of qualifying midwives will be sufficient to fill future vacancies in Wales. Recruitment to midwifery education in recent years has been robust with minimal attrition. There are no unemployed midwives reported following qualification. The number of new midwifery training places is based on the workforce plans prepared by each Local Health Board and therefore reflects local need. Reviewing the place of care will provide the opportunity for skill mix to be reviewed across all members of the health care team. This must result in the right member of the team delivering care, for example appropriately trained support workers could deliver components of the public health agenda. Local Health Boards currently report that maternity services do meet the Birth Rate Plus recommendations. In addition, to support the work of midwives and maintain a quality service, Wales has developed a national curriculum for Maternity Support Workers and all current health care workers are expected to enrol on the programme. Underpinning evidence based midwifery care is the role of the consultant midwife who plays a significant part in facilitating change and developing a positive practice culture in which the quality of care is of a consistently high standard (Midwifery 20:20, 2010). The development of these roles is essential for innovative practice to flourish and for role models for junior midwives. 15
3.7 Medical Workforce The current arrangement of maternity services in NHS Wales creates a number of problems for the safety and sustainability of those that depend on a medical workforce. The Royal College of Obstetricians and Gynaecologists sets standards for consultant hours physically present on labour wards, depending on annual delivery numbers, and also for the grade and competencies of doctors providing on-site cover when consultants are not present and our services should always meet these standards. Local Health Boards currently meet this standard, with some difficulty, but a greater focus on midwifery led births will result in fewer obstetrician led services, improving compliance through greater critical mass, thus improving the safety of the service. More focused obstetrician led services will also help to address concerns from within the service that the range and complexity of clinical work in each unit may not be sufficient to maintain the skills of the full time medical workforce and to deliver suitable training to trainees. Each Local Health Board is responsible for determining the allocation of consultant sessions between obstetrics and gynaecology, based on local need. In the future it is anticipated that consultants will be appointed to more specific roles in either obstetrics or gynaecology, although there may be efficiencies in these services being co-located where possible. For junior doctors, changes in hospital based services will also need to reduce their dependency on doctors in training as some Local Health Boards are already experiencing significant recruitment difficulties to the posts currently required. Recruitment difficulties are increasingly severe also in paediatrics and this also will influence the optimal arrangement of obstetrician led services and neonatal units. An extra challenge for the sustainability of services and training and experience for junior doctors is provided by the European Working Time Directive (EWTD) that limits the hours of weekly work. All Local Health Boards are currently operating EWTD compliant medical cover rotas in principle but not in practice when vacancies arise. This represents a clinical risk that also will be addressed by changing the arrangement of medical maternity services. A large part of the medical workforce in obstetrics and gynaecology (O&G) has been made up of international medical graduates (IMGs). This specialty appears to be unpopular with UK graduates. The apparent decline in IMG numbers coming to the UK in recent years is likely to be a major contributory factor to the current recruitment shortages being experienced for middle grade doctors which Local Health Board will need to consider when developing their service model. There are no imminent consultant retirement concerns at an All-Wales level as at least half of the specialty s consultants across both NHS Wales and NHS England are aged 40-49 years. Wales has a relatively young medical workforce working in maternity services, although there are differences between Health Boards. However, NHS Wales Associate Specialist workforce in O&G is generally older, and up to half of its current Associate Specialists will be aged 60 or above by 2016. 16
We are pleased to note that, unlike most specialties, females account for the majority (65%) of medical staff in obstetrics and gynaecology in Wales, a higher proportion than in England. This applies also to the consultant workforce (49% female in Wales versus 37% in England). 17
4. Progress To Date Delivering the Future in Wales (WAG 20024) promoted women centred services with a focus on increasing choices in antenatal provision and place of birth. The availability of home birth and birth in a Midwife Led Unit has increased and Heads of Midwifery have made great strides in collaborative working by setting up an effective all Wales group that advises Welsh Assembly Government and shares and develops good practice across Wales. The National Service Framework for Children, Young People and Maternity Service (2005) sets out evidence based standards and progressively, local NHS bodies have been bringing their services in line with these standards. The majority of theses standards have now been delivered. The Wales Audit Office Maternity Services Report (WAO 2009) recommended areas for improvement and these have been introduced across Wales. 4.1 Highlights The following highlight some of the progress to date: Local Health Boards have been charged with setting up Maternity Service Liaison Committees to ensure that the views of users are fully considered in service planning. All Local Health Boards are compliant with Birth Rate Plus midwifery staffing recommendations. A national curriculum for training of midwifery support workers has been introduced to ensure that they have the appropriate skills. The consultant job planning process has been strengthened so that Local Health Boards can distinguish time spent on obstetrics and gynaecology. A review of the provision of antenatal classes has taken place in each Local Health Board and new classes introduced based on feedback from women and their partners. An all Wales hand-held maternity record has been introduced across Wales. Routine enquiry into domestic abuse has been introduced in all maternity units. Based on feedback from users, postnatal services have been adapted to ensure new mothers feel supported. A common data set for maternity services has been agreed. Breastfeeding support and advice is improving as the number of Local Health Boards awarded UNICEF Baby Friendly status increases in Wales. In particular the training of mother peer supporters has been a great success (examples of good practice can be found in appendix A). 18
5. The Way Forward The majority of key actions from the NSF and recommendations from the WAO have now been addressed and it is time to focus on those that have presented challenges. Given the high level of social inequality in Wales, action should focus on reducing these inequalities. However, Marmot (2010) stresses that in acknowledging the social gradient in health the lower a person s social position, the worse his or her health focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage - proportionate universalism. The following section sets out the challenges that must be addressed. In order to meet these challenges, Local Health Boards in association with the Local Service Boards will be expected to produce coordinated partnership arrangements which incorporate the key elements of Our Healthy Future, health and wellbeing plans, social care plans and children and young people plans. 5.1 Challenges Teenage pregnancies There has been some progress in provision of specialist services for young pregnant teenage girls but there needs to be more consideration on how best to support young mothers and their families. Perinatal mental health Whilst midwives now discuss mental health needs with pregnant women, the provision of specialist perinatal mental health services is not universal. Obesity, smoking and alcohol There are examples of groundbreaking work in relation to supporting women who are overweight at the beginning of their pregnancy and women can be referred to other agencies for support in quitting smoking and reducing alcohol intake. To maximise uptake, midwives may need more training in motivating women to seek support. Education and information Provision of information and classes for pregnant women and new parents is improving in many areas of Wales. However, new and innovative ways of engaging with maternity service users need to be constantly explored and introduced. Promulgating good practice If maternity services in Wales are to be amongst the best anywhere, it is essential that examples of innovative practice are shared, adapted and adopted throughout 19
Wales and the principle of proportionate universalism applied. The following two sections set out the principles that should underpin best practice and the Welsh Assembly Government s expectations for the improvement of services that need to be ensured by the Local Health Boards. 20
6. Principles For Best Practice The Welsh Assembly Government s vision is a maternity service that promotes pregnancy and childbirth as an event of social and emotional significance. For every mother wherever they live and whatever their circumstances, pregnancy and childbirth will be a safe and healthy experience and one that she can describe as satisfying. To ensure that is the case and mothers and families receive excellent care everywhere some clear principles need to be in place to guide service development. Identifying what should be done is not enough. There must be clear responsibilities to meet the specified requirements and good data on what is happening. Targets have played an important role in recent NHS improvements to service delivery and health outcomes and performance has improved significantly as a result. The next step is to move away from top-down targets and further raise the quality of care provided. This requires a cultural as well as a system change, with the NHS in Wales owning the responsibility and desire to improve. It is the responsibility of Local Health Boards to plan and deliver maternity services that match the Welsh Assembly Government's vision and expectations as set out in this document. It is the responsibility of the Welsh Assembly Government to hold Local Health Boards to account through a meaningful mechanism of monitoring the effectiveness of maternity care across Wales. Local Health Boards will keep their plans and their implementation under constant review and will report progress to the Assembly Government on a regular basis. The Government will review these and require action in case of any poor performance. An outcomes-based approach to planning and monitoring services is being developed, focusing on the outcomes that the services are intended to achieve. For each of the principles identified in the following section, specific actions will be required and progress will be measured. 21
7. Expectations For Improvement 7.1 Protecting and improving health All possible should be done to protect and improve the health of could-be mothers, mothers-to-be, mothers and children. Maternity services are delivered chiefly by midwives, obstetricians, anaesthetists, paediatricians and neonatologists assisted by maternity care support workers. The services aim to be cohesive, providing care for healthy women with normal pregnancies and for those with risk factors or more complex needs. However, to ensure as far as possible that health is protected and promoted before, during and after pregnancy, it is vital that of the focus on maternity care be extended to include involvement from others eg. school nurses, social services and the third sector. The public health skills of midwives will also need to be reviewed to ensure that they are able to fulfil this role effectively. Healthy lifestyle options that positively impact on a woman and her family s health will be actively promoted by all health professionals caring for pregnant women. A number of government policies are in place that can support this approach including the Healthy Schools Initiative, the appointment of school nurses in each secondary school across Wales, the Child Poverty Strategy and the Inequalities in Health Strategy currently under development and Sure Start, Flying Start and Communities First provide services to the most vulnerable. The Government will review these in order to ensure that as much as possible is being done in this area. Measures of progress will initially be: Evidence that women are offered support in quitting smoking, reducing consumption of alcohol and offered support to minimise weight gain during pregnancy, especially for those with a raised BMI. Evidence of schools achieving the Welsh Network of Healthy Schools National Quality Award. Local Health Boards demonstrate that consideration has been given, in the Children and Young Persons Plans, of maternity services, breastfeeding and early years work. 22
7.2 Using women s experience of care Women s experiences of care should drive quality improvement. Women themselves are best placed to judge the performance of services in this most sensitive of services. The Government and Local Health Boards are aware that services need to be improved in certain specific areas such as for those preferring to use the Welsh language. Therefore the Government will require that women s views of their care are regularly collected and published and responses seen to be used in the development of services. Evidence-based information on local services will be made easily available to women. Every woman will be informed who is her lead professional, responsible for planning her care. Measures of progress will initially be:- Clear evidence that views are collected and heeded. Evidence of a functioning Maternity Service Liaison Committee in each Local Health Board. 7.3 Providing a range of high quality choices of care for women There should be a range of high quality choices for women, from midwife to consultant led services, in a range of settings that include home, hospital or midwife led birth centres; the presumption should be that most services will be for healthy women with normal pregnancies, but there must be safe, realistic and cost effective choices for all women tailored to their needs. The midwife will be the first point of contact for women who access maternity services to ensure women receive relevant information, advice and support about pregnancy services and are referred to the appropriate lead professional. Each Local Health Board will provide a range of services for women to give birth including at home, in a birth centre or consultant led obstetric unit. For women with complex needs and high risk pregnancies, obstetric services will be provided without due delay. Local Health Boards will need to implement their Caesarean section toolkit plans and report on progress. Local Health Boards will need to ensure that the different needs of their local community are kept under review and that no group is neglected in planning services, including hard to reach groups such as the homeless and travellers. The particular needs of black and ethnic minority groups must be understood, provided for and respected. 23
Measures of progress will initially be:- Evidence that women are able to see a midwife as first contact with maternity services. Numbers of women giving birth in midwife led units and at home. Falling Caesarean section and induction rates. Consultant led obstetrician services provided without undue delay. All modalities of analgesia available on a 24 hour basis, within consultant led services. Consultant led obstetric services are supported by at least level 2 neonatal services. 7.4 Offering support to all new families All new families should be offered support in adapting to the changes need to love and nurture a new member of the family. To ensure a successful start in life for the whole family, specific forms of support may be needed. Initial assessment and preparation will need to start early, and therefore care should be coordinated and planned antenatally and revised following birth to ensure that each new mother is offered individualised postnatal care. Consistent advice and support should be available for women who choose to breast feed their babies. Information should be given to women on local postnatal/parenting advice and support groups. Third Sector organisations and other agencies can have an important role in the planning and delivery of services to support vulnerable people and communities by maximising the outcomes for pregnant women, their babies, the wider family and the community. Measures of progress will initially be:- Evidence of continuous individualized care planning Increased breast feeding rates. Evidence of the Third Sector organisations and other agencies are involve in supporting people and communities. 7.5 Assuring the appropriate number of adequately trained staff Local maternity services must be safe in terms of the appropriate number of adequately trained staff The 2010/11 review of maternity services required the Local Health Boards to: Assess staffing requirements. Ensure that all maternity staff received the required clinical training. Review staff training programmes to ensure that there is sufficient focus on the principles of respect, well being, choice and dignity. 24
Local Health Boards should plan staffing levels by: Checking compliance of midwifery staffing levels with Birth Rate Plus. Establishing an appropriate skill mix balance between medical, midwifery and support staff. Securing clarity on the ratio of time consultant spend on obstetric as opposed to gynaecological work. Measures of progress will initially be:- Evidence that skill mix plans are in place. Birth Rate Plus compliance. Relevant staff training in place based on need. That midwives are able to access specific training to enable them to deliver their enhanced public health role. Clear consultant job plans that distinguish between time spent in obstetrics and gynaecology. That consultant led obstetric services comply with the Royal College of Obstetricians and Gynaecologists guidance for hours of consultant labour ward presence per week, depending on number of deliveries per year. That a middle grade doctor (level ST3 or higher or SAS grade) will cover the labour ward at all times that a consultant is not present. 7.6 Collecting, publishing and using information on performance The quality of maternity services will be routinely monitored and the data published. Clarity about performance is vital if the goals are to be achieved. The Welsh Assembly Government will lead work on agreeing a minimum data set that all Local Health Boards will collect and report nationally. It will also include assessment of the feasibility for an all Wales electronic maternity information system. A working party will be established to agree standardised definitions. The measure of progress will initially be an agreed data set to be in place by June 2012. 7.7 Constant review and improvement Services will be constantly reviewed to improve quality and safety in the light of user feedback, quality monitoring and emerging evidence on good practice. A new impetus for improving the quality and safety of care provided to woman and their babies will come as a result of extending the successful 1000 Lives Plus Programme to this area of care. In addition, following a review of the evidence a number of focussed interventions to improve safety and reduce the risk of avoidable 25
harm have been identified as a priority to take forward. A new initiative, the Transforming Maternity Services collaborative, will be launched in March 2011 and will be a powerful support for achieving the vision in this document. Measures of progress will initially be:- The 1000 Lives Plus Maternity Collaborative in place by April 2011. A set of clinical outcome and women focussed quality measures based on that work in place by April 2012. 7.8 Research and Development Health Boards in association with Higher Education Institutions will actively engage in the research and development of the evidence base that will lead to future service/care improvements for the benefit of mothers and babies. This will include the facilitation of staff to contribute to the respective Local Health Board s research agenda and will include participation in research fellowships, supported by the Academic Health Science Collaboration. It will also include supporting staff to actively review evidence and where appropriate implement research findings in practice. Academic appointments and university links will be encouraged where appropriate as clinical standards will be raised and recruitment facilitated. We want NHS Wales to be known to be a place where any member of the maternity team can come to train and practise to the highest standards. Measures of progress will initially be:- Health Boards will have in place R&D strategies that include addressing the development needs of maternity services. 26
8. The Role Of Government The Welsh Assembly Government sets the vision and must also create the conditions where this vision can become reality. However, responsibility and accountability for planning and delivering effective and safe local services lies clearly with Local health Boards. Government s role is to hold local organisations to account for the delivery of their local services. The new Local Health Boards in Wales are responsible for the planning and development of fully integrated health services. This will ensure that care is patientcentred, delivered seamlessly and better co-ordinated through shared access to knowledge and shared processes. There will be a far greater emphasis on preventing problems and dealing with them earlier. The Government s aims and expectations are set out in a 5-year Service, Workforce and Financial Strategic Framework, the Annual Operating Framework and guidance and standards relating to specific services such as the National Service Frameworks and the guidance on the preparation of Children and Young People s Plans. Applying these principles to maternity services will mean that these services will be better planned, delivered and better monitored, with much stronger links between primary and community based care and hospital services. There will be a much stronger focus on efforts to improve and protect children s life chances before and after their birth, bringing the efforts of government as a whole to bear on creating the best possible chances in life for every child. The Welsh Assembly Government is also responsible for supporting Local Health Boards and for monitoring improvements to maternity services. An all Wales implementation group will be established. This group will facilitate the sharing and promulgating of best practice, commission all Wales work and initiatives and monitor the pace of improvements to services and outcomes. 27
9. The Role Of The Local Health Board Planning and providing local services, getting these right on a daily basis, is a matter for the Local Health Boards. It must meet national and local requirements. It must be a continuous process, and Boards are required to refresh their local plans annually, within a local 5-year Framework. They must constantly monitor and test their services, to ensure that they remain safe and sustainable, and take any action needed to keep them so. The Boards cannot work in isolation. They know that to work well their services must interact effectively with those of partner organisations and must meet the needs and expectations of the local community. Local partnership arrangements should ensure that there is appropriate governance of these relationships under the auspices of the Local Service Boards and that different agencies plans are aligned to provided integrated services for local people. In addition, there must be continuous engagement with the local population and key interest groups around how services are being managed and developed. Local Health Boards must now review their current services against the vision, principles and specific measures set out in this strategy document and produce revised maternity service plans. Specifically these plans must address and provide evidence of how they will achieve: Safe sustainable consultant led units staffed to RCOG standards. Safe, sustainable Midwife Led Units. The midwife as first point of contact for women accessing maternity services. User engagement that contributes to service development and improvement. Access and engagement from hard to reach groups. 28