Workig i partership with the Materity Service Liaiso Committees Materity Matters What does a great service look like? February 2016 Report author Dr Rohhss Chapma Healthwatch Cumbria
Part 1 Executive Summary 2 Ackowledgemets 3 Itroductio 3 Materity services i Cumbria ad North Lacashire 4 Cumbria ad North Lacashire cotext 5 Previous reviews of materity care 6 Healthwatch Cumbria survey a partership approach 9 Aalysis 11 Part 2 Report of the Survey 12 Sectio 1 - Details about respodets 12 Sectio 2 - Pre pregacy 13 Sectio 3 - Care ad support durig pregacy 14 Sectio 4 - Care ad support durig the birth 16 Sectio 5 - Care ad support after the birth 18 Sectio 6 - Reflective levels of ivolvemet 21 Summary of Report Fidigs 25 What would a great materity service look like? 25 Refereces 26 Appedices Survey Mokey 28 Facilitator otes 42 Part 1 Storyboards 46 Survey postcard 51 Executive Summary Healthwatch Cumbria has worked i partership to fid out the views of wome ad their sigificat others regardig their materity services. The survey took place i Cumbria ad North Lacashire durig November 2015. There were 1234 respodets. The survey foud there were geerally high levels of satisfactio with the care received at all steps of pregacy ad after the birth of the baby. However there were commets about how services could be improved.the themes of most sigificace were; the importace of cotiuity of care, cosistecy of iformatio, postatal support for breastfeedig, support to make iformed choices ad accessible, local services. The aalysis begis o page 12 ad a summary of fidigs is o page 25. These fidigs are a sapshot of the perspective of those who participated. 2
Materity Matters What does a great service look like? Ackowledgemets Healthwatch Cumbria (HWC) has welcomed the opportuity to work i partership i developig ad coductig egagemet with the Materity Service Liaiso Committees (MSLCs) i Cumbria ad North Lacashire. We would also like to ackowledge the support of all members of the Royal College of Obstetricias ad Gyaecologists (RCOG) Implemetatio Group, the HWC ambassadors, the may NHS staff who have bee helpig ad the Health ad Social Care Evaluatios team (HASCE), led by Dr Tom Grimwood at the Uiversity of Cumbria. We are idebted to the people of Cumbria ad North Lacashire who gave their time to take part i this coversatio. Itroductio I the autum of 2015, HWC was commissioed by NHS Cumbria Cliical Commissioig Group (CCG) ad NHS North Lacashire CCG to udertake a coversatio with the public regardig their experieces of materity services i Cumbria ad North Lacashire. This proposal was a cotiuatio of ogoig egagemet with the public supportig the implemetatio of the RCOG materity review 1. The aim of the coversatio was to uderstad, what a does a great service look like, focused o the views ad experieces of (maily) wome of childbearig age ad their sigificat others. The coversatio was part of a series of activities takig place withi the RCOG review process, which had bee commissioed by the CCGs with a commitmet to extesive egagemet i supportig the developmet of a materity pathway, rather tha formal public cosultatio. It builds o previous egagemet material ad itelligece from local MSLCs ad their represetatives of the North ad South Cumbria Egagemet sub groups ad a represetative from the Natioal Childbirth Trust (NCT). I the spirit of coproductio, HWC worked i partership with the MSLCs ad the idepedet egagemet advisor from RCOG, Cath Broderick. HWC also worked with the North ad South Cumbria Commuicatios ad Egagemet groups as well as may NHS workers i codesigig a iteret based survey that ra through the moth of November 2015 ad resulted i 1234 resposes. I additio, HWC, alogside voluteers from the groups above, ra complimetary egagemet sessios icludig drop-i s, to ehace ad supplemet the take-up of the survey, usig hard copies of the survey where appropriate ad alogside other complimetary methods. The MSLC represetatives dissemiated the survey through their etworks for further reach. HWC worked i partership with HASCE at the Uiversity of Cumbria, to provide both quatitative ad qualitative aalyses of the subsequet resposes. We would like to ackowledge the assistace ad support of the orgaisatios, groups ad idividuals, especially through the RCOG egagemet sub groups, who have helped us to obtai ad uderstad the views of people usig materity services i the area. There are iheret limitatios to the survey ad further aalysis could be udertake i a loger timeframe. There is a wealth of additioal data, especially i the free text sectios ad from the complemetary activities that may prompt RCOG Implemetatio group to cosider requestig further aalysis as the process of reviewig materity services moves o. The followig report details the backgroud, process ad aalysis of results of the HWC materity survey. For those who are mostly iterested i the ew survey results these are reported from page 12 owards. Through discussio ad commet, icludig iformatio from the other coversatio activities, we are addig to the previous work of this ature udertake i Cumbria. 1 The RCOG (2014) Review, commissioed by NHS Cumbria CCG ad NHS North Lacashire CCG, is to provide a appraisal of optios for future arragemets for materity services i Cumbria ad North Lacashire, based o iformatio from CCGs, Hospital Trusts ad iterviews with with professioal experts. 3
Materity Services i Cumbria ad North Lacashire Materity Services i Cumbria ad North Lacashire are provided by the North Cumbria Uiversity Hospitals Natioal Health Service (NHS) Trust ad the Uiversity Hospitals of Morecambe Bay NHS Foudatio Trust. NHS Cumbria CCG ad NHS Lacashire North CCG hold resposibility for plaig ad buyig hospital ad commuity health services i these areas, icludig materity services. Regardig regulatio, the Care Quality Commissio s (CQC 2 ) role is to ispect the quality of health ad social care, icludig materity uits. The limitatios of ispectios are discussed i the Ham ad Murray (2015) Kigs Fud report. There are two cosultat led hospital uits ad a midwifery led uit i each of the two areas. Overall, these materity services are providig support for over 4000 births aually. Additioal services for over 500 Cumbria wome are provided by the Royal Lacaster Ifirmary as detailed below. The total i this table refers to live Cumbria births: Materity Service Type Live Births 2013-2014 Cumberlad Ifirmary Cosultat Led Uit 1672 West Cumberlad Hospital Cosultat Led Uit 1279 Perith Birth Cetre Birthig Uit 24 Furess Geeral Hospital Cosultat Led Uit 1030 Westmorlad Geeral Hospital (Helme Chase) Midwifery Led Uit 165 Royal Lacaster Ifirmary (RCOG, 2014:11) Cosultat Led Uit 1968 (549 Cumbria patiets) Total 4719 2 The Care Quality Commissio is the idepedet regulator of health ad social care i Eglad; see http://www.cqc.org.uk. 4
Materity Matters What does a great service look like? Cumbria ad North Lacashire cotext Materity Services i Cumbria ad North Lacashire are uderpied by a uique ad challegig cotext of geography, circumstaces ad evets, listed below: The geography of the area creates some distictive challeges specifically regardig road ifrastructure ad trasportatio impactig o time, safety, coveiece, cost ad commuicatios. There are issues of deprivatio i larger urba areas such as Barrow ad West Cumbria as well as some very rural commuities. Evidece demostrates a rage of specific health iequalities (RCOG, 2014:6). There are logstadig problems withi local health services. I September 2015, Eglad's Chief Ispector of Hospitals recommeded that North Cumbria Uiversity Hospitals NHS Trust should remai i special measures followig its latest ispectio by the CQC. Followig o from this, West, North ad East Cumbria were selected to be ivolved i the atioal Success Regime iitiative (NHS Eglad Natioal ad Regioal Tripartite Group, 2015) described by the Govermet as a whole systems itervetio set out i their Five Year Forward View (NHS, 2014). Alogside Essex ad Devo, Cumbria is viewed as oe of the most challeged health ad care systems i the coutry. These challeges iclude problems i recruitig to key cliical posts, a history of fiacial challeges ad the eed to improve quality of service (NHS, 2015). This ew regime is developig a Cliical Strategy to be ready by the ed of March 2016, which takes ito accout the previously agreed strategy for local services; Together for a Healthier Future (NHS Cumbria CCG, 2015). This forms the five year pla for North Cumbria. Historically some of the problems outlied above have led to vigorous campaigig by local groups to save their services from the threat of closure, particularly i West Cumbria (News ad Star, 2014). I 2005 it was apparet that materity services i West Cumbria were uder threat of beig cetralised ito Carlisle. A local campaig, Do t move our mums reported: Staff at West Cumberlad Hospital have lauched a petitio i a bid to stop ay possible chages which could mea may hudreds of wome i West Cumbria havig to travel to Carlisle to give birth (Whitehave News, 2005). A similar article appeared agai i 2014 ad is still curretly uder discussio. Give the atioal call to patiet voice ad coproductio, the views of patiets ad the local commuity are paramout ad will eed to be take seriously as set out i Trasformig Participatio i Health ad Care (NHS Eglad, 2013). Of crucial sigificace to the area has bee the Furess Geeral Hospital tragedy, related to evets betwee 2004 ad 2013, which resulted i the deaths of eleve babies ad oe mother. The ivestigatio ito the tragedy was headed by Dr Bill Kirkup, a former seior Departmet of Health official. He reported 20 major failigs ad cover up s at all levels as a lethal mix of failures (Kirkup, 2015: 7; BBC, 2015). Kirkup made 44 recommedatios which, due to such acute systemic failure, icluded a atioal review of materity services. Part of this review, which was uder the umbrella of the Five Year Forward View, icluded a atioal olie survey which was still ruig live i November 2015. The review was idepedetly chaired by Baroess Julia Cumberlege who, as part of her atioal itierary, visited Cumbria materity services to uderstad better the service provisio ad views of professioals ad people who used the services i the area. This distictive set of backgroud circumstaces with their ramificatios ad sesitivities uderpi the preset day materity services i the Cumbria ad North Lacashire areas. May local evets ad circumstaces are liked ito atioal policy moves aroud improvemets i healthcare ad materity services, creatig a challegig ad complex ladscape. 5
Previous reviews of materity care This sectio reviews some of the work that has take place sice 2006, which has bee utilised i Cumbria ad North Lacashire reviews ad has subsequetly iformed the directio of the HWC/ MSLC 2015 survey. Research ad reviews of materity services iterlik atioal policy reachig out ito localities, although, as i the case of the Furess Geeral Hospital tragedy, the call for review ca also geerate from what happes i the locality. Overall, the CQC (previously Healthcare Commissio) had udertake a atioal survey of materity care every three years. This iformatio ca be viewed at http://hssurveys.org/surveys/299. The West Cumbria Commuity Materity Project group was set up i 2006 to uderstad the views of materity service users ad their families i the local area. This was i the wake of public cocers about cosultat led services at West Cumbria Hospital possibly beig relocated to Carlisle as reported above 3. The aim of their survey was to feed these views ito a public cosultatio, Care Closer to Home (Cumbria NHS Primary Care Trust, 2007) regardig the future of materity ad other health services i the area, whilst it was takig place. It is reported that the questioaire was desiged after a process of group facilitatio, supplemeted by questios from the project group particularly related to home births (Adewoye et al, 2008). The survey, which ra from April util July 2007, was distributed to 151 differet groups ad orgaisatios takig ito accout areas of deprivatio, rural populatios ad disadvataged groups. This resulted i 1456 completios from the 5020 questioaires distributed. A prelimiary quatitative aalysis was udertake, usig a Microsoft access database. This iformatio was supplemeted by some emerget qualitative themes. The prelimiary report demostrated that most respodets had a high degree of satisfactio with West Cumbria materity services. Iterestigly West Cumbria culture was high o the ageda: a strog sese of watig their babies to be bor i West Cumbria. Some respodets said they did ot wat Carlisle to show up o the birth certificate Adewoye et al (2008:19) Much of the additioal commet raised was about proximity to cosultats ad home. It was reported there were may remarks about the iadequacy of road ifrastructure particularly i relatio to the perceived future risk of wome havig to travel from West Cumbria to Carlisle. There were fears of what might happe if there were complicatios durig the jourey. This was uderpied by the questio, What cocers would you have if you eeded materity services that were ot located i West Cumbria? Iterestigly there were o questios about views ad experieces of care after the baby was bor. The report was produced as prelimiary ad there was plaed to be a follow up report that reflected a deeper aalysis of the qualitative themes, however this additioal work did ot materialise due to lack of resources. Aroud the same time, the three yearly atioal survey was uderway. The survey of materity services was udertake withi the atioal programme of geeral health services focused o the experietial views of NHS patiets (Healthcare Commissio, 2007). The results from 26,000 wome who respoded to their 2007 postal questioaire 4, demostrated that, i the mai, they had bee happy with the care they received from their services before ad durig childbirth but that care after the birth of their baby was watig. Lack of iformatio, poor clealiess i hospital postatal spaces ad lack of kidess ad uderstadig were some of the mai issues raised. From this the Commissio suggested that trusts should ivolve wome more i decisios about their care. From this survey, ad for other reasos discussed later, we icluded a sectio o aftercare i the HWC/MSLC survey. 3 The West Cumbria survey followed the North Cumbria Materity Review (2006) chaired by Maggie Blot, which cocluded there was o obvious solutio aroud the future of obstetrics at WCH. 4 The questioaire was based o that used i the Natioal Materity Survey, 2006, udertake by the Natioal Periatal ad Epidemiology Uit which was co-fuded by the Healthcare Commissio. 6
Materity Matters What does a great service look like? The followig 2010 atioal survey (the udertake by the CQC programme) reached 25,000 wome. This report demostrated geeral improvemets from the perspective of the wome but there were fewer wome attedig ateatal classes tha i 2007 ad more wome givig birth i o-active positios. It was also oted that iformatio was limited regardig chages i emotioal state followig birth. These poits were raised by the CQC as problematic. The 2013 CQC survey maaged to reach 23,000 wome. Agai the survey reported geeral improvemets o the 2010 results but highlighted cocers aroud iformatio or support beig provided icosistetly, ad i some cases basic kowledge such as medical history was ot kow. Issues were also raised about clealiess ad cocers of some wome beig left aloe (usually at the early stages of labour). I March 2015, Simo Steves, Chief Executive of NHS Eglad aouced the NHS Five Year Forward View 5 (NHS, 2014), which set out a visio for the future of the NHS. Amogst the other idetified care streams, this icluded (backed by Kirkup) a atioal review of materity services. As previously metioed this review was idepedetly chaired by Baroess Julia Cumberlege ad was tasked to assess curret materity care provisio across Eglad deliberatig how services should be developed to meet the chagig eeds of wome ad babies withi the curret climate. The terms of referece for the atioal review stated that: i developig proposals, the review will pay particular attetio to the challeges of more geographically isolated areas, as highlighted i the Morecambe Bay Ivestigatio report (NHS Materity Review Terms of Referece, NHS Eglad, 2015). The atioal materity review pael established a umber of workig groups to take the review forward. These groups icluded NHS staff, professioal bodies ad patiet represetatives who were tasked to brig forward ideas for improvig materity care; the RCOG was ivolved as a pael member. The cosultatio work was udertake withi a ie moth timespa usig a variety of differet foci ad methodological approaches. The esuig iteret based survey was respoded to by over 6000 people. As part of the may other egagemet evets, Baroess Cumberlege visited differet parts of the coutry, for regioal drop i evets which icluded Cumbria. The Baroess spet time at the local geeral hospitals ad atteded a atioal public egagemet evet i Carlisle, which was part of the ogoig couty egagemet. There were also meetigs with professioals ad other stakeholders. The discussios over her visit icluded: geography ad access, exterally defied stadards ad their applicatio to small uits ad the greater importace of outcomes, the use of Midwifery time, cotiuity of care, ad the use of IT (NHS Cumbria CCG Goverig Body, 7th October 2015). 5 The thrust of the NHS five year forward view was that although some of the chages expected i services were NHS based, lot of actios would require ew parterships ad coectios withi local commuities ad local authorities ad employers. This was to respod to the predictio of a 30 billio fudig mismatch betwee patiet demad ad fiaces available by 2020. 7
RCOG review of materity services across Cumbria ad North Lacashire I 2014 NHS Cumbria CCG ad NHS North Lacashire CCG commissioed a idepedet review of materity services i their two areas. I lie with oe of the recommedatios of this review led by Dr A. Falcoer, the RCOG Implemetatio Group was established. The egagemet activities which were delivered as part of this implemetatio process were aliged with ogoig egagemet activity i both areas. It was also set agaist the backdrop of sigificat local feeligs about materity services, icludig the cotiuig cocers about the closure of the West Cumberlad materity uit. I additio there were strog public feeligs ivoked by the baby ad patiet deaths that had occurred i Morecambe Bay, ivestigated by Kirkup 6, as explaied at the start of this report. The aim of the RCOG Optios Appraisal was to provide expert advice o developig high quality, safe ad sustaiable (RCOG, 2014) materity services for the future ad to cosider what would be eeded to keep four cosultat led uits at Barrow, Carlisle, Lacaster ad Whitehave ad to develop midwifery led uits ext to or o the same site as the cosultat led uits i order to provide more choice for wome. The report describes this as optio 1 i its recommedatios, which also called for the developmet of materity services to be uderpied by holistic commuicatios strategies icluded commuities, political leaders, professioal stakeholders ad patiet ad lay represetatives. This uderscores a strog commitmet to a coproductive approach, outlied i the Five Year Forward View ad later demostrated i the HWC/MSLC survey approach. Summary of implicatios of previous reviews There has bee a substatial amout of review ad research o materity services udertake both atioally ad i the local areas. This evidece has ofte demostrated cosistet views with some icremetally improvig experieces but has also evideced repeated ad, latterly, icreasig cocers, leadig to the recet proclivity of ivestigatio. This mirrors the fudametal atioal ad ecoomic issues facig the NHS uderpiig specific local problems. This evidece led to a sigificat amout of discussio withi the HWC team about esurig the survey ad other data collectio methods were idepedet of ay pre-set assumptios ad prefereces, whilst beig midful to take local sesitivities ito accout. Earlier public egagemet cited above had provided a strog message about keepig cosultat led services local, but HWC were clear i their service level agreemet that the survey was ot a cosultatio about the RCOG optios but a geeral eed to ask questios afresh of the wome ad their sigificat others actually usig, or plaig to use Cumbria/North Lacashire materity services. We wated to kow what local people thought a great materity service would look like. 6 The itroductory pages of the review explai that oe of the team ivolved were privy to what would become the Kirkup report results. 8
Materity Matters What does a great service look like? Healthwatch Cumbria/ MSLC survey a partership approach Nicol ad Eato (2013: 143) set out that if the NHS is to survive, the health leadership [is] a coproductive edeavour betwee health workers ad patiets, workig withi ad beyod traditioal NHS boudaries. The cocepts of egagemet ad empowermet are core to the success of the NHS ad care services for the future ad mapped out throughout the last decade of health ad social care policy reports ad statemets. HWC, as part of this trasformative approach, is tasked to champio the views of patiets ad social care users. Maitaiig the idepedet positio of HWC was therefore of prime importace. Workig i partership with the MSLCs esured access to local kowledge ad up to date iput with those liaisig with local mothers ad their families. HWC had raised the issue of ethical approval for the coversatio ad supplemetary activities, but accordig to the Itegrated Research Applicatio System 7, the Health Research Authority would classify the exercise as evaluatio rather tha research, makig a applicatio redudat. HWC were kee to follow ethical priciples ad icluded a statemet at the start of the survey to assure cofidetiality ad usage withi the parameters of the Data Protectio Act (1998) 8. I desigig the survey (appedix 1) the HWC research team elected to use SurveyMokey 9. Previous Cumbria (ad may of the atioal) surveys have used postal questioaires, which we viewed as problematic. We were acutely aware of the time limitatios placed o the coversatio regardig the potetial success of postal resposes, but also wated to utilise techology for coveiece whilst optimisig the umber of resposes. The draft survey was desiged to be short ad easy to access, comprisig 43 questios over 9 pages. Learig from the approach of previous local ad atioal surveys, we divided the questioaire ito five distict sectios: Details about the respodet Pre pregacy Care ad support durig pregacy Care ad support durig the birth Care ad support after the birth. I order to follow a collaborative spirit, we eeded to balace the sesitivities of our parters whilst upholdig the itegrity of HWC idepedece. We had bee asked to make use of previous group facilitated sessios that had take place i South Cumbria usig a café style tablecloths 10, approach i order to iform the questios ad so we icorporated some of the suggestios. This was a method developed by Cath Broderick for egagemet i Morecambe Bay ad used as the basis for facilitated coversatios across Cumbria, which demostrates joit workig, co-desig ad testig of methodology. The Bluebell Foudatio 11 ad The Cumberlad Ifirmary Materity Bereavemet Support uit, also kidly agreed that we could iclude their phoe umbers ad website address for ayoe who had bee, affected i ay way by the loss of a child through a pregacy. 7 IRAS is a UK olie system for preparig regulatory ad goverace applicatios for health ad social care research. It is provided by the Health Research Authority o behalf of IRAS parters. 8 HWC statemet of cofidetiality This survey is beig udertake by Healthwatch Cumbria i associatio with the Materity Services Liaiso Committees ad the aalysis will be shared with the NHS to iform future service plaig. We have asked for persoal details from our survey populatio to uderstad if ay sigificat comparative factors arise. All iformatio supplied will be held by Healthwatch Cumbia ad will remai secure ad cofidetial. Your details will oly be used for research purposes ad will ot be passed o to ay third parties or used for marketig purposes i accordace with the Data Protectio Act 1998 9 SurveyMokey is a olie, cloud-based, survey buildig facility. 10 Tablecloths were spread over tables at drop i sessios ad allowed people space to write i their commets uder a rage of broad questios. 11 Bluebell Foudatio ca be foud at www.bluebell.org.uk 9
The draft survey wet through a process of several iteratios, ivitig commet ad suggestios for improvemet from the wider partership, icludig: West Cumbria MSLC Ede ad Carlisle MSLC Materity Matters i Furess Materity Matters i South Lakes Materity Matters Lacashire North. This process was very useful as it helped to refie questios ad esure that parters were satisfied their ideas were valued ad take ito accout. This process cotiued ito the report stage. Occasioally there were cotradictig requests so HWC established a audit trail for justifyig stasis or chage. A paper copy of the questioaire was developed out of the electroic template which was desiged for specific ease of use. These paper questioaires were to be collected ad trasferred oto electroic versios by the facilitators ad HWC admiistrative staff to maximise the electroic survey mokey aalysis. HWC/ MSLC orgaised a timetable of sessios across the couty supported by the HWC team, their ambassadors ad voluteers from the other groups ivolved. The sessios icluded chats with the public, iteractive sessios ad drop i evets at local toddler groups, Sure Start cetres, play cetres, cliics, schools ad leisure cetres. There were podiums available for people to fill i feedback sheets to support facilitated coversatios at the drop i sessios. There were also facilitated group sessios usig the café style tablecloth techique discussed above. These additioal activities created a wealth of iformatio that afforded a more qualitative iterpretatio, some of which was aalysed separately to supplemet the iformatio from the survey. HWC developed facilitator otes (appedix 2) for those supportig the activities o the day. The CCG also produced Story Boards (appedix 3), which provided a easy to read defiitio of key phrases ad termiology typically used i materity services. This was to esure that there was cotiuity i approach as far as possible. As each locatio was differet there were limitatios to costacy. The coversatio should be uderstood as a oe moth sapshot of 1234 idividuals opiios ad experieces, supplemeted by iformatio from other more qualitative supportig group activities. Overall, throughout the coversatio period of November 2015, which proved to be a moth of itese ad targeted activity, there were: 18,000 postcards distributed 1234 electroic surveys completed 70 egagemet sessios 11 drop is May tablecloths ad feedback sheets 31 had held ad podium based resposes 100 s of facilitated coversatio. The CCGs led a media campaig to support the programme. The promotioal materials desiged by HWC were take out to wider cosultatio. The postcard (appedix 4) developed to advertise the survey, was dropped ito schools (to be placed ito the childre s book bags to take home), GP surgeries ad other locatios with a likelihood of the target populatio passig through. Press releases were provided to local media ad the survey was discussed o local radio ad through the HWC ad other relevat websites. 10
Materity Matters What does a great service look like? Aalysis The Uiversity of Cumbria Health HASCE team, udertook the aalysis of the survey. They provided a quatitative aalysis which was complimeted with a thematic cotet aalysis of some of the ope-box questios. There was a variatio of types of questios across the survey icludig multiple choice questios ivitig specific resposes ad drop-dow box icludig ope questios seekig more qualitative iformatio. There was a large variatio i respose to the ope box questios ad, it was foud, the resposes were ot always related to what the questio had asked. The survey had a mixed respose rate for each questio. The results were aalysed for statistical sigificace ad relevace. However the amout ad variety of material icluded prompted may questios - ivitig further aalysis outside the scope of the report. It is clear that people have much more to say about their materity services i Cumbria ad North Lacashire. The overall aalysis produced some headlies ad subsequet themes of iterest. These results capture idividuals perceptios of services, which ca be very persoal, so it would ot be appropriate to claim geeralisability. However, the material is also potet ad, withi the limitatios of the method, ca provide some useful poiters for further aalysis ad discussio. 11
Part 2 Report of the Survey The results below are preseted to match the five mai sectios of the electroic survey plus a summary of reflective thoughts. Threaded throughout the differet themes are quotatios i large prit that lik ito the qualitative aalysis of each area from the ope box questios. The report fiishes with the mai themes put forward through the cafe style tablecloth exercise, costitutig what does a great service look like? We have used the qualitative aalysis to supplemet the survey fidigs. Sectio 1 - Details about the respodets Geder, ethicity, age ad disability Of the 1234 resposes, 1156 (94%) of the respodets were female. I relatio to ethicity, 1188 (97%) of the respodets were White British. 18 described themselves as white other. There were two respodets from a Idia backgroud ad oe from a Malaysia backgroud; this does to some extet reflect the lack of ethic diversity i Cumbria. The highest age groupig - 401 respodets (33%) was 31-35years. There were 300 aged 25-30 ad 202 aged 36-40 i the ext largest groupigs. 41 people (3%) replied that they were disabled. Use of materity services 76% had used materity services over the past five years. This meas that they were reflectig o recet experieces maily withi Cumbria services. Of those wome, (18%) were curretly usig materity services ad 8% were itedig to be usig services i the future. District The highest respose rate was from those i Copelad, followed by Allerdale. This may have bee because of a wider cocetratio of activity evets i that area. However, the survey was web based ad, as discussed earlier, West Cumbria s had bee historically egaged i campaigig. This populatio is curretly cocered about maitaiig a local materity service, which may also have led to a more vigorous respose. For future referece ad aalysis, the survey had also collated 1182 postcodes of the respodets. Chart showig respose rate by area. Allerdale Carlisle Copelad Ede Furess South Lakelad North Lacashire 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 12
Materity Matters What does a great service look like? Sectio 2 Pre pregacy Themes ad figures pre-pregacy Whe asked how iformed respodets were prior to pregacy, 52% felt that they were reasoably iformed. This questio allowed space for commet which icluded that may wome already had childre ad had leared by experiece. Others talked about doig their ow research, whilst some others reported a lack of iformatio forthcomig. Overall the respose was rated 3 out of 5. Havig had my baby i aother regio, I was slightly apprehesive as I had bee previously told that the materity services i Cumbria were poor. I did ot fid this to be the case however! Respodets were also asked i a ope box questio, what their impressios were about materity services i Cumbria or North Lacashire before pregacy. May of the resposes were positive but there was, predictably, metio of the Furess Geeral Hospital tragedy as well as very positive metios of West Cumbria materity services. Some people had o opiio at all o this questio. At the ed of sectio two, respodets were directed to the rest of the survey if they had bee through pregacy, or to the ed of the survey if ot; 830 respodets (89%) of the 933 who aswered this questio carried o. 13
Sectio 3 - Care ad support durig pregacy Ateatal checks Prior to birth the level of satisfactio with ateatal checks, ad their locatio, were 88% positive. There were 12% usatisfactory resposes due to: Car parkig difficulties Ucomfortable coditios at some commuity settigs, ad; Excessive travel. Based o the survey results, Excessive travel (see Figure 1), would seem to be over 40 miutes. A cosultat led materity is what we deserve to have Fig 1. Reasoable travel time to access ateatal care? Less tha 20 miutes 20-40 mis 40 mis - 1 hour 1 hour - 1 hour 20mis 1 hour 20 mis - 1 hour 40 mis 1 hour 40 mis - 2 hours Ateatal Classes I regard to ateatal classes, the overall respose shows a sigificat reply reportig satisfactio. I a closer aalysis of commets, the importace of locally accessible classes, i order to meet other parets, was sigificat. The resposes were aalysed for causes of dissatisfactio with ateatal classes to highlight areas for improvemet. Fig 2. Ateatal class satisfactio levels We are quite isolated where we live, so we were happy to be able to access services that are relatively close to us. 700 600 500 400 300 200 100 0 Satisfactory Usatisfactory Cotact ad Iformatio The geeral theme to emerge regarded issues aroud cotact ad iformatio. Some o-first time parets reported feelig beig overlooked. Although they were familiar with the process, they would have liked a refresher course. Some respodets had missed out i areas where ateatal classes were highly atteded ad felt they should have bee iformed sooer regardig ateatal classes. 14
Materity Matters What does a great service look like? Our so was bor before the ateatal classes I relatio to satisfactio aroud geerally havig time to talk to their doctor or midwife about ay issues or decisios regardig their care, 90% of respodets felt it was at least adequate. Figure 3: Satisfactio levels regardig time allocated to discuss decisios ad issues relatig to materity care Eough time About right Not eough time It s ice to have a midwife who has the kowledge of the full pregacy to date A. I a hospital uit B. I a uit with midwives etc C. I a uit with midwives oly Table 1: Where the baby should be bor 12 Aswer Choices D. At home with Commuity Midwife 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Resposes A. I a hospital uit with midwives ad doctors (called a Obstetric Uit). 69.24% 556 B. I a uit with midwives, ext to or aloside a hospital uit with doctors ad cosultats (called a Alogside Midwifery Uit). C. I a uit with midwives oly (called a Freestadig Midwifery Uit). D. At home with a commuity midwife. 20.30% 163 5.23% 42 5.23% 42 Whe asked where the respodet would prefer the baby to be bor, 69% preferred a hospital settig with midwives ad doctors (a cosultat led uit) ad 20% i a midwifery uit alogside a hospital uit. Oly 10% favoured a freestadig midwifery uit or a home birth. Whe asked what a reasoable travel time would be to where the baby was bor, 60% replies less tha 20 miutes ad 37% betwee 20 ad 40 miutes. 12 The questio reflects the NICE guidace to offer wome four places of birth. 15
Sectio 4 - Care ad support durig the birth Experiece through labour ad birth Respodets were asked to commet o their treatmet durig labour ad birth. The majority reported a good or excellet stadard of treatmet. The service we received was exemplary 2.64% 1.81% Two themes related to low levels of satisfactio were highlighted: Respodets reported poor treatmet due to staff members ot listeig to them particularly i terms of their birthig pla ad pai relief Respodets reported dissatisfactio due to overstretched staff, which left them uchecked for log periods of time. The aaesthetist was very rude Figure 4: Treatmet durig labour Good stadard of treatmet Poor treatmet Not eough staff 95.55% he said if I did t shut up he would t give me the epidural The midwives were so busy, they did t seem to have a break Birthig Plas The majority of respodets felt that their birthig pla had bee followed as much as possible uless it was ot possible due to uforesee complicatios. 44 respodets reported that their birthig pla had ot bee followed, particularly i terms of pai relief. I was beig told to get a epidural by the midwife whe I did t wat it 700 Figure 5: Birthig Pla ad prefereces 600 500 400 300 200 100 0 Birthig Pla followed Birthig Pla ot followed No Birthig Pla 16
Materity Matters What does a great service look like? Birthig Rooms Birthig Rooms were geerally well appreciated. It was comfortable ad clea, I have o complaits Figure 6 demostrates overall levels of satisfactio, i relatio to experieces at Cumberlad Ifirmary, Furess Geeral Hospital, Perith Birth Cetre, Helme Chase, West Cumberlad Hospital ad Royal Lacaster Ifirmary. There were o egative or mixed commets from respodets who gave birth at Helme Chase ad Perith Birth Cetre. 600 500 400 300 200 100 0 Satisfactory Mixed Usatisfactory Figure 6: Birthig room levels of satisfactio My parter was set home I wated him to be there Where there were commets about usatisfactory or mixed levels of satisfactio, Figure 7 shows the mai causes based upo a cotet aalysis of the commets provided: The mai reaso give came uder the theme of room stadard ad size. This icluded poits such as the quality of the décor (e.g. curtais eeded replacig ), as well as the space to accommodate parters. This last poit appears agai whe respodets were asked about their experiece of the whole pregacy, ad metioed parters ot beig allowed to stay o the ward. Fig 7. Mai causes of dissatisfactio with Birthig Room Shared bathroom Clealiess Room stadard ad size Noise Ucomforable room was clea, maybe the curtais could of doe with beig chaged but other tha that, good effort 17
Sectio 5 - Care ad Support After the Birth Iterestigly, 97% of respodets said that the baby was bor i hospital, higher tha previous figures from the atioal surveys, although wome i Cumbria have less choice of birth places tha most other parts of Eglad (RCOG, 2014). The questios i this sectio are aimed at the reflectios of the respodets. Post birth treatmet ad care Experieces of support ad iformatio whilst i hospital were aalysed i terms of positive ad egative experieces. Figure 8: Support ad iformatio provided by hospital post-birth 600 500 400 300 200 100 0 Adequate Support ad Iformatio Iadequate Support ad Iformatio Negative experieces were reported oly i Cumberlad Ifirmary, Furess Geeral Hospital, Royal Lacaster Ifirmary ad West Cumberlad Hospital: Staff Support Overstretched Professioal Attitudes Lack of Cosistecy Lack of Breast Feedig Support Beig Left to it Staff A high umber of respodets reported feeligs of the staff beig overstretched o the materity ward, particularly at Royal Lacaster Ifirmary ad West Cumberlad Hospital. This led to ot oly usatisfactory reports of feelig rushed or forgotte about but also reports of cocer of midwives wellbeig. Everywhere seemed short staffed ad the midwives were ru ragged Professioal attitudes of midwifery staff was also a theme highlighted withi the resposes. Reports of a lack of compassio ad poor professioal attitudes from some staff members resulted i a egative experiece of aftercare o the materity ward. The doctor was havig a row with the midwives as I was sat there i the stirrups waitig to be stitched up A umber of usatisfactory resposes were due to a lack of cosistecy of advice betwee materity staff, leadig to cofusio ad frustratio. 18
Materity Matters What does a great service look like? Support A lack of breast feedig support was the leadig cause of dissatisfactio regardig support resposes to this questio. Agai, some dissatisfied respodets reported icosistecies regardig breast feedig advice from midwives. I was left to my ow devices whe the baby was strugglig to feed May resposes from mothers who were ot first time mothers teded to idicate that they had bee left to it. Whilst some respodets preferred this approach, others reported feeligs of beig overlooked ad would have preferred more assistace. Leavig hospital Overall, i relatio to leavig hospital, there was a large proportio of cofidece. For those who had experieced feeligs of axiety about beig discharged, this was maily due to perceptios of: 5.22% 5.07% Beig discharged too soo after log or traumatic births Breastfeedig axiety Lack of support while o the materity uit which left patiets feelig vulerable ad uprepared upo discharge. 90.755% Dissatisfactio was expressed whe there were: I was happy to leave the hospital whe I did Log ad arduous discharge procedures Poor facilities that left patiets watig to leave prematurely. Fig 9. Respodets feeligs regardig leavig hospital Happy ad cofidet Axiety Dissatisfactio The support was really good At home The levels of support ad iformatio from health care professioals, whe retured to home, largely reported as good or excellet. 700 600 500 400 I was emotioal leavig as my baby was still i the 300 200 100 special care uit 0 Good level of support ad iformatio Not eough support ad iformatio Fig 10. Levels of satisfactio of support ad iformatio provided by health care professioals at home. 19
Differet people had differet iterpretatios ad advice The first two weeks of visits caused me to feel iadequate as a mother The mai themes emergig from the egative experieces were: Breastfeedig Support - more support was required regardig breastfeedig, alogside frustratio with health visitors criticised for givig coflictig advice regardig breastfeedig. Differet people had differet iterpretatios ad advice. From Health Visitors respodets felt that health visitors could be more ope mided regardig differet paretig optios ad more supportive with sesitive issues, such as post-atal depressio. The first two weeks of visits caused me to feel iadequate as a mother. Staff Cotiuity - respodets were uhappy about lack of cotiuity of health care visitor or midwife, which fits with the first poit i this sectio about coflictig advice ad iformatio provided by staff. It was felt there are differig stadards of care betwee the care provided by midwives ad that provided by health visitors. There were also commets about the service provided by health care visitors perceived as uprofessioal. The theme of staff cotiuity was also expressed whe respodets were asked directly, via a 1-5 Likert Scale, what the importace was of beig supported by the same, small team of midwives. This figure demostrates the importace placed o cotiuity by the wome. Figure 11 (right) shows the mea average of resposes to this questio. 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 You re able to build a trustig relatioship with your midwife, this eables you to ask questios ad take advice 20
Materity Matters What does a great service look like? Sectio 6 -Reflective levels of ivolvemet Respodets aswered usig a Likert scale to idicate their level of ivolvemet. They were the provided the opportuity to explai their resposes further. These resposes were the aalysed to highlight key areas of cocer: Fig 12. Experieces through the whole of pregacy Likert scale. Did you feel ivolved i the choices ad decisios about the followig. 900 800 700 Yes - I was ivolved i the choices ad decisios ad it was followed through 600 500 I was ivolved i the choices ad decisios but due to circumstaces it was ot possible at the time 400 300 I was ivolved i the choices ad decisios but I felt it was ot listeed to 200 No - I was ot ivolved i the choices ad decisios but I was cotet with that 100 0 No - I was ot ivolved i the choices ad decisios I'm ot sure/not applicable to me Where to have the ateatal checks Where to have the screeig checks The birth pla Where to give birth What kid of birth to have e.g, water birth, cesarea sectio Positios i which to give birth How to maage the pai of labour Thikig how to feed the baby A parter beig able to stay overight Where to have postatal checks How may postatal checks Overall the mai themes to emerge through the aalysis, based o what has bee reported above were as follows: Parters Stayig o the Ward There is cocer about parters ot beig able to stay overight, both prior to ad post birth experiece There is frustratio with visitig times - ie parters were ot allowed to stay after their parters had bee iduced which would help ease feeligs of fear ad exhaustio. My husbad was set home ad I sat aloe ad cried 21
Patiets Not Listeed To Feeligs of ot beig listeed to durig the labour Choice to access pai relief ad birthig positio Some reports of o choice or ifluece over the delivery ad that they had bee pushed ito decisios they were uhappy with. I felt aloe ad vulerable I wish I d kow that beig iduced reduces Ward Overcrowdig ad Lack of Facilities your freedom to choose what happes Some were uhappy that birthig pla could ot be followed due to busy wards ad lack of facilities - i particular the choice to access a birthig pool. Excessive Travel Fear of birthig plas ot beig possible to follow due to excessive jourey legth to the hospital. Much of this issue was based i West Cumbria where there are cocers of the closig of the WCH materity facility. 21.23% 0.80% Relatioships with Medical Professioals I lookig at what worked ad what did t work well, it was clear that the majority of respodets were extremely positive about all staff cocered with their materity experiece. They said i geeral that they: Received high levels of care Had excellet relatioships with the midwives, GPs ad cosultats at each stage Ejoyed feeligs of reassurace due to the friedly ad approachable maer of the midwives Appreciated the ability to cotact midwives by telephoe at ay time with their cocers Had strog relatioships formed with their commuity midwives particularly for those who had bee able to see the same midwife cotiually. This cotiuatio was highly valued. 6.27% Figure 13: Professioal relatioships helped through pregacy 77.97% All staff members Midwives Ateatal class staff 13.99% 10.29% 17.20% 3.05% 49.20% We were iformed every step of the way Figure 14: Areas that did t work well i professioal relatioships No complaits Cotiuity Overstretched ad busy wards Poor professioal coduct Commuicatio betwee departmets Poor aftercare 22
Materity Matters What does a great service look like? Just uder half of the respodets reported o complaits at all. However, for situatios ad experieces where thigs had ot worked so well, there were five mai themes cited: Poor Professioal Coduct Respodets who reported to this questio talked of experieces of poor professioal coduct from cosultats ad midwives. Of the various complaits of poor coduct, the leadig themes were: As a youg perso I foud I was patroised Some cosultats poor people skills A lack of patiece ad poor attitudes from staff members which left the respodets feelig uhappy ad usupported The perceptio of ot beig listeed to Fidig some midwives to be pushy ad rude which resulted i poor relatioships with their midwives. Some of the midwives could be icer but there were two that came i Cotiuity betwee the differet staff members who the mother sees Respodets were uhappy with the umber of differet midwives ad cosultats they saw. The icosistecy of staff members resulted i failure of commuicatio of birthig plas, particularly i terms of pai relief. This led to feeligs of icosistet care ad support. There was a distict lack of trasitio the agecy midwife was very abrupt I asked for o studet urses Over-stretched Staff ad Busy Wards A umber of respodets felt that staff members were overstretched which took away from the care they felt they should have received. Busy wards resulted i log ad ucomfortable waitig times. They seemed to be very busy Poor Commuicatio Respodets reported poor commuicatio, both betwee hospitals ad betwee midwives ad cosultats which left them feelig frustrated ad resulted i a loss of cofidece. For example, o occasio persoal details ad materity iformatio were lost. Poor Aftercare A umber of respodets felt that their aftercare could have bee better, particularly i terms of breast feedig support but also i immediate aftercare o busy wards, where some respodets felt they had bee rushed home before they were ready. There eeds to be much better breastfeedig support both i hospital ad at home 23
32.09% 32.56% Suggested improvemets Respodets were give the opportuity to provide their thoughts ad ideas as to how to improve the experiece of materity services. The key areas highlighted through aswer aalysis are show i the followig chart. 9.77% 9.30% 16.28% Figure 15: Suggestios of improvemet to materity services Icreases staffig levels Greater support More discussios over birthig optios Better commuicatio ad orgaisatio betwee departmets Keep materity services local Maybe takig ito accout previous pregacies ad the experiece that you gai as a mum ad the cofidece that it brigs. It's importat to be iformed the first time but secod, third ad fourth, I felt I kew my body ad my baby ad I wated less iterferece from others 24
Materity Matters What does a great service look like? Summary of report fidigs The iformatio preseted above represets a sapshot i the perspectives of the wome ad their sigificat others who filled i the survey; they are goig through or have bee through a life chagig evet ad their views matter. The report is ot represeted as scietific but as a potet reflectio of their experieces ad views. There are themes that have emerged from the questios icludig the free text. The most sigificat of these were: The importace of cotiuity of care throughout the pregacy, the birth ad postatal period Cosistecy ad quality of iformatio ad commuicatio Postatal support for breastfeedig Support ad iformatio for wome to make iformed decisios ad choices Accessible services ad choice, thikig about some specific issues such as youg mums, wome with specific eeds, travel, ad place of birth Additioal qualitative material I additio to the survey, we used the more qualitative data gathered from the facilitated groups which had used the café style tablecloths iformatio as explaied earlier. The tablecloths were aalysed thematically by two separate ad idepedet researchers. Usurprisigly, it was foud there was much i commo with the results of the electroic survey, so there is a good match with the survey headlies. We have set the themes that emerged from the additioal qualitative aalysis ito a list to provide a summary respose to the questio we asked at the begiig: What does a great service look like? I additio to the fidigs above, the qualitative aalysis from the tableclothes would suggest some further themes: A great service would have: Well traied midwives who are kowledgeable ad pleasat Midwives who are properly supported i their role Eradicated the eed for agecy staff Cotiuity of midwife support throughout pregacy ad labour Holistically well traied health care staff Health care staff beig respectful to the wome ad families they serve Good commuicatio beig practiced ad fostered betwee staff ad staff ad betwee staff ad wome Sesitivity towards family wishes ad eeds Wome treated as autoomous adults. The coversatio was about explorig views. There is a wealth of iformatio available that has bee geerated by the coversatio, icludig permissio from 235 respodets who gave their e mail addresses for follow up cotact. Similar to the 2006 West Cumbria Survey, much more ca be extrapolated if there is a will to do so whe future choices eed to be made. February 2016. 25
Refereces Adewoye, S., Guise, S., & Stamper, D. (2008) West Cumbria Commuity Materity Survey 2007: Prelimiary Report, North Cumbria MSLC ad Cumbria PPIF; NHS Cumbria CCG. BBC, March 3rd 2015 - http://www.bbc.co.uk/ews/health-31699607 Cumbria NHS Primary Care Trust (2007) Closer to Home: A NHS cosultatio o providig more healthcare i the commuity i North Cumbria, 27 September 2007 to 4 Jauary 2008, Perith. Falcoer, A., Broderick, C., Eardley, S., Kirby, J., Lambert, J., Leather, A., Rasaayagam, R. & Wilso, N. (2014) Optios Appraisal: Recofiguratio of Obstetrics ad Materity Services i Cumbria, Lodo, Royal College of Obstetricias ad Gyaecologists. Ham, C. & Murray, R. (2015) How the NHS is regulated i Implemetig the NHS five year forward view: aligig policies with the pla, Lodo, The Kigs Fud Healthcare Commissio (2007) Wome s experieces of materity care i the NHS i Eglad: key fidigs from a survey of NHS trusts carried out i 2007), Lodo, Commissio for Healthcare Audit ad Ispectio. News ad Star (November 6th 2014) Campaigers take fight to save hospital services to Dowig Street, Article by Jei Barwise, http://www.ewsadstar.co.uk /ews/campaigers-take-fight-to-save-hospitalservices-to-dowig-street-1.1173179 NHS Cumbria CCG Goverig Body (2015) Royal College of Obstetricias ad Gyaecologists (RCOG) Materity Review Update, Ageda umber 11, 7th October 2015, see - http://www.cumbriaccg.hs.uk/about-us/howwe-make-decisios/goverig-body-meetigs/2015/2015-07-10/11materityreviewreport.pdf NHS Cumbria CCG (2015) Together for a Healthier Future a five year pla for the North Cumbria local health ecoomy http://www.cumbriaccg.hs.uk/get-ivolved/egagemet/together-for-ahealthier-future/togetherfor-a-healthier-future-summary.pdf NHS Eglad (2013) Trasformig Participatio i Health ad Care - https://www.eglad.hs.uk/wp-cotet/uploads/2013/09/tras-part-hc-guid1.pdf NHS (2014) Five Year Forward View see https://www.eglad.hs.uk/wp-cotet/uploads/2014/10/5yfvweb.pdf NHS (2015) Success Regime http://www.successregimecumbria.hs.uk NHS (2015) Better Care Together Strategy: the future for health ad care services i Morecambe Bay, Better Care Together Team, NHS Moor Lae Mills Moor Lae, Lacaster LA1 1QD. NHS CQC (2015) Survey of wome s experieces of materity care, Statistical Release NHS CCG (2015) Headlies from Earlier Egagemet o Materity Services NHS Eglad (2015) Materity Review Terms of Referece see https://www.eglad.hs.uk/wpcotet/uploads/2015/03/materity-rev-tor.pdf NHS Trust Developmet Authority (2015) Success Regime Iitiative see http://www.tda.hs.uk/blog/2015/06/03/orth-cumbria-to-beefit-from-success-regime Nicol, E., & Eato, S. (2013) Health Leadership for the 21st Cetury a ew, holistic, co-productive edeavour i C. Davies, R. Flux, M. Hales ad J. Walmsley (eds.) Better Health i Harder Times, Chapter 35, pp143-148, Lodo, Policy Press Ltd. Royal College of Obstetricias ad Gyaecologists (2014) Optios Appraisal: Recofiguratio of Obstetrics ad Materity Services i Cumbria, by Falcoer, A., Broderick, C., Eardley, S., Kirby, J., Lambert, J., Leather, A., Rasaayagam, R. & Wilso, N. Lodo, RCOG. Whitehave News, (28th July 2005) Do t Move Our Mums! article by Gill Elliso - http://www.ewsadstar.co.uk/do-t-move-our-mums-1.403498 26
Appedices
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 28
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 29
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 30
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 31
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 32
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 33
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 34
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 35
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 36
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 37
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 38
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 39
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 40
Appedix 1 Materity Matters What does a great service look like? Survey Mokey 41
Appedix 2 Materity Matters What does a great service look like? Facilitator otes 42
Appedix 2 Materity Matters What does a great service look like? Facilitator otes 43
Appedix 2 Materity Matters What does a great service look like? Facilitator otes 44
Appedix 2 Materity Matters What does a great service look like? Facilitator otes 45
Appedix 3 Materity Matters What does a great service look like? Storyboards 46
Appedix 3 Materity Matters What does a great service look like? Storyboards 47
Appedix 3 Materity Matters What does a great service look like? Storyboards 48
Appedix 3 Materity Matters What does a great service look like? Storyboards 49
Appedix 3 Materity Matters What does a great service look like? Storyboards 50
Appedix 4 Materity Matters What does a great service look like? Survey Postcards 51
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