Local Maternity System Board Plan

Local Maternity System Board Plan Fay Baillie on behalf of the Herefordshire & Worcestershire LMS Board September 2017 1

Executive Summary The birth of a child should be a wonderful, life changing time for a mother and her whole family. It is a time of new beginnings, of fresh hopes and new dreams, of change and opportunity; it is a time when the experiences we have can shape our lives and those of our babies and families forever. These moments are so precious, and so important. It is the privilege of the NHS and healthcare professions to care for women, babies and their families at these formative times. (5 year Forward Review for Maternity Services Better Births. 2016. To deliver this vision Baroness Cumberledge set out an ambitious new model of commissioning The Local Maternity System (LMS). At the same time the Secretary of State asked for a 20% reduction in Stillbirths, neonatal death, Maternal Death and neonatal Brain Injury by 2020 and a 50% reduction in the same by 2030, this is based on 2010 data. Local Maternity Systems will also implement the recommendations from the Marmot Review (2010) and the Annual Report of the Chief Medical Officer, Our Children Deserve Better: Prevention Pays (2012) which states that the health and nutrition of expectant mothers is critical to the physical, emotional and intellectual wellbeing of their unborn babies, both pre and post birth. Herefordshire & Worcestershire providers will ensure that midwives and the broader workforce involved in supporting women and their families play a crucial role in enabling every child to have the very best start in life and in reducing health inequalities across the life course. The LMS has been established on the Sustainability and Transformation Partnership (STP) local population footprint of Herefordshire and Worcestershire. The purpose of the LMS is to deliver this vision and provide place-based planning and leadership for transforming the way maternity care is delivered to women and new-borns. The plan will develop how the Local Maternity System in Herefordshire & Worcestershire delivers the following by the end of 2020/21: Improving choice and personalisation of maternity services so that: o All pregnant women have a personalised care plan. o All women are able to make choices about their maternity care during pregnancy, birth and post-natally. o Most women receive continuity of the person caring for them during pregnancy, birth and post-natally. o More women are able to give birth in midwifery led settings (at home and in midwifery units). Improving the safety of maternity care so that by 2020/21 all services: o Have reduced rates of stillbirth, neonatal death, maternal death and neonatal brain injury during birth by 20% by 2020 and 50% reduction by 2030. o Are investigating and learning from incidents and sharing this learning through their Local Maternity System and with others. o Fully engaged in the development and implementation of the NHS Improvement Maternity and Neonatal Health Safety Collaborative. 2

Vision for the Worcestershire & Herefordshire Local Maternity System Our vision is that our citizens have access to high quality, safe and sustainable, acute, Women and new-born/neonatal and mental health services localised where possible and centralised where necessary. Our Vision The removal of traditional county boundaries with sharing of community and hospital based resources across a wider area. This is not expected to result in a change to the provision of obstetric services in Herefordshire. A joint maternity care offer with common clinical pathways that guide women to the most clinically appropriate place of birth. Review maternity specifications to reflect the requirements of a local maternity system. Our Values We commit to: Listening to women & families Achieving personalised care Learning together To be better than the national average Working together to sustain viability Our LMS partner Organisations Worcestershire Acute Hospitals NHS Trust Wye Valley NHS Trust Worcestershire Health & Care NHS Trust West Midlands Ambulance Service Public Health England Worcestershire Clinical Commissioning Groups Herefordshire Clinical Commissioning Group NHS England Health Education England NHSE Specialised Commissioning University of Worcester Healthwatch Herefordshire Healthwatch Worcestershire Worcestershire County Council Herefordshire Council Maternity Voices Partnership 3

Background to the Herefordshire & Worcestershire Maternity System Local Locality Data Herefordshire Council Herefordshire CCG Wye Valley NHS Trust 2gether NHS Foundation Trust Taurus GP Federation Worcestershire County Council Redditch and Bromsgrove CCG South Worcestershire CCG Wyre Forest CCG Worcestershire Acute Hospitals NHS Trust Worcestershire Health and Care NHS Trust 4 Primary Care Collaborations Herefordshire and Worcestershire is one of the largest counties with one of the smallest populations. It has the M5 running through the centre of Worcestershire and the M50 running from the M5 to South Wales through Herefordshire. There is a good road infrastructure across the county but very poor public transport services, e.g. there is no direct bus or train line from Redditch to Worcester. This means the population of Redditch have to travel to Birmingham or Bromsgrove to access hospital services at Worcester when using public transport. Many of the villages around Evesham, Malvern, Ledbury, and Bromyard do not have a daily bus service. By way of example the distance between Hereford County Hospital and Worcestershire Royal Hospital is more than 30 miles and typically takes more than an hour to drive on single carriageway roads The population of Herefordshire & Worcestershire is approximately 785,000. The population is 97% white with 2% Polish & Eastern European, 0.5 % Asian & Afro-Caribbean. The population is centred around two main cities, Worcester and Hereford, with many young people moving for work to Birmingham, Gloucester and Bristol. There is a good train network between Worcester and Hereford. There is a large rural population which means that there are migrant and casual labourers as well as an extensive Gypsy, Romany traveller communities around Evesham and Hereford. There is also a high incidence of teenage pregnancy predominantly in Worcester City Centre. 4

Public Health Data - The following public health data, which determines and influences Fetal and Maternal Wellbeing, has been derived from the Local Authorities. The following analysis, comparison and trends between Worcestershire and Herefordshire have been used to establish the LMS priorities and objectives. Below are the vital elements of data used to base the LMS plan upon. To view the full data sets, please see appendix. 1. Smoking in Pregnancy Definition: Percentage of women who smoke at time of delivery 1.1 Herefordshire and Worcestershire in context 2. Maternal Obesity Definition: Percentage of women who are classified as Obese at booking appointment (where valid height and weight recorded). This data is collected via the national Maternity Services Minimum Dataset and reported monthly by Provider. 2.1Herefordshire and Worcestershire in context The following graph shows the official reported percentage of women classified as obese by month by Provider for the latest period (April 2016 February 2017). 5

Percentage of Women classified as Obese at Booking 2016/17 30 25 20 15 10 5 Wye Valley Worcestershire Acute 0 Worcestershire Acute looks to have almost consistently higher percentages than Wye Valley, however, care should be taken when interpreting these official statistics, as included in the denominator is those women with 'missing values'. This is a particular problem with Wye Valley who consistently reported between 15% -20% unknown values compared with just 3% of Worcestershire Acute. If we exclude the 'missing values' from the denominator the overall percentage of obese women for the 11 month period is 23.5% in Wye Valley compared with 22% for Worcestershire Acute and 20% in England. Wye Valley Worcestershire Acute BMI Band Number of Number of women seen women seen at booking % of total % with band at booking % of total % with band Underweight * suppressed because of small numbers 135 2.5% 2.6% Normal 745 41.6% 50.7% 2525 47.2% 48.4% Overweight 380 21.2% 25.9% 1410 26.3% 27.0% Obese 345 19.3% 23.5% 1145 21.4% 22.0% Missing Value 320 17.9% 140 2.6% Total 1790 5355 Total (BMI band) 1470 5215 3. Premature Birth Rate Definition: Number of premature births (live or still) defined as gestational age less than 37 weeks per 1000 births (live and still) 6

3.1 Herefordshire and Worcestershire in context Worcestershire has a statistically significantly higher rate than England, however, Herefordshire consistently has an average rate. 4. Caesarean Section % Definition: Total number of deliveries with OPCS Procedure codes R17 or R18 as a percentage of the total deliveries 4.1 Herefordshire and Worcestershire in context Caesarean section % 2015/26 Percentage point - % The official figures above indicate that both Herefordshire and Worcestershire are statistically significantly higher than the England average. 7

5. Breastfeeding Definition: Percentage of women who initiate breastfeeding within 48 hours of delivery 5.1 Herefordshire and Worcestershire in context Both Herefordshire and Worcestershire are statistically significantly worse than England for breastfeeding initiation. 6. Stillbirth Rate 6.1 Definition: Number of stillbirths (fetal deaths occurring after 24 weeks of gestation) per 1000 births (live and still) Herefordshire and Worcestershire in context Herefordshire had a higher stillbirth rate than England in the three year period 2013-2015 although this is not statistically significant. Worcestershire was average. 8

7 Perinatal Mortality Rate Definition: Number of stillbirths and deaths of infants aged under 7 days per 1000 births (live and still) 7.1 Herefordshire and Worcestershire in context Both Herefordshire and Worcestershire have higher PMRs than England, however, these are not statistically significant. Perinatal Mortality (2013-15) Area Value Lower CI Upper CI England 6.6 6.5 6.7 West Midlands region 8.2 7.8 8.6 Birmingham 10.6 9.8 11.6 Coventry 6.6 5.4 8.1 Dudley 6.7 5.4 8.4 Herefordshire 7.7 5.7 10.4 Sandwell 9.6 8.1 11.3 Shropshire 6.0 4.6 7.9 Solihull 8.1 6.2 10.5 Staffordshire 6.7 5.8 7.8 Stoke-on-Trent 8.9 7.3 10.9 Telford and Wrekin 8.0 6.1 10.6 Walsall 8.3 6.8 10.2 Warwickshire 6.0 4.9 7.2 Wolverhampton 8.5 6.9 10.4 Worcestershire 7.3 6.2 8.7 9

8 Neonatal Mortality Rate Definition: Deaths of infants aged <28 days per 1000 live births. 8.1 Herefordshire and Worcestershire in context Neonatal Mortality (2013-15) Area Value Lower CI Upper CI England 2.7 2.6 2.8 West Midlands region 4.2 3.9 4.5 Birmingham 5.6 5.0 6.3 Coventry 2.4 1.7 3.4 Dudley 3.5 2.5 4.7 Herefordshire 2.8 1.7 4.7 Sandwell 4.4 3.4 5.6 Shropshire 2.2 1.4 3.5 Solihull 4.1 2.9 6.0 Staffordshire 3.4 2.8 4.2 Stoke-on-Trent 5.8 4.5 7.4 Telford and Wrekin 4.8 3.3 6.8 Walsall 5.2 4.0 6.7 Warwickshire 3.4 2.6 4.3 Wolverhampton 4.0 2.9 5.4 Worcestershire 3.5 2.7 4.5 9 Maternal death There have been two maternal deaths in Worcestershire and none in Herefordshire in the past 5 years. 10

Joint Strategic Needs Assessment The Future of Worcestershire Acute Hospital Services is a commissioning strategic vision for services in Worcestershire and has recently been agreed for implementation. In Herefordshire at the time of writing there is no clinical strategic document published by the CCG. Wye Valley NHS Trust is currently being managed by South Warwickshire NHS Foundation Trust through a management agreement set up by NHS England. The strategic intention for the LMS is to continue to have two obstetric based services, one in Wye Valley Acute Hospital Trust and one in Worcestershire Acute Hospital Trust. The LMS will remove the geographical boundaries to support women accessing the right care in the right unit. The need for access to midwife led care has been debated widely this choice for women has been accommodated in the Worcestershire Acute Hospital unit and midwife led care could be established in Wye Valley by remodelling internal pathways. There are currently a decreasing number of doctors in training in Obstetrics and Gynaecology and Paediatrics, leading to maternity and neonatal units across the country developing new ways of working to sustain local services for women and families. There are inconsistencies across the two counties in how maternity and neonatal services are commissioned and delivered, for example, there is no perinatal mental health Service and no maternity specification in Herefordshire. Associated Strategic Needs Assessments There are no perinatal mental health services within Herefordshire and this need to be developed to offer women access to services. This could be through the Worcestershire Health & Care Trust or through 2gether NHS Foundation Trust. Neonatal care has been reviewed by specialist commissioning and a strategic vision has been published (2016) which outlines how the neonatal networks plan to maximise cot occupancy and keep mothers and babies together, as close to home as possible, whilst being in a place which maximises outcomes for both. Implications for this document for Herefordshire and Worcestershire are minimal because Wye Valley NHS Trust offers transitional care and level 1 cots and Worcestershire Acute Hospitals offers level 2, 1 and transitional care. Better Birth sets out care as close to home as possible, being delivered through HUBS. The LMS has identified geographical bases to offer this but believe the economies of scale and opportunity to link other services for families would be a strategically stronger opportunity for the STP programs of care being developed. 11

Service Provision Wales Worcestershire service provision Currently at Worcestershire Acute Hospital Trust women are offered Obstetric Consultant Led care, as alongside birthing unit and Home Confinement. The service offers level 2 Neonatal intensive care, high dependency, special care, transitional care and outreach Care. Community Midwifery services are geographically split over 4 areas, being based in Worcester City, Kidderminster, Bromsgrove & Redditch and Evesham. The unit supports a population of 6000 women and delivers approximately 5650 per annum. The difference in the population deliver in Gloucester, Warwick and Birmingham. Herefordshire service provision In Wye Valley NHS Trust there is a Consultant Led and a Home Confinement service. Midwife led care is offered however there is no defined separate midwife led delivery area. There are level 1 special care unit cots. The unit supports approximately 2000 women across the county, delivering 1700 women per annum. The population gap delivers in Shropshire, Gloucester or Worcester. Wye Valley support approximately 150 birthing women from across the Powys boarder per annum. These women have a high home confinement rate as the distance to travel to the hospital can be over an hour. 12

Worcester Acute Hospital Trust Shared care with GP General obstetric/maternity services Midwife Led Care Consultant Fetal medicine Cardiology ultrasound scanning Amniocentesis Joint care maternal cardiology clinics Twin Services Joint care Diabetes Pregnancy Service Joint care Perinatal Mental Health Service Consultant neonatal care levels 1 & 2 Transitional Care Outreach neonatal care Antenatal screening General Maternity Ultrasound Home birthing Alongside midwife led unit Bereavement services Post-delivery counselling care Breast feeding consultant care Parent Education Wye Valley Acute Hospital Trust Shared care with GP General obstetric/maternity services Midwife Led Care Neonatal level 1 care Antenatal screening General Maternity Ultrasound Home birthing 13

Specialist service provision Perinatal Mental Health: The impact of mental health problems experienced by women in pregnancy and during the first year following the birth of their child can be devastating for both mother and baby, as well as their families. By 2020/21, NHS England should support at least 30,000 more women each year to access evidencebased specialist mental health care during the perinatal period. This should include access to psychological therapies and the right range of specialist community or inpatient care so that comprehensive, high-quality services are in place across England. Key recent national strategies have also outlined perinatal mental health as a priority where improvements in access and outcomes for women and families are required. These include NHS England s Five Year Forward View for Mental Health4 and the maternity review report Better Births, Improving Outcomes of Maternity Services in England5 Perinatal Mental Health in Worcestershire Current service provision: Worcestershire has a Community Perinatal Psychiatry Team that is a countywide service which is commissioned to provide a service to: Meet the needs of women with severe mental disorder in pregnancy and the post-natal period up to 12 months of the infants age, including those with bonding disorder. Screen for serious mental disorder during pregnancy and offer care to those considered of high risk. To provide a service for the family network. To ensure that safeguarding is a priority and paramount, the service ensures that older children and other dependants are supported appropriately; this is often done via other services such as early help, children and family social services and the health visitor. Develop joint working relationships to facilitate admissions to a mother and baby unit if necessary. The team provides an antenatal mental health screening clinic within the acute trust existing antenatal services. This safeguards an integrated care pathway to identify those at risk of a recurrence of serious mental disorder following delivery. The Community Perinatal Psychiatry Team will provide assessment, care and treatment for pregnant women and those with a baby up to 12 months of age. The team will work in conjunction with the Child Adolescent Mental Health Service for any female aged under 17 ½ years. Referrals to the team are accepted by all professionals and we encourage referrers to contact the team for specialist advice and support which includes prescribing in pregnancy and whilst breastfeeding. The team have extensive knowledge and skills to deliver a specialist perinatal care service. The team is an integrated service between Health and County Council and consists of qualified community psychiatric nurses, social worker, psychotherapist, Consultant Psychiatrist and a specialist staff grade Doctor. The delivery of care is holistic and collaborative across all services and professionals, promoting person centred care, maternal mental health and family support. This will include mother and infant bond, psycho- social and psycho- therapeutic interventions, treatment planning and extensive specialist assessments, medication and risk monitoring. 14

The model supports the Acute Trust midwifes who have a specialist interest in mental health, this promotes stronger working relationships which bridge the gap between maternity and mental health, incorporating the parity of esteem. This ensures that all women are receiving an equitable service provision countywide. A NHSE bid to enhance the current model to ensure that the team are fully NICE concordant has been submitted, this will allow the recruitment of a psychologist, OT and community nursery nursing support to cover the gaps against national guidance. The team are working towards national Royal College of Psychiatry accreditation and subsequently the achievement of a successful bid will enable achievement of accreditation. Perinatal mental health in Herefordshire Current service provision: Local statistics identify that just under 50% of women commence their pregnancies with varying levels of need with regard too emotional, depressive illness to chronic disorders that predisposes them during their pregnancy and post- delivery to increased illness and poorer outcomes for the babies. Currently Wye Valley NHS Trust do not have a robust system of support or help for vulnerable women. There are no commissioned counselling referral pathways and no mental health referral support mechanisms. A local bid for NHSE perinatal mental health development through the STP is being developed with "2Together ", the mental health provider in Gloucester. The Obstetrician and Midwives identify and monitor the mental health and emotional needs through careful assessment during planned and emergency contacts. Findings are recorded in the electronic patient record. There is no real referral pathway to Psychologist or Psychiatrist. Women with complex pre - existing factors often have a community psychiatric team support and treatment, however those with lower level vulnerability do not. When a woman becomes acutely ill a referral to the crisis team is made but can only happen if the woman is an inpatient. Where there are low level anxieties support with CPN and GP/medication, personalised management plans are developed with woman for appropriate support. Should a women require a referral to a Consultant psychiatrist this is made by the Consultant Obstetrician or general practitioner. Specialist commissioning of Neonatal services; Specialist commissioning have completed a review of neonatal services nationally. An interim report has identified the opportunity to increase cot occupancy at WAHT and use the level 1 cots better at Wye Valley. This objective supports the Herefordshire and Worcestershire LMS plan to identify babies at risk and offer the most appropriate place of birth. This change in pathway designed to ensure capacity is maintained so the hospital offering the right level of care required can be accessed and retaining all level 2 and 1 neonatal care within the counties.this will mean the level 3 units need to also move women to a level 2 unit, if that s the right level of care, to create capacity. Worcester have been working with the network to review unintended admissions to the NNU and action plans were developed to correct practice last year as part of a CQUIN. This led to practice change in the giving of hypo stop, the wearing of red and green hats for the babies in post-natal and increased training and awareness of cold babies care and treatment. This year the CQUIN is centred on neonatal out- reach development and the potential for home photo therapy being developed. 15

More work and improved joint working is required to enable returning babies to the unit close to home to improve families experiences and maintain cot capacity across the network. Activity (total births including location of birth, neonatal activity by level and location of unit) 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Local Maternity System Baseline Data, 2016/17 Herefordshire % Worcestershire % National target Baseline activity data 2016/17 Workforce We have a stable workforce in our LMS, turnover for trained midwifery staff is less than 10% as staff tend to move to Herefordshire and Worcestershire to live and don t move. The age profile of midwives is one where the most experienced midwives are in the over 55 age bracket. This will need to be carefully managed as midwives can retire at 55 years. Flexible retirement and part time flexible working are options for both units to retain staff. Research from Aston University, Lancashire University and work based studies looking at the generational differences and attitudes from the baby boomers to generation z needs to be carefully integrated in to our plan to ensure we have a work force who is able to offer what women and families want from maternity services. Delivering continuity and 1 to 1 care as an ambition in Better Births may not be what our work force can offer. In Neonatology there continues to be difficulties in achieving qualified in speciality nurses. This is due to difficulties in releasing staff to complete the qualified in speciality course but fundamentally it is difficult to attract nurses to work in the speciality. That means we need to think differently and offer 16

more creative roots into through transitional care, secondments to the transport team, or level 1 2 or level 3 units or outreach. Medical staffing, consultant numbers are achieving full establishment. There are different models in both units with consultant s resident on call in Wye Valley NHS Trust and a traditional on call system for Worcestershire Acute Hospital. Both units have paediatric consultant rotas which cover Neonatology. The main problem for both units is one where the doctors in training grades are not consistently filled by Health Education England leading to difficulty in planning and delivering activity. The risk associated with this is an over reliance on locum or temporary staff which is linked to an increase in recorded serious incidents and Caesarean Section. Workforce numbers for the different disciplines are proved in the appendix document. System engagement, Interdependencies and alignment with the STP All provider organisations, commissioning organisations and the Local Authorities have ratified the terms of reference and reporting lines of accountability through their executive team, Board or governing body. Support organisations have been involved in the development of the Herefordshire and Worcestershire LMS. Patient groups and patient advocates have been actively involved and approved the development of the LMS and the proposed ways of working. The LMS actively works with the West Midlands Clinical Senate, Southern Midlands Maternity and Neonatal network, the Midlands and East Maternity Alliance and Local West Midlands maternity and new-born alliance. The LMS is actively participating in research, through CLAHRC WM [the west midlands collaborations for leadership in applied health research and care] Place of Birth. The LMS is linked to the STP through the communications and the information technology work streams. In STP workforce discussions, joint roles for obstetricians and gynaecologists and paediatrics and neonatology are discussed in relation to the maintenance of level 2 networked care and training of generalist to continue to support rural units. In the STP elective care and primary care work streams fertility care and management plans are scheduled to be discussed following the commissioned service specification being published. Financial Case for Change The financial case for change has been driven by the need for the population to have local maternity services which are sustainable. The service leaders recognise that both Herefordshire and Worcestershire need the skills and capital infrastructure to work together to be viable. It is also recognised that there are huge manpower shortages predicted for midwifery, nursing allied health professionals and medical staff which would become easier to manage if there were joint interdependencies and collaboration. Maternity services are financially supported through a tariff which is paid in 3 care bandings, standard, intermediate and intensive for antenatal care, with comorbidities and complications and without comorbidities and complications for intrapartum, plus, standard, intermediate and intensive for postnatal care. This payment structure was first implemented approximately 8 years ago and has 17

become more and more problematic for maternity services to deliver commissioned specifications. The Secretary of State accepted the service arguments and has in 20016 increased the tariff by 8% from 2017 to support his ambition to reduce still birth, neonatal death, neonatal brain injury and maternal death. The STP Strategic Board for Herefordshire and Worcestershire agreed that the maternity and neonatal vision could only be met if any savings created through the plan be reinvested in to the emerging manpower plan. It is also recognised that the Better Births vision emphasis the need for choice and care close to home through local HUBs. These hubs will need capital to support the purchase of ultrasound machines, information technology connection and wiring to support electronic patient data from laboratories, electronic prescribing, PACs and electronic patient records integrated with tertiary level 3 units and primary care. Currently Herefordshire maternity services have an end to end electronic patient record for maternity and neonatal services, Badger net. Worcestershire has paper records and an intrapartum electronic record, K2, Neonatal services in Worcester has Badger net. To deliver the vision and dismantle the boundaries Worcester must adopt a paperless system which integrates with Herefordshire and other associated databases which enable local care delivery. The cost of this will be circa 450k capital and 7.00 per birth revenue. Capital charges for room rental are being levied for the community midwives delivering shared care in primary care settings as a result of recent changes in how the district valuator has assessed room usage in GPs surgeries despite the midwives delivering care on behalf of GPs to their patients in an agreed and commissioned model. Options will need to be explored with the Local authorities and the community providers to see if the hub model can be jointly accommodated with other specialities in the STP foot print to reduce costs. A costing model will need to be completed to truly understand the increased pressure on tariff. A full assessment of the ultrasound requirement and how this can be delivered in the hubs also needs to be completed. Cardiotocograph machines, Sonicaid monitors, carbon dioxide testing equipment and diabetic monitoring equipment and testing will be required. The cost of continuity of carer has to be modelled locally and nationally but the evidence in the Place of Birth study shows that where the women receives continuity she will have less intervention, less pain relief and a quicker recovery. This is hard to quantify in terms of cash releasing but it must be a key strategic aim for women. An understanding of what personalised budgets for women encompasses and how this is to be administered is required 18

Gap Analysis Publication Worcestershire Position Herefordshire Position GAP Better births personalised care Better birth -Perinatal mental health services is offered to all women in need Better births birth choices offered Better birth personal budgets Saving babies lives Care planning is led by the lead professional with women s input Service available for moderate and high risk women but self-help and low moral /previous history has no defined pathways Women are disappointed when they deliver elsewhere or don t get what they desire Women are unsure what this can be used for or how to access the money Smoking cessation for mother only not smoke free home Scanning skill deficit to meet demand Obesity strategy not impacting preconception as women continue to present obese Care planning is led by lead professional with women s input Women must be hospitalised before referral to a consultant psychiatrist is offered Women would like a defined midwife led care pathway Women and families are unsure on how to use this money Smoking cessation should be commissioned for the whole family The obesity strategy needs to start impacting prenatally increased mentorship and ultrasound machines are required Care needs to be planned by women and supported by professionals The LMS must commission a full service for any women who needs help or support. Mental health is the largest cause of maternal death We need to commission place of birth research to help the midwife offer consistent unbiased choice.women should not determine place of birth until there is enough information about likely comes for the pregnancy The LMS is waiting national guidance The LMS must seek smoke free homes for families by changing smoking cessation access The LMS workforce and training plans must support increased ultrasound training. The capital plans must support increased purchase of ultrasound equipment. The obesity strategy needs to be part of every contact counts in primary and secondary care Better births breaking down boundaries Better Births and saving lives and EMBRAC- learning together To breakdown boundaries the midwives and GPs need to be able to access information to deliver care seamlessly An end to end computerised patient record is required. A service specification is available Governance systems in place to identify variation and harm. Lessons learnt discussed, but themes continue to recur. Part of larger networking groups An end to end computerised record is available and boundaries are not an issue for existing referrals but women in Worcestershire or Herefordshire can interchange providers. No service specification is available Governance systems in place, recurrent themes continue.part of larger networking groups The LMS must secure an end to end computerised for Worcestershire An integrated commissioned service specification needs to be developed for the LMS Need to share and challenge more. Need to do more multidisciplinary learning which involves families. Rolling out SCOR to create uniformity of data capture and professional challenge across the sites. 19

Better births women and families involvement in care setting and commissioning The MLSC chair resigned in 2016 and the group has crumbled no meetings have been held in 2017 An active MSLC and women s forum in in place Maternity voices partnership needs to be established for the LMS Better births unwanted variation Saving babies lives and better births serial scanning, care close to home A service specification is available with a dashboard and performance KPIs Serial scanning to monitor growth is led from the hospital DAU No service specification is available,dashboard and KPIs available Serial scanning to monitor growth is led from the hospital DAU The LMS needs to exchange unit data and have a joint specification dashboard and KPIs. shared audit programs and clinical effectiveness needs to be established Serial scan should be in the community HUBS but ultrasound machines will be required. there is no capital budget Better birth community hubs Community hospital facilities to develop hubs are available Community hospital sites are available to develop Sites available to deliver the agenda but rent of rooms being requested. no non pay has been allocated to run the HUBS 20

Governance Governance structure for Local Maternity System National Maternity Board NHS England Midlands & East Maternity Board Worcestershire Acute Hospitals NHS Trust Worcestershire Health & Care Trust West Midlands Ambulance Service Wye Valley Clinical Commissioning Group NHSE Specialised Commissioning Maternity Voices Partnership Health Education England University of Worcester Trust Board Wye Valley NHS Trust NHS Worcestershire NHS England Primary Care Herefordshire LA Public Health England Worcestershire LA Healthwatch West Midlands Maternity Alliance W&C Divisional Performance review WAHT Herefordshire & Worcestershire STP Programme Board Trust Divisional Board Local Maternity System Board for Hereford & Worcestershire 21

Governance Every provider and commissioning organisation has adopted a personalised governance model based on the above example. The outside line demonstrates the relationship with the alliance and the maternity transformation board whilst the other arm represents the relationship with the STP. Each organisation has personalised their organisational reporting/governance through the centre as described. The LMS Board has been assured that each organisation has approved the governance structure. The board will be the accountable authority, seeking improvement trajectories on objectives which deliver a 20 % reduction in still birth, neonatal death, maternal death and brain injury based on 2010 data and a 50% reduction by 2930. The LMS Board will receive work group updates. It will receive feedback from the clinical senate and maternity and new born network, HEE and PHE on any National or local developments. A discussion will be developed around learning from serious incidents. This will start though each provider unit presented a closed SI to the Board to start a learning conversation. This must develop with trust to a sharing of statistics for perinatal mortality, still birth, neonatal and maternal mortality. Brain injury claims will be analysed and understood, a joint review of the past with any trends will be identified and actions adopted to learn and avoid repetition of the past. A dash board will be developed using the performance data available for both organisations. This is likely to include booking before the 12th week, smoking at booking, feeding intention, measurement of weight and actual BMI calculation, and any indicator of mental health, mode of delivery, patient satisfaction and delivery outcome. Other quality indicators will be identified and scrutinised Compliant responses will be completed in 20days. SI and comprehensive reviews will be completed in 45 days to allow the commissioner sign off and discussion. More importantly the LMS recognises this is a rich source of information and learning to be able to improve the care for women and families. The LMS alongside the National team will adopt the EMMBAC recommendations to have one way to review still birth, neonatal death and perinatal mortality, this will take over a year to implement and therefore Wye Valley and WAHT will adopt the Perinatal mortality SCOR package pending the availability of the new National product being developed. The roll of the training for SCOR (standardised computer outcomes review) is underway. A summary of the case presentation will be shared with staff at perinatal and morbidity meetings. Wye valley and Worcester prepare a dash board of outcome measures linked to the commissioner specification and national outcomes. These will be monitored at the LMC board as well as form part of each organisations governance framework. When a suspected brain injury level 2 or3 occurs each organisation will notify their legal department who will inform the NHS early resolution scheme within 14 days. Duty of candour will form part of the 22

parental discussion and a comprehensive or serious incident review will take place. This will involve the family and any care aspects they wish to understand will be included in the terms of reference. To ensure we learn together the consultants will review clinical cases from each organisation, offering challenge and debate. AUDIT Audit will be a key area of work. Initially we will use the national audit material and formulate action plans to develop working together. The EMMBRC report 14/15 will start this process CLINICAL GUIDELINES We believe that in the LMS clinical guidelines will be the key to transformational change. To this end we know this will be the most difficult area of work as it will mean tackling culture. An Organisational Development Strategy for the LMS will need to be developed to ensure cultural change happens and is embedded. We aim to start with ante natal screening as both organisations need each other to be sustainable. Families will also benefit as it gives care closer to home and increases choice. Worcestershire Acute hospital trust offers amniocentesis but only does 30 per year, to retain the service they must do a minimum of 45. Wye Valley sends 15 to Birmingham women s. This is a cost to wye valley as it is a fetal medicine referral. A clinical pathway has been developed and a service level agreement developed, it s awaiting signature, this will save money for Wye Valley and support care and choice. The next pathway will be cardiac scanning. This is currently a routine fetal monitoring service for women at WAHT. At Wye valley the women travel to Birmingham women s where they have the scan and stay in the women s for their care. This is only necessary if they require level 3 neonatal services. The women can have a cardiac scan at WAHT, have a personalised care plan and deliver locally where level 1 and 2 cots are available. WAHT has developed a fetal medicine MDT. It is hoped at it matures that the consultants from Wye Valley will join the clinical debate and from this more individualised care planning for pregnancies with problems will be managed locally and again utilise the level 2 cot availability. The LMS recognises the difficulty of running a small unit in a rural setting. The LMs has been invited to join the National Rural maternity transformation group first meeting on the 4 th October 17 and accepted the invitation 23

Postnatal care in hospital, Community hubs or at home. Hand over to Health Visitor Pre-conception care Delivery Model - Local where possible. Centralised where necessary Maternity Pathways in the Local Maternity System Single point of access to maternity services Life style choices Primary care Perinatal mental health support Home birth/midwife led unit Midwife led care Community Hub Shared care Midwife Led unit/obstetric unit Pre-conception care Specialist Antenatal Clinic Obstetric/Specialist mother & baby care Obstetric Unit with Level 2 or 3 Neonatal unit Social care support Early years support Pregnancy 9 Weeks 18 20 Weeks 28 30 Weeks Up to 28 Days 24

The model is essentially based on the traditional values where childbirth is a normal event and midwives supported by primary care, obstetricians and neonatologists working together to achieve a healthy mother and baby. Women and families are at the centre of the model and they require care as close to home as possible but they will recognise the need to move to a centralised service to achieve optimal care. The LMS covers one of the largest geographical areas in the country. This means the model has to be flexible enough to manage the rural and the urban challenges which include transport deprivation, poverty, seasonal employment, social isolation. To this end the role of primary care and shared care is essential as is linking to practice nursing district nursing the local authority support services in terms of health visiting safeguarding social care and social work, education, childcare and schools The Vision is to deliver services locally where possible and centralised where necessary. To achieve this vision local HUBS will be developed in Kidderminster, Evesham, Bromsgrove, Redditch, Ledbury, Bromyard, Leominster and Kingston with hub consultant obstetric and neonatal services based at Wye Valley and Worcestershire Acute Hospital trusts. A maternity Voices Partnership will be developed to work alongside the maternity system manager to consistently support a cultural shift from professional s acting for women to a culture of women being empowered to lead there care planning to achieve their choices. We recognise from the data that booking before the 13 th completed week is not consistently above 95% compliance. This is due to women confirming pregnancy and not being able to directly contact a service but need to see primary care and be referred. We aim to set up a single point of access which will stream line the process for women and offer a booking service in a local HUB. Wye Valley Hospital Trust will lead this project. A home assessment visit can be completed later in the pregnancy. The hubs will deliver all antenatal booking and routine screening from a group of locality based community midwives with a linked obstetric consultant in each HUB. Ultrasound scanning will be offered from the hubs by either midwives trained to do this or from a radiologist or obstetrician. Ultrasound will be for first trimester, second trimester and third trimester. Where specialist scanning or consultant advice is required this may need to be offered in the tertiary centre in Birmingham Women's and Children s Health care Trust. The hubs will offer a bespoke range of services including antenatal screening both routine and specialist, exercise, dietary advice and support, mental health outreach, health visiting, antenatal parent craft, infant feeding support, antenatal and post-natal drop in clinics, scheduled antenatal and post-natal clinics and after birth counselling and VBAC service. Specialist disease related clinics such as diabetes, twins or multiple pregnancy, cardiology, blood and endocrine disorders will be based in the hospital centres of Wye valley and/ or Worcester. Pregnancy care plans will be developed by the women and her family supported and informed by the locally based community midwives, the linked or specialist Obstetrician. 25

To ensure women are offered the widest choices in care but receive a bespoke care plan and model for them the place and range of birth choices will start to be discussed after the initial booking and data capture. Place of birth choices will be risk assessed to avoid mixed communication and disappointment though unfulfilled expectation for women and families. for example a women with known cardiac disease who is likely to have an elective premature delivery in a centre with cardiologists and neonatal intensive care should be delivered in the tertiary centre in Birmingham and we would not offer home confinement. Should antenatal support be requiring a hospital triage service will be available to contact 24/7 or the women s locality midwife team will offer an on call advisory support service? Triage will offer midwifery advise, advice to call an ambulance through 999, travel to the hospital where booked by car or stay at home and call through an agreed plan. Antenatal inpatient beds are available for monitoring of high risk pregnancies and induction of labour. A joint agreement based on risk and the women's individual care needs and choices will be agreed at 30 weeks and constantly revised alongside the continual assessment and monitoring or the mother and baby`s wellbeing. The birth discussion will offer home confinement, midwife led care in a birth unit or in a midwife led pathway, hospital based birth being midwife led and/or jointly managed with an obstetrician. Midwife 1 to 1 care will be offered during labour and delivery. Hospital services will include elective and emergency caesarean section. Pain relief will be dependent on place of birth. Delivery suite will be staffed by consultant obstetricians 24/7 and supported by obstetric anaesthetists. Post-natal care will be at home, in the hospital setting and through community drop in clinics in the HUBS. Hearing screening will be at the bedside if in a hospital setting. Women who deliver at home may need to return to a hospital for this service. An oxygen saturation test will also be carried out on your baby to screen for cardiac disease. Bereavement services will be offered to women who have pregnancy loss after 16weeks. Wye Valley and Worcester acute hospital trust maternity and neo natal services work in a network linked to Birmingham and Coventry, the network has hospital and neonatal services graded to deliver the smallest sickest babies and women, the women and babies who need less support and those where they are well and need minimal medical support. Heart of England foundation trust, Birmingham Women's and Children s NHS Foundation Trust, University Hospital Coventry & Warwick are level 3 units who care for babies less than 27weeks, Worcestershire Acute hospitals trust, Sandwell & West Birmingham NHS Trust are level 2 who manage babies from 27 week and Wye Valley NHS Trust manage babies greater than 37 weeks, level 1. Preconception advice and care will be commenced during the post-natal period to maximize the opportunity to have a healthy second pregnancy in optimal health. 26

Implementation Plan Leadership: A LMS Board has been formed with the TOR and governance agreed and approved by all constituent organisations. Maternity Safety champions have been appointed on the Board of Wye Valley NHS Trust and Worcester Acute Hospitals NHS Trust. A non-executive Chair has been appointed to lead the LMS Board and an executive has been appointed as the LMS SRO reporting as a board member to the STP Partnership Board. A project consultant has been appointed for 2 days a week to develop the plan to meet the national time table for approval and create the cross boundary and cross site clinical engagement to enable the plan to be owned locally and be able to identify where centralisation is required to gain better outcomes for women and babies. Objectives Improving choice and personalisation of maternity services so that: o All pregnant women have a personalised care plan. o All women are able to make choices about their maternity care during pregnancy, birth and post-natally. o Most women receive continuity of the person caring for them during pregnancy, birth and post-natally. o More women are able to give birth in midwifery led settings (at home and in midwifery units). Improving the safety of maternity care so that by 2020/21 all services: o Have reduced rates of stillbirth, neonatal death, maternal death and neonatal brain injury during birth by 20% by 2020 and 50% reduction by 2030. o Are investigating and learning from incidents and sharing this learning through their Local Maternity System and with others. o Fully engaged in the development and implementation of the NHS Improvement Maternity and Neonatal Health Safety Collaborative. Work streams: Two work streams have been created to deliver the Local Maternity System. Clinical and Non- Clinical. A stream lined approach in terms of number of work streams will support the development and delivery of the plan: Clinical Work stream: This work stream will drive the development of clinical pathways, develop and monitor the quality and safety metrics, support the learning and development and training of our workforce. The pathways will address personalisation, choice and continuity. Public Health interventions to tackle 27