Local Maternity System Transformation Plan

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

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Report To: Governing Body Meetings in Common

Report Title: Local Maternity System Transformation Plan

Report From: Andrea Green, Chief Officer

Date: 8th March 2018

Previously Considered by: STP Programme Board

Action Required (delete as appropriate)

Decision: Assurance: Information: Confidential

Purpose of the Report:

To share the Local Maternity System (LMS) Transformation Plan.

Key Points:

• In 2016, NHS England produced ‘Better Births’, the Five Year Forward View for Maternity Care, which detailed the national vision for maternity services of the future:

o safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances;

o and where all staff are supported to deliver care which is women centred; working in high performing teams, in organisations which are well led, and in cultures which promote innovation, continuous learning, and which breakdown organisational and professional boundaries.

• Local Maternity Systems are designed to provide place-based planning and leadership in support of the implementation of ‘Better Births’ and have two distinct purposes:

o to develop and implement a local plan to transform maternity services as part of their local Sustainability and Transformation Partnership and;

o to establish and operate shared clinical and operational governance to enable enhanced cross organisational working.

• The plan describes how ‘Better Births’ will be delivered in our local area to ensure mothers and babies in Coventry and Warwickshire receive the best quality of care and achieve the best outcomes. There are three core workstreams:

o Health and Well-being; o Quality and Safety; o Personalisation and Choice

• Key drivers for change: o Population growth. o Stillbirth rates in Coventry are not reducing in line with England averages. o The complexity of births has increased. o Neonatal admissions have increased. o Women are still smoking during pregnancy. o Mental health prenatally and postnatally remains a concern. o The availability of certain grades of specialist doctors is likely to compromise neonatal units. o There is a shortage of sonographers therefore midwives will need to be trained. o The midwifery workforce is ageing and there are workforce challenges associated with the

retention and recruitment of trained midwives. • There are four key issues to be addressed in neonatal care:


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o the type and location of neonatal cots are not aligned with demand; o arrangements for transfer and discharge are inconsistent; o the interface between maternity and neonatal care can be improved; o emotional and practical support for parents is highly variable.

Recommendation:

The Governing Body notes and endorses the LMS transformation plan.

Implications

Objective(s) / Plans supported by this report:

Commissioning Intentions and Operational Plan to implement the recommendations of the national maternity review – Better Births

Conflicts of Interest: N/A

Financial:

Non-Recurrent Expenditure:

• For 2017/18 the LMS received from NHS England an allocation of £86,666 to provide admin, project support, engagement and clinical backfill.

• The LMS will receive approximately £150,000 in 2018/19

Recurrent Expenditure: N/A

Is this expenditure included within the CCG’s Financial Plan? (Delete as appropriate)

Yes No N/A

Performance: N/A

Quality and Safety:

Safety of maternity care will be improved so that by 2020/21 all services: • Have reduced rates of stillbirth, neonatal death, maternal death and

brain injury during birth by 20% from the 2015 baseline, and are on track to make a 50% reduction by 2025;

• Are investigating and learning from incidents, and are sharing this learning through their Local Maternity Systems and with others;

• Are fully engaged in the development and implementation of the NHS Improvement Maternity and Neonatal Health Safety Collaborative.

• Are in a position to achieve the neonatal safety ambition to reduce admissions of pre-term births from 8% to 6% by 2025.

Equality and Diversity:

General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful.

Has an equality impact assessment been undertaken? (Delete as appropriate)

Yes (attached) No N/A

Patient and Public Engagement:

• The CCGs undertook engagement on maternity services in Coventry and Warwickshire between December 2016 and April 2017.

• Altogether 79 interviews were carried out at a range of community and health venues.

• Engagement was targeted at parents and carers, in order to understand


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their experience of care before, during and after the experience of birth. • In summary, key points that interviewees felt were important included:

o consistency of care o being listened to o personalised care o family friendly care o professional attitude of staff o being reassured o support with breastfeeding and other aspects of caring for a new

baby, including antenatal classes and postnatal support groups o access to information o good communication

A further period of engagement is being planned over the next 3 months to inform the Maternal and Child Health Strategic Commissioning Group of the critical success factors for the future model of maternity care.

Clinical Engagement: Initially clinical engagement will be undertaken through the Choice and Personalisation workstream of the LMS to develop a list of future clinical models for maternity and neonatal services.

Risk and Assurance:

• Clinical, managerial leadership and project management capacity to further develop and deliver the plan.

• Difficulty in engaging users via Maternity Voices in shaping the LMS Plan, particularly the clinical model options.

• Difficulties achieving clinical ‘buy in’ from the whole LMS to the short-listed options due to conflicts of interest.


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2016 - 2021

Better Health, Better Care, Better Value

Coventry and Warwickshire

Local Maternity System (LMS) Transformation Plan

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FOREWORD The NHS ‘Five Year Forward View’ (NHS England 2014) outlined that the NHS in England needed to change to address three fundamental issues (the ‘triple aim’):

• The health and wellbeing gap: if the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness.

• The care and quality gap: unless we reshape care delivery, harness technology, and drive down variations in quality and safety of care, then patients’ changing needs will go unmet, people will be harmed who should have been cured, and unacceptable variations in outcomes will persist.

• The funding and efficiency gap: if we fail to match reasonable funding levels with wide-ranging and sometimes controversial system efficiencies, the result will be some combination of worse services, fewer staff, deficits, and restrictions on new treatments.

In response to this, ‘Sustainability and Transformation Partnerships’ were set up across England to develop plans to address these gaps at a local level. Within Coventry and Warwickshire the ‘Better Health, Better Care, Better Value’ Partnership set out its plan in 2016. A key work-stream within that plan is Maternal and Child Health, in recognition that the best start in life and in early years is critical in supporting a reduction in the three gaps of the ‘triple aim’, as detailed above. In 2016, NHS England produced ‘Better Births’, the Five Year Forward View for Maternity Care, which detailed the national vision for maternity services of the future:

• safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances; and

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• and where all staff are supported to deliver care which is women centred; working in high performing teams, in organisations which are well led, and in cultures which promote innovation, continuous learning, and which breakdown organisational and professional boundaries.

Local Maternity Systems are designed to provide place-based planning and leadership in support of the implementation of ‘Better Births’ and have two distinct purposes:

• to develop and implement a local plan to transform maternity services as part of their local Sustainability and Transformation Partnership and;

• to establish and operate shared clinical and operational governance to enable enhanced cross organisational working. The Coventry and Warwickshire Local Maternity System has been set up to specifically develop and implement a plan to transform and sustain improvements in maternity and neonatal services and forms part of the Maternity and Paediatric work-stream of the Sustainability and Transformation Partnership. This plan describes how ‘Better Births’ will be delivered in our local area to ensure mothers and babies in Coventry and Warwickshire receive the best quality of care and achieve the best outcomes. This is a collaborative plan, co-produced with women and families who use our services; with midwives, doctors, nurses and clinicians who provide our services; and with commissioners who will ensure services for their local populations become safer, more personalised, kinder, professional, and more family friendly. In line with the aspirations of ‘Better Births’: Choice and Personalisation of maternity services will be improved so that:

• All pregnant women have a personalised care plan; • All women are able to make choices about their maternity care during pregnancy, birth and postnatally; • Most women receive continuity of the person caring for them during pregnancy, birth and postnatally;

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• More women are able to give birth in midwifery settings (at home and in midwifery units).

Safety of maternity care will be improved so that by 2020/21 all services: • Have reduced rates of stillbirth, neonatal death, maternal death and brain injury during birth by 20%, and are on track to make a 50%

reduction by 2025; • Are investigating and learning from incidents, and are sharing this learning through their Local Maternity Systems and with others; • Are fully engaged in the development and implementation of the NHS Improvement Maternity and Neonatal Health Safety Collaborative. • Are in a position to achieve the neonatal safety ambition to reduce admissions of pre-term births from 8% to 6% by 2025.

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CONTENTS

Foreword ............................................................................................................................................................................................................................................................................................................. 2

Our Plan on a Page………………………………………………………………………………………………………………………………………………………………….7

1. Background...…………………………………………………………………………………………………………………………………………………………………… 8

2. Coventry and Warwickshire Demographics ………………………………………………………………………………………………………………………………….…17

3. Strategic Plan: ……………………………………………………………………………………………………………………………………………….………………... …

Where are we now?..................................................................................................................................................................................................................................................................24

Where do we want to be?........................................................................................................................................................................................................................................................45

How do we get there? ………………………………………………………………………………………………………………………………………………… 56

4. Risks and Mitigation……………………………………………………………………………………………………………………………………………………………. 68

5. Financial Overview………………………………………………………………………………………………………………………………………………………………70

6. Communications and Engagement……………………………………………………………………………………………………………………………………………….74

7. Conclusion………………………………………………………………………………………………………………………………………………………………………..78

Appendices

1. LMS Terms of Reference

2. LMS Draft Quality and Safety Dashboard

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3. West Midlands Neonatal Review recommendations

4. Community Hubs - Work to Date

5. Initial Better Births Questionnaire

6. Spring 2018 Strategic Engagement Exercise

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OUR PLAN ON A PAGE

For Mothers and Mothers-to-be Improve satisfaction through: a choice of place of care according to you and your baby’s needs ; access to safe, high quality personalised care; continuity of carer provided by a caring and compassionate team. A healthy pregnancy and safe birth

For Services:

new models of care offering Continuity of Carer, community hubs and more home and midwife led births a 'learning culture' improving outcomes better integration and cross- organisational working services designed in conjunction with service users and staff

For Staff:

access to the support you require to perform your job to the highest standards respected and valued roles within an MDT structure regular training and development within a learning culture better job satisfaction through enhanced continuity of care

By March 2021: 100% of pregnant women have a personalised care plan; 100% of pregnant women are able to make choices about their maternity care, during pregnancy, birth and postnatally; 20% of pregnant women receive full continuity of the person caring for them during pregnancy, birth and postnatally; 20% of women are able to give birth in midwifery settings (at home and in midwifery units); 100% of women are assessed and supported to stop smoking, manage their weight and address mental health and wellbeing needs, including domestic abuse By 2020 and 2025 respectively, reduce rates of stillbirth, neonatal death, maternal death and brain injury by 20% and 50%

OUTCOMES

HEALTH AND WELLBEING QUALITY AND SAFETY FUTURE CLINICAL MODEL WORKSTREAMS

VISION

Key Performance

Indicators

To improve choice and personalisation of maternity services. To improve the quality and safety of maternity and neonatal care. To implement the recommendations of the West Midlands Neonatal Review To support an integrated and holistic approach to maternity and postnatal care

COMMITMENTS

To improve health outcomes for mothers and babies in Coventry and Warwickshire through a healthy pregnancy and safe birth in the preferred place, supported by a known midwife

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1. BACKGROUND Maternity services are unique. They are a choice for women. They cannot be demand managed, and activity cannot be controlled through referrals. They are a core NHS service, but one that whilst delivered by acute trusts, happens mainly in the community with interdependencies with primary care and other community services, such as health visiting. Good maternal health and high-quality maternity care throughout pregnancy and after birth can have a marked effect on the health and life chances of new-born babies, on the healthy development of children, and on their resilience to problems encountered later in life. Safe, high quality services are crucial to ensuring women’s physical and mental health during this important time in their lives and are fundamental in reducing the gap in infant mortality and in overall life expectancy. Giving every child the best start in life is crucial to reducing health inequalities across the life course. The foundations for virtually every aspect of human development, ‘physical, intellectual and emotional’, are laid in early childhood. What happens during these early years, starting in the womb from the point of conception, has lifelong effects on many aspects of health and well-being. NATIONAL CONTEXT Maternity Services have been subject to much political and policy scrutiny over recent years and there is a wealth of evidence-based guidance on clinical and cost-effective care. In 2016 the National Maternity Review, ‘Better Births’, was published, setting out the 5-year national vision for maternity services in England to improve outcomes for mothers and babies. “Our vision for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances.

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And for all staff to be supported to deliver care which is women centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries.1” ‘Better Births’ outlines the need for services to become safer, more personalised, kinder, professional and more family-friendly. The focus of the review was on improving outcomes of maternity services in England. Its recommendations propose how services should change over the next five years. The review sets out wide-ranging proposals designed to make care safer and give women greater control and more choices. Every woman, every pregnancy, every baby and every family is different. Therefore, quality services (safe, clinically effective and providing a good experience) must be personalised. This Five Year Forward View for NHS Maternity Services in England aims to deliver two key improvements by 2020/21:

• improving choice and personalisation; • improving the safety of maternity services.

As an adjunct to this, the national ‘Saving Babies Lives’ care bundle, aims to reduce stillbirth and early neonatal death by 50% by 2025 through the systematic implementation of specific elements of care that are recognised as evidence based and/or best practice:

• Raising awareness of reduced fetal movements; • Reducing smoking in pregnancy; • Risk assessment and surveillance for fetal growth restriction; • Effective fetal monitoring in labour.

11 National Maternity Review Better Births DOH 2016

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The Coventry and Warwickshire Local Maternity System recognises that the national vision, as outlined in ‘Better Births’, can only be achieved through locally led transformation that focuses on the specific needs and drivers within the Coventry and Warwickshire maternity system. With that in mind, this plan takes the national vision and recommendations and links them to local needs and drivers, in order to produce a plan that is bespoke to Coventry and Warwickshire; a plan which reflects a prioritised programme of work and pace of change applicable to the local situation. LOCAL CONTEXT Sustainability and Transformation Partnership Coventry and Warwickshire’s Sustainability and Transformation Partnership (STP), called ‘Better Health, Better Care, Better Value’, comprises the following organisations:

• South Warwickshire NHS Foundation Trust • University Hospitals Coventry and Warwickshire NHS Trust • George Eliot Hospital NHS Trust • Coventry & Warwickshire Partnership Trust. • South Warwickshire CCG • Coventry and Rugby CCG • Warwickshire North CCG • Warwickshire County Council • Coventry City Council.

A key work-stream within the STP Plan is Maternity and Paediatrics, which focuses on the transformation programme for both maternity and acute paediatric service provision. This programme is steered by a strategic commissioning maternal and child health programme which aims to ensure

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services deliver the best possible outcomes for mothers and children during pregnancy, childbirth and during childhood/young adult years from 0-25. Within this context, the Local Maternity System has been established to specifically focus on transforming maternity and neonatal services to deliver improved outcomes for mothers and babies. There is recognition locally however, that the LMS transformation work needs to be linked with acute paediatrics transformation work given the critical relationship between neonatal and acute paediatric care, specifically that changes in neonatal provision have potential consequences for paediatric provision within an acute hospital setting. Figure 1 demonstrates this. Figure 1. The interface between the strategic commissioning Maternal and Child Health work-stream and the Local Maternity System (LMS) is shown in Figure 2. Importantly, the LMS’ role is to ensure maternity and neonatal services are transformed to deliver improved outcomes for both mothers and babies across Coventry and Warwickshire. These outcomes, whilst not yet set in stone, will be focused on the nationally identified outcomes in ‘Better Births’ and ‘Saving Babies’ Lives’ plus locally defined outcomes, identified partly through the strategic engagement exercise with women and their families, shortly to be undertaken in Coventry and Warwickshire.

Maternity Services Acute Paediatric Services Neonatal Services

Interdependencies relate to medical workforce, estate and IT, in particular.

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Figure 2.

The STP work-stream on maternity and paediatric services is currently working through the elements of the full programme of work and how they link together from a logistical perspective in terms of whole system transformation of service delivery. Given the timeline for implementation of Better Births however, the LMS will focus on transforming its model of care in line with Better Births with work around acute paediatrics following, once maternity/neonatal options have been produced.

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LMS Governance Coventry and Warwickshire’s local maternity system is a formal subgroup of the Maternity and Paediatrics work-stream of the Coventry and Warwickshire STP and reports through that work-stream to the STP Board. The LMS also reports, however, through the NHS England Midlands and East Programme Board to the NHS England National Maternity Transformation Programme Board. Peer review, support and collaborative working opportunities are provided through the West Midlands Maternity and New-born Alliance. The outcomes to be delivered by the LMS will be communicated through the Maternity and Paediatrics work-stream of the LMS, which reports to the STP Board. This is shown diagrammatically in Figure 3. Figure 3.

Coventry and Warwickshire STP Board

Maternity and Paediatrics

Local Maternity System NHS England Midlands and East Programme Board

NHS England National Programme Board

West Midlands Maternity and Newborn Alliance

Strategic Commissioning Maternal and Child Health Work-stream

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The LMS has clear terms of reference (Appendix 1). At its meeting in January 2018 the LMS ‘took stock’ of its work programme in recognition of the critical interface with the maternity and paediatrics programme of the STP. This ‘stock-take’ resulted in the clarification of three core work-streams for the LMS focused on:

• Health and Well-being; • Quality and Safety; • Personalisation and Choice.

As detailed in Chapter 3 of this plan, each of these work-streams has a clear programme of work which will enable delivery of specific improvements over time. When delivered together and in full, these elements will ensure the delivery of:

• The recommendations of Better Births; • The recommendations of ‘Saving Babies’ Lives’; • The recommendations of the West Midlands Neonatal Review for which the LMS is responsible.

The focus of the LMS during the next 9 months is detailed in Figure 4 below. Essentially, the LMS will focus on health and wellbeing, and quality/safety improvement initiatives in the short to medium term (and on an on-going basis thereafter). The third work-stream, Personalisation and Choice, meanwhile, will be focused on working up the future clinical model by Autumn 2018. This work-stream will generate short-listed options for consideration within the context of acute paediatrics given the interdependencies between the services in relation to neonatology. Planning for implementation of the preferred clinical model will begin, in earnest, in 2019 once the preferred clinical model has been agreed. Implementation will commence in 2020, as per the Better Births timeline. Figure 4 demonstrates the process over the coming months to work up the longer term clinical model. This work will be undertaken, in earnest, between Spring and Autumn 2018.

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Figure 4.

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Figure 5.

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2. COVENTRY AND WARWICKSHIRE DEMOGRAPHICS Coventry is a city and metropolitan borough in the West Midlands. Historically part of Warwickshire, it is the 9th largest city in England and the 12th largest in the UK. Warwickshire is a shire county comprising 5 boroughs/districts: North Warwickshire, Nuneaton and Bedworth, Rugby, Warwick, and Stratford on Avon. This section of the plan examines the size of the populations of women aged 15-44 within Coventry and Warwickshire, along with a comparison of the ethnic mix and an explanation of the deprivation in the area. Coventry and Warwickshire are subject to migration, including amongst the student population who attend the two Universities in Coventry and Warwick. There is a projected increase in birth rate of up to 31% by 2039 in this geographical area: https://apps.warwickshire.gov.uk/api/documents/WCCC-644-475. In Coventry, the total population in 2015 was 345,385, of which 77,000 were women aged 15-44. This compares with the total population of Warwickshire of 554,000 at the same time, of which 98,500 were women aged 15 to 44 years old. Figure 7 shows the numbers of women aged 15 to 44 years in each of the local authority areas in Warwickshire. In Warwickshire Stratford-on-Avon District has the lowest proportion of 15-44-year-old women (15.3%), while Warwick District has the highest (19.5%). Warwickshire’s proportion of females aged 15-44 years (17.8%) is slightly lower than the national average (19.4%) whereas Coventry has a higher than national average percentage of women aged 15-44 at 22.3%.

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Figure 6. Mid-2015 population estimates

Total Female (15-44 years)

Count Count % of total population

North Warwickshire 62,800 10,600 16.9%

Nuneaton & Bedworth 126,300 23,400 18.5%

Rugby 103,400 18,700 18.1%

Stratford-on-Avon 121,500 18,500 15.3%

Warwick 139,900 27,300 19.5%

Warwickshire 554,000 98,500 17.8%

Coventry 345,400 77,000 22.3%

England 54,786,300 10,634,900 19.4%

Source: Office for National Statistics, 2015 ETHNICITY The ethnicity of women aged 15-44 in Warwickshire is predominantly white British (84.1%) which is higher than the equivalent national figure (73.2%). The proportion of non-white British or black and minority groups is highest in Warwick district and lowest in North Warwickshire. The Asian/ Asian British group is estimated to be the largest BME group in Nuneaton and Bedworth. In North Warwickshire, Rugby and Stratford the largest BME group is White Other.

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Coventry’s population is much more diverse with only 61% white British. 39% are from Black and minority ethnic groups, of which 20% are from Asian groups. The White Other group in Coventry is higher than the White Other group in Warwickshire at 7.4%. This group likely comprises individuals from Eastern European countries. Coventry is a national immigrant dispersal city. Figure 7 provides the detail. Figure 7. Proportion of women aged 15-44 years, by ethnic group

North

Warwickshire Nuneaton & Bedworth Rugby

Stratford -on-Avon

Warwick Warwickshire Coventry England

White British 94.6% 85.8% 79.0% 89.7% 77.9% 84.1% 61.0% 73.2%

Black & Minority Ethnic (BME) Of which:

5.4% 14.2% 21.0% 10.3% 22.1% 15.9% 39.0% 26.8%

White: Irish 0.5% 0.2% 0.6% 0.5% 0.9% 0.6% 0.9% 0.8%

White: Gypsy or Irish Traveller

0.1% 0.1% 0.3% 0.2% 0.0% 0.1% 0.1% 0.1%

White: Other White

2.1% 2.8% 8.8% 5.5% 7.1% 5.5% 7.4% 7.5%

Mixed/multiple ethnic group

0.9% 1.2% 2.0% 1.1% 2.2% 1.5% 2.7% 2.5%

Asian/Asian British

1.5% 8.3% 6.7% 2.5% 9.8% 6.6% 19.1% 10.3%

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Black/African/ Caribbean/Black British

0.3% 1.1% 2.3% 0.4% 1.0% 1.0% 7.2% 4.4%

Other ethnic group

0.1% 0.5% 0.4% 0.2% 1.1% 0.5% 1.6% 1.2%

This ethnic diversity presents particular challenges, not only in terms of language and communication barriers, but also in terms of access to services with many immigrant mothers only accessing services late in their pregnancy.

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DEPRIVATION

In Coventry, there are 81 areas ranked within the 30% most deprived lower layer super-output (LSOAs) nationally, constituting 42% of the areas in the city. There are 29 areas in the 10% most deprived LSOAs nationally and five areas in the 1% most deprived. Whilst infant and child mortality is similar to the England average, the health and wellbeing of children in Coventry is generally worse than the England average; poverty is worse given 25.4% of children under 16 live in poverty; and homelessness is another key concern, being worse than the England. Source: Right Care (2016) Commissioning for Value: Where to Look (Gateway ref: 04599) The health and wellbeing in Warwickshire, meanwhile, is mixed compared with the England average. Infant and child mortality rates are similar to England average and the level of child poverty is better than the England average, with 14% of children (under 16 years old) living in poverty. The rate of family homelessness however is similar to England. Source: Right Care (2016) Commissioning for Value: Where to Look (Gateway ref: 04599) Figure 8: Deprivation Affecting Children Index.

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PROJECTED NEEDS: PROJECTED BIRTHS

By 2039, there is projected to be a 5.1% increase in the number of births in Warwickshire and a projected increase of 31.5% in Coventry based on 2014 population projections. The national rate of increase is 6.8% between 2014 and 2039. This has implications for service delivery in Coventry, in particular. Within Warwickshire there is considerable variation at District/Borough level (Figure 9). Warwick District is projected to see the greatest increase in numbers of births: a total projected increase of 163 births or 10.9%, whilst Stratford-on-Avon has the second highest projected rate of increase in Warwickshire at 6.8% from 2014 to 2039. This is a direct result of significant housing development in the south Warwickshire area. Source: Warwickshire & Coventry Public Health. Figure 9: Change in numbers of live births between 2014 and 2039 (Coventry and Warwickshire Public Health data) Change in births 2014-2039

Number % change

North Warwickshire 8 1.3% Nuneaton & Bedworth 46 3.0% Rugby 14 1.1% Stratford-on-Avon 70 6.8% Warwick 163 10.9% Warwickshire 303 5.1% Coventry 1,433 31.5%

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Source: Sub-national population projections, Office for National Statistics Clearly, caution must be taken when analysing live birth projections as these are subject to fluctuate due to migration, economic factors affecting housing growth and changes in local demographics but, from the figures above, it can be seen that the local maternity system for Coventry and Warwickshire needs to develop service transformation plans which accommodate a significant increase in birth for women and families from diverse backgrounds.

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3. STRATEGIC PLAN: WHERE ARE WE NOW? OVERVIEW The Coventry and Warwickshire Maternity System is a complex one, comprising three acute hospital trusts, all of which currently provide maternity and neonatal services to the local populations of Coventry and Warwickshire. Figure 10 shows the geography. Figure 10

George Eliot Hospital Trust

University Hospitals Coventry and Warwickshire Trust

South Warwickshire Foundation Trust

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University Hospitals Coventry and Warwickshire Trust provides a level 3 obstetric unit, as well as a midwife led unit. South Warwickshire Foundation Trust and George Eliot Hospital Trust have obstetric units with level 1 neonatal cots; there is also a well-developed plan for a midwife led unit at South Warwickshire Foundation Trust, to be sited at Warwick Hospital. Community midwifery is provided by each of the three units supporting antenatal and postnatal care and a small volume of home births. An overview of services in the three Trusts is provided in Figure 11 below: Figure 11: Service provision

UHCW GEH SWFT Births • Between Nov 2016/Oct 17 6,039 babies were

born, including 1.4 % at home

Births • Between Nov 2016/Oct 17 2,096 babies were

born, including 1% at home

Births • Between Nov 2016/Oct 17 2,962 babies were

born, including 1.4 % at home

Staffing • The midwife to birth ratio is 1:34 • There is 96 dedicated hours of consultant cover on

the labour ward

Staffing • The midwife to birth ratio is 1:27 • There is 46.5 dedicated hours of consultant cover

on the labour ward

Staffing • The midwife to birth ratio is 1:30 • There is 63 dedicated hours of consultant cover on

the labour ward Services include the following specialist posts: • Screening • Vulnerable adults • Practice development • Risk management • Teenage pregnancy • Infant feeding • Smoking cessation

Services include the following specialist posts: • Screening • Vulnerable adults • Practice development • Risk management • Teenage pregnancy • Infant feeding • Smoking cessation

Services include the following specialist posts: • Screening • Vulnerable adults • Practice development • Risk management • Teenage pregnancy • Infant feeding • Smoking cessation

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Facilities • Lucina - an alongside midwifery led birth unit

with 5 rooms and 3 birthing pools • 11 birthing rooms 2HDU beds & 2 bedded

induction bay on Labour ward with 1 birthing pool

• 6 admission rooms • X2 dedicated obstetric theatre with 24 hour

obstetric / anaesthetic cover including epidural cover.

• There are 20 inpatient antenatal beds / 34 postnatal inpatient beds plus a transitional care unit which is staffed by the neonatal service.

• There is ultrasound scanning, fetal medicine & day assessment unit.

• Neonatal Care including Neonatal Intensive Care, Neonatal Care and Special Care Baby Unit.

Facilities • 10 birthing rooms and 2 birthing pools on the

labour ward • 5 admission rooms and a bereavement suite. • 1 dedicated obstetric theatre with 24 hour obstetric

/ anaesthetic cover including epidural cover. • There are 23 bedded ante / postnatal inpatient

beds plus 2 transitional care beds. • There is ultrasound scanning and a fetal / maternal

assessment unit. • SCBU with 8 cots.

Facilities • 7 birthing rooms and 1 birthing pool on the labour

ward • 1 admission rooms and a bereavement suite.

1x dedicated obstetric theatre with 24 hour obstetric / anaesthetic cover including epidural cover.

• There are 23 bedded ante / postnatal inpatient beds plus 6 induction of labour beds and 0 transitional care beds.

• There is ultrasound scanning and a fetal / maternal assessment unit.

• SCBU with 11 cots.

Births Figure 12 quantifies the number of live births for the populations of Coventry and Warwickshire during the period 2011-2015 and demonstrates a reduction in the birth rate in all areas other than North Warwickshire. The biggest decrease in birth rate currently is in Coventry with 4,801births in 2011compared to 4,517 births in 2015 (a 6% change during the five-year period compared to the national average of 3.4%). This trend is set to be reversed as a result of population growth within the areas, with Coventry anticipated to see the greatest increase in birth rate.

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Figure 12: Number of live births 2011-2015

Source: Office for National Statistics

2011 2012 2013 2014 2015

% change (2011-2015)

North Warwickshire

651 688 676 568 664 2.0%

Nuneaton & Bedworth

1,639 1,598 1,582 1,528 1,589 -3.1%

Rugby 1,273 1,261 1,243 1,246 1,266 -0.5% Stratford-on-Avon 1,153 1,139 1,068 1,037 1,103 -4.3% Warwick 1,557 1,619 1,521 1,506 1,464 -6.0% Warwickshire 6,273 6,305 6,090 5,885 6,086 -3.0% Coventry 4,801 4,731 4,495 4,572 4,517 -5.9% England 688,120 694,241 664,517 661,496 664,399 -3.4%

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Figure 13: Live births by Lower Super Output Area (LSOA), 2015

The current output of live births has been assembled in geographical areas (Figure 13). For confidential reasons the data has been arranged into wide intervals however the diagram emphasizes the areas with the higher number of births in 2015. There are several zones where services are in more demand and this has implications in terms of service delivery which will need to be taken into account when planning the new clinical model, particularly in relation to the siting of community (family) hubs.

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In general, Coventry and Warwickshire women give birth in Coventry and Warwickshire. Based on 2016/17 data there are relatively small (4%) ‘outflows’ to other areas, as demonstrated in the Figure 14 below. Unfortunately, we are unable to separate midwife led births at the current time. For South Warwickshire these outflows are largely to Oxford, Worcester and Birmingham; to Warwickshire North they are largely to Leicester. Figure 14: Location of Births by CCG 2016/17 CCG UHCW SWFT GEH Out of Area

Coventry and Rugby 5319 188 146 49 South Warwickshire 148 2200 2 181 Warwickshire North 142 2 1554 193 Total 5609 2390 1702 423 With changes to maternity services in Worcestershire and Oxfordshire, in particular, Warwick Hospital is seeing increasing volumes of births both from within South Warwickshire and from outside South Warwickshire (i.e. from Worcestershire and Oxfordshire). Figure 15 demonstrates this. With the opening of the new MLU at SWFT it is feasible that much of the South Warwickshire CCG activity currently flowing to the Lucina Birthing Unit at UHCW will be repatriated to SWFT. Figure 15: Volume of Births by Provider 2014/15 to 2017/18 (forecast) Trust 2014/15 2015/16 2016/17 2017/18 FOT as at M9 GEH 1930 2110 2161 2138 SWFT 2638 2626 2853 2944 UHCW 6223 6332 6217 6257

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In addition to the ‘in-flows’ to SWFT noted above, GEH has ‘in-flow’ activity from West Leicestershire included in the figures above. Choice in Maternity Services There are three types of birthing units in Coventry and Warwickshire, offering: • Obstetric Led (at all three sites • Alongside Midwifery Led Unit at UHCW (Lucina) • Home birth. SWFT has a well-established plan to implement a further alongside midwifery led unit at Warwick Hospital. A standalone midwifery unit is situated at Solihull Hospital (part of the Birmingham and Solihull LMS), which is readily accessible for some of our population. Maternity care is given by the three acute providers during the antenatal, intrapartum and postnatal periods. A more detailed description of the current range of services available is outlined in the tables below. Antenatal care

Pregnant women currently access maternity services through a self-referral or via their GP. Each woman has a Community Midwife linked to her GP practice and all normal midwifery care is currently provided either at her GP surgery or at a local community centre/hub. However, local research has shown that provision of antenatal classes is seen by parents as a gap as its availability is variable across Warwickshire (ref: https://www.warwickshire.gov.uk/smartstart).

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A schedule of antenatal appointments is determined by the function of the appointments. A nulliparous (has not given birth before) woman with an uncomplicated pregnancy will generally have a schedule of 10 appointments; a parous woman (has given birth before) with an uncomplicated pregnancy will generally have a schedule of 7 appointments. Care given during these antenatal appointments is documented in hand held records.

Early in pregnancy, every woman should receive appropriate written information about services available to inform her choices about place of birth and about her care giver. A recording of her smoking status will be taken. Contact phone numbers of the Community Midwife and the booked maternity unit will be given.

At each appointment, there will be a clinical examination to monitor fetal growth and well-being. Lifestyle considerations and manging common symptoms and screening is discussed. Planning the place of birth is also discussed, either at a routine appointment, and/or at antenatal classes. There is NHS provision for antenatal classes as well as private provision by local organisations, usually at a charge.

There is a well-defined referral pathway to specialist obstetric Consultant services/ clinics for pregnant women requiring high risk care who are likely to require more frequent and intensive appointments bespoke to their particular needs.

Giving Birth The majority of women in Coventry and Warwickshire give birth at one of the three maternity units. 30% of women will birth with a midwife only, with around 1% of all births being home births. UHCW has an alongside midwife led unit (the Lucina Birthing Centre). GEH and SWFT try to keep some rooms in delivery suite available for midwife led care but this is dependent upon capacity on labour ward at the time so cannot be guaranteed. This activity is not coded as midwife led so cannot be identified through contracts data. Postnatal Care

After giving birth, the woman and her baby are cared for at the inpatient postnatal ward and then at home.

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Each postnatal contact should be provided in accordance with the principles of individualised care. In order to deliver the core care recommended, postnatal services should be planned locally to achieve the most efficient and effective service for women and their babies.

A coordinating healthcare professional should be identified for each woman. Based on the changing needs of the woman and baby, this professional is likely to change over time.

- women should be offered an opportunity to talk about their birth experiences and to ask questions about the care they received during labour.

- a woman should be asked about her health and wellbeing and that of her baby. This should include her experience of common physical health problems and any symptoms reported by the woman or identified through clinical observations should be assessed.

- a woman should be offered consistent information and clear explanations to empower her take care of her own health and that of her baby, and to recognise symptoms that may require discussion.

- A woman and her family should be encouraged to report any concerns in relation to her physical, social, mental or emotional health, discuss issues and ask questions

The coordinating health professional should document in the care plan any specific problems and follow-up required.

At the end of the postnatal period, the coordinating healthcare professional should ensure that the woman's physical, emotional and social wellbeing is reviewed. Screening and medical history should also be taken into account.

Breastfeeding support should be made available regardless of the location of care, and there should be sufficient time, as a priority, to give support to a woman and baby during initiation and continuation of breastfeeding.

Midwives should ensure mothers who choose to use infant formula are shown how to make up a feed before leaving hospital or the birth centre (or before the mother is left after a home birth). This advice should follow the most recent guidance from the Department of Health about bottle feeding.

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A woman's experience with breastfeeding should be discussed at each contact to assess if she is on course to breastfeed effectively and identify any need for additional support. Breastfeeding progress should then be assessed and documented in the postnatal care plan at each contact.

Neonatal care The majority of babies are born healthy and remain with their mother at all times. A small proportion of babies will however, need to be nursed on a Neonatal unit. SWFT and GEH provide level 1 neonatal care, whereas UHCW provides levels 1, 2 and 3. Figures 16, 17 and 18 provide a summary of the activity (in cot days) by Trust.

Figure 16. BAPM (2011) Activity levels by Trust and Unit 2015 Level 1

Neonatal Intensive Care

Level 2 Local Neonatal Care Unit

Level 3 Special Care Baby Unit

Level 4 Transitional Care

Total

UHCW 2384 1774 893 0 5051 GEH 46 244 1885 0 2175 SWFT 52 277 2024 398 2751 Grand Total 2482 2295 4802 398 9977

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Figure 17. BAPM (2011) Activity levels by Trust and Unit 2016 Level 1





Total

UHCW 2344 2175 1028 0 5547 GEH 29 271 2100 0 2400 SWFT 61 371 1910 276 2618 Grand Total 2434 2817 5038 276 10565 Figure 18. BAPM (2011) Activity levels by Trust and Unit 2017 (forecast) Level 1





Total

UHCW 2229 2302 1359 0 5890 GEH 33 130 2239 0 2402 SWFT 43 479 2249 197 2968 Grand Total 2305 2911 5847 197 11260 The data shows the majority of intensive care and local neonatal care activity at UHCW, as would be expected from a full Level 3 obstetric unit. The small volumes of Level 1 and Level 2 care at SWFT and GEH relate to the stabilisation of babies in an emergency situation. Transitional care is not well recorded at units other than SWFT therefore this data needs to be treated with caution. Data will be refined to ensure robustness for future activity modelling purposes but reveals an increasing level of activity, both in total and in complexity, during the past three years. Cot occupancy figures for 2017 (1.4.17 to 30.9.17) have been obtained from NHSE specialised commissioners across the levels of neonatal care. However, as with the data above, these figures need to be treated with extreme caution due to coding issues (for example, UHCW’s SCBU activity includes transitional care activity carried out on the postnatal ward). Based upon the volume of cots declared (8 at GEH, 32 at UHCW and 11 at

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SWFT) occupancy is above 90% for all levels at all units with the exception of high dependency (level 2 at UHCW – 72.2%) and transitional care (level 4 at UHCW – 32.1%), the latter being due to care of these babies on postnatal wards. Special care baby (level 3 activity) at UHCW appears exceptionally high at 193% - likely to due to coding issues. Perinatal Mental Health Care

During pregnancy, and in the year after birth, at least 10% of women are affected by a range of perinatal mental illnesses. If left untreated, this can have a devastating impact on mothers and their families. Children are more likely to experience behavioural, social or learning difficulties and fail to fulfil their potential. According to the Maternal Mental Health Alliance, perinatal mental illness costs approximately £8.1 billion annually; mostly relating to long term impacts for the baby.

Through early identification and expert management of a woman’s condition it is possible to prevent the onset and escalation of perinatal mental illness and much can be done to support women and prevent negative impacts on the family.

A review of Perinatal Mental Health services in Coventry and Warwickshire has led to commissioning a specialist service covering pre-pregnancy, during pregnancy, labour and delivery, postnatal care, tertiary services, out- of-hours advice and support and access to assessment and treatment.

We now have a specialist team working beyond traditional organisational boundaries, comprising perinatal psychiatrists, psychologists and community psychiatric nurses, as well as health visitors with specific training in perinatal mental health. The team provides a consistent, safe, high quality service, which is compliant with NICE guidelines and ensures the right specialist staff is in place to ensure women have easy access to specialist support when they need it.

Patient satisfaction data shows consistently positive ratings, with individuals rating the service as good or better in all instances. In addition the service can demonstrate improved outcomes, the HADS (Hospital Anxiety and Depression Scale), shows a consistent decline in actual levels of depression and

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anxiety as well as a decline from baseline to end of therapy in terms of numbers of patients who are originally clinically depressed or anxious and are no longer at clinical levels by the end of treatment.

Perinatal mental health and well-being is required to strengthen dyadic relationships to improve attachment between parents and infant and reduce later demands on health, education and social care. A peer support approach is planned through better integrated midwifery and health visiting teams. This will enable delivery of evidence based Video Interaction Guidance (VIG) to strengthen Parent-Infant Mental Health and Well-being, through early intervention in the perinatal period. VIG enables the promotion of parent-infant relationships and secure attachment. It is proposed that a cohort of VIG experts are developed within the Coventry and Warwickshire health visiting teams in close alignment with all three midwifery services across Coventry and Warwickshire. This will ensure robust, integrated pathways. Additional capacity building in VIG is also proposed for psychologists and selected perinatal professionals via the ‘fast track’ one-year programme. This will up-skill our existing workforce and ensure the delivery of high quality interventions within the Primary Mental Health team.

QUALITY AND SAFETY The CCGs in Coventry and Warwickshire have had maternity quality dashboards in their contracts with providers for the past 4 years. These vary significantly and, in that context, the LMS in in the process of agreeing the KPIs for a consistent performance framework across all three providers which will be fully implemented from 1st April 2018. The draft indicators are detailed in Appendix 2. Improving Outcomes Four maternity related measures are included in the CCG Improvement and Assessment Framework: • Neonatal mortality and stillbirths • Maternal smoking (at time of delivery) • Women’s experience of maternity services • Choice in maternity services

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The current performance against these indicators by CCG is shown in Figure 19: Figure 19. Performance against Maternity Outcomes Indicators (IAF) by CCG

Data Source: MyNHS

CCG Name

Maternal Smoking at Delivery

Neonatal mortality and stillbirths

Women’s experience of maternity services

Choice in maternity services

NHS SOUTH WARWICKSHIRE CCG 6.0% 3.5 72.1 56.1 NHS COVENTRY & RUGBY CCG 13.6% 5 78.8 63.9 NHS WARWICKSHIRE NORTH CCG 12.4% 5.8 77.1 60.8

Time period Q1 17/18 2015 2015 2015 The data demonstrates a greater challenge in relation to addressing smoking and stillbirths in Coventry & Rugby and Warwickshire North, whilst women’s experience of maternity services and choice in maternity care is worse in south Warwickshire. Specifically in relation to stillbirths, the data available for Coventry and Warwickshire (Figure 20) demonstrates that whilst the Warwickshire stillbirth rate has reduced in line with the England average, the same cannot be said of Coventry. Further work is required to establish the reasons for the higher stillbirth rate in Coventry and to tackle the issue through a concerted plan of action.

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Figure 20: Coventry & Warwickshire Stillbirth Rates, per 1,000 live and stillbirths

Source: Office for National Statistics

0

1

2

3

4

5

6

England Coventry Warwickshire

2010 - 12 2011 - 13 14 2012 - 2013 - 15

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THE BETTER BIRTHS MODEL

Better Births sets out a vision whereby: • All women have a choice of where they give birth: obstetric unit, midwife led unit or at home; • Community midwifery services are better integrated with other family-centred health and well-being services in community hubs; • A woman’s care is personalised to her and she can have a high expectation of continuity of carer throughout pregnancy, during birth and

postnatally; • Her care and that of her baby is safe and optimises their health outcomes for the future, including access to the full range of mental health and

well-being services, if required.

A gap analysis against the Better Births recommendations has been undertaken by the three maternity units. This has informed a SWOT analysis which strategically assesses the current position of the LMS against the Better Births guidance and the LMS’ ability to achieve the Better Births vision based upon current services. It has also informed the development of the work-stream action plans within this document.

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SWOT ANALYSIS Strengths

• Tier 1 NNU and 2 Tier 1 SCBU in the area • Good liaison and collaboration between maternity and neonatal units,

particularly with regards to the development and implementation of guidelines and protocols

• All units rate well on all four Friends and Family Test (FFT) touch points • Last CQC report rated Maternity/Gynaecology services in two trusts as good. • Choice of place of birth (obstetric unit, midwife led unit and home birth)

options available to all women in Coventry and Warwickshire • Small community midwifery teams • Established perinatal mental health service across the system • Collaborative working across the system • Royal College of Midwives Nomination for maternity unit of the year • A-EQUIP (advocating for education and quality improvement) Pilot • Reduction in stillbirth rate in GEH by 80% since 2015/16

Weaknesses • Poor neonatal cot capacity • One obstetric unit rated ‘requires improvement’ in last CQC inspection • FFT response rates are poor at SWFT • Still birth rates in Coventry have not been reducing in line with England

averages • Continuity of care generally poor • Antenatal support not as good as it could be • Postnatal satisfaction with midwifery support in the community could be

improved

Opportunities • Deliver the safer care collaborative – 2 wave 1 trusts established • Increase home birth rates • Deliver the Care Bundle and continue to reduce still births • Agree a shared key performance indicator dashboard to ensure consistency

of approach to improving quality Personalised care plans developed for each woman

• Create a single point of access to promote personalised care • New workforce models across the LMS to promote recruitment and retention

of midwives and obstetricians

Threats • Financial constraints within the STP • Failure to engage the public/patients compromises the development of

future clinical models • Failure to engage the workforce compromises the development of future

clinical models • Clinical models do not meet future need due to poor activity modelling • Huge potential increase in births in Coventry

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• Increased focus on prevention • Working in partnership with Third Sector • Strengthened working arrangements between CCG and NHSE specialised

commissioners to drive quality improvements in neonatal care • Reshaping of children’s centres by the Local Authorities provides a good

base for the development of community hubs

The SWOT analysis reveals the LMS is starting from a good base: choice of provision is already strong and will be strengthened further by the opening of a second midwife led unit at SWFT. Collaborative working between the three units is good, with a strong partnership approach to the development and implementation of guidelines and protocols. Women’s satisfaction with their maternity care, as taken from Friends and Family surveys, benchmarks well nationally, although the CCG outcomes indicators suggest there is further work to do in this area, particularly in South Warwickshire. The LMS has been successful to date in securing additional income from NHS England to support the development of services locally. The 4 elements of Saving Babies Lives care bundle have been implemented. An audit midwife has been funded to assess the effectiveness of shared guidelines across the system. Future action plans will ensure collaborative work continues. In addition, the LMS has successfully raised the profile of work in Coventry and Warwickshire on an international stage, having presented several papers at the International College of Midwifery Conference in Toronto in 2017. That said, the SWFT maternity service was as ‘requires improvement’ by the CQC in 2016 and neonatal cot capacity is poor at times due to longer lengths of stay than may be anticipated. Importantly, stillbirth rates in Coventry have not reduced in line with England averages and, whilst this is possibly due to late bookings of immigrants, this needs to be further understood and addressed. It is important that the LMS has a solid plan and works constructively to overcome these current weaknesses.

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We believe the LMS offers significant opportunities to improve the quality of care for mothers and their babies across Coventry and Warwickshire through improved collaboration between providers, more consistent approaches (including standardised guidelines and protocols) and the recognition of Coventry and Warwickshire as an exciting place to work for staff. Clearly there are some threats to be managed as work is taken forward but the LMS firmly believes that with strong clinical and patient engagement significant improvements to quality of care can be achieved in the short and longer term. DRIVERS FOR CHANGE The Coventry and Warwickshire Local Maternity System Plan is being developed as part of the Maternal and Child Health work-stream of the Coventry and Warwickshire Sustainability and Transformation Partnership. There is wide recognition within the STP that transformation of services is required to address the ‘triple aim’ of improving outcomes, enhancing quality and reducing cost, known locally as ‘Better Health, Better Care, Better Value’. National drivers for change have been reflected in maternity policy over the years:

• ‘Maternity Matters (DH 2007) outlines the focus on commissioning high quality, safe and accessible maternity services through the implementation of a choice guarantee for all women, ensuring that women will have choice about the type of maternity care that they receive, together with improved access to services and continuity of midwifery care and support.

• The National Service Framework for Children, Young People and Maternity Services: Standard 11 (Maternity Services) states that women should have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies (DH 2004).

• The NHS Outcomes Framework 2013/14 (and the associated CCG Outcomes Indicator Set) is grouped around five domains, which set out the high-level national outcomes that the NHS should be aiming to achieve, including within maternity services.

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‘Better Births’ now brings many of these together in one document, setting our clear expectations, not just of delivery of outcomes, but in relation to how services should be shaped in order to deliver these outcomes for women and children. Regardless of the ‘Better Births’ requirements however, there are also local drivers for change; and these local drivers are not insignificant:

• Population growth will result in a significant increase in births across Coventry and Warwickshire – as described within the Local Context section.

• Changes to neighbouring services (particularly in Oxfordshire and Worcestershire) may result in the repatriation of out of area births back into Coventry and Warwickshire, as well as potentially births from women living in Oxfordshire and Worcestershire.

• Stillbirth rates in Coventry are not reducing in line with England averages. • The complexity of births has increased as a result of increased maternal age, co-existing medical problems and greater levels of obesity

within the population. • Neonatal admissions have increased as birth complexity has increased, compromising neonatal cot capacity. • Women are still smoking during pregnancy, affecting both their own health and their baby’s health. • Mental health prenatally and postnatally remains a concern and has the potential to impact on the longer term health and wellbeing of both

mother and baby. • Whilst breastfeeding initiation is good, fewer mothers manage to sustain breastfeeding beyond 2 weeks (when there is a significant ‘drop off’)

and beyond 6 weeks, when there is a further drop-off. • The availability of certain grades of specialist doctors is likely to compromise neonatal units. • There is a shortage of sonographers therefore midwives will need to be trained to undertake sonography, particularly in community hubs. • The midwifery workforce is ageing and there are workforce challenges associated with the retention and recruitment of trained midwives. • West Midlands Specialised Commissioners have undertaken a review of neonatal services and have identified four key issues to be addressed

on a local basis, which will affect the future clinical model of care: o the type and location of neonatal cots do not meet the demand we have for the service;

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o arrangements for transfer and discharge are inconsistent; o the interface between maternity and neonatal care can be improved; o emotional and practical support for parents is highly variable.

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STRATEGIC PLAN: WHERE DO WE WANT TO BE? VISION

The LMS’ vision is to improve health outcomes for mothers and babies in Coventry and Warwickshire through a healthy pregnancy and safe birth in the preferred place, supported by a known midwife

Our Plan on a page demonstrates how this vision is underpinned by a set of commitments and will be delivered through three clear work-streams to deliver the benefits and outcomes desired by women and their families, staff and service providers. LMS COMMITMENTS The LMS commits to: Improve choice and personalisation of maternity services, so that:

• All pregnant women have a personalised care plan; • All women are able to make choices about their maternity care, during pregnancy, birth and postnatally; • Most women receive continuity of the person caring for them during pregnancy, birth and postnatally; • More women are able to give birth in midwifery settings (at home and in midwifery units).

Improve safety of maternity care, so that all services:

• Have reduced rates of stillbirth, neonatal death, maternal death and brain injury by 20% by 2020 and by 50% by 2025; • Are investigating and learning from incidents and sharing the learning within the multi-disciplinary team; • Are fully engaged with improving quality in Neonatal and maternity programmes.

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Implement the recommendations of the West Midlands Neonatal review to optimise the long term health outcomes of pre-term, low-birth weight or ‘sick’ babies. Support an integrated and holistic approach to maternity and postnatal care. TRAJECTORIES The West Midlands Maternity and Neonatal Alliance, as well as support through NHS England and Health Education England funding streams, will play a pivotal role in helping transform our services. The LMS has declared to NHS England a set of trajectories to be achieved in relation to the specific expectations of Better Births and Saving Babies’ Lives, as detailed:

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Number of births and projection for each year to 2020/2021

Local baseline 2018/19 2019/20 2020/21

6098 (UHCW) 6200 6250 6300 2115 (GEH) 2200 2300 2400 3000 (SWFT) 3200 3350 3550 11213 11600 11900 12250

As can be seen, there are projected increases in the volume of births at all trusts, but specifically at SWFT due to the repatriation of south Warwickshire CCG births from other providers and the attraction of additional out of area births.

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The quality and safety initiatives outlined in this plan support the delivery of a 20% reduction in stillbirths/neonatal deaths from the 2015 baseline (EMBRRACE data) by 2021, as well as a 20% reduction in intrapartum brain injuries from the local baseline of 5 in 2016.

Local baselineTrajectory March

2019Trajectory March

2020Trajectory March

2021Local baseline

Trajectory March 2019



5.17 4.6 4.14 3.6 5 5 4 4

A. Are there clear and credible plans to improve the safety of maternity care so that by 2020/21 all services have made significant progress towards the “halve it” ambition of halving rates of still birth and neonatal death, maternal death and brain injuries during birth by 50% by 2030? (This should include an assessment of the current position and a clear improvement trajectory)

Stillbirths and neonatal deaths Intrapartum brain injuries

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D. Are there clear and credible plans to roll out personalised care planning as envisaged in section 7.3.2 of the LMS resource pack? (single point of access type model)

Number of personalised care plans

Local baseline Trajectory March 2019



0% 0% 0% 100%

The LMS will be working up its plans for a single point of access to support personalised care plans and choice as part of its future models of care work-stream. In practice, full implementation of the preferred model will not go live until 2020/21 therefore this trajectory assumes ‘big bang’ delivery at that point.

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E. Are there clear and credible plans to improve the choices available so that all women are able to make choices about their maternity care as envisaged in Better Births? This means that choices must be available in terms of antenatal care and postnatal care, and of the type and place of birth (homebirth, in a midwifery unit, or in a hospital obstetric unit) even if it means crossing tradition boundaries. (This

must include a baseline of current choice offer and a clearly stated ambition.)

Number of women able to choose from three places of birth




0% 3% 15% 100% The LMS has submitted a transformation funding bid to support a continuity of carer model, based on community practices of <=6 midwives to be implemented wholescale in south Warwickshire in support of the midwife led unit in 2018/19 and on a smaller, pilot scale in Coventry and north Warwickshire during the same time period. This model of care will support provision of choices. On this basis, given the part year effect for women, a marginal increase in choice is assumed by March 2019 with an increase to 15% in March 2020, based upon full pilot implementation amongst low-risk mothers in south Warwickshire. The expectation is that the full clinical model, with a single point of access and support by community practices of midwives, will enable full choice to be implemented by March 2021.

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F. Is there a local ambition for how women will receive continuity of the person caring for them during pregnancy, birth and postnatally and are there clear and credible plans for implementing

it? (This should include current position and project numbers of women receiving continuity over agreed period.)

Number of women receiving continuity of carer




0 300 1501 2450 The trajectory above represents the numbers of women where it is anticipated full continuity will be achieved across the pathway. It is based upon an assumption that 20% of women (all low-risk) will achieve full continuity of care across the pathway by 2021. The LMS has yet to debate and agree whether additional interpretations of continuity of care are possible during elements of the pathway. If this is the case these numbers will increase by March 2021.

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G. Is there a local ambition and clear and credible plans to enable more women to give birth in midwifery settings (at home and in midwifery units)?

Number of women giving birth in midwifery settings




0 300 1501 2450

These figures reflect the numbers underpinning the percentages of women receiving full continuity of care and able to give birth in a midwifery setting as these are all low-risk women.

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In addition, as a LMS, we will work on the following areas to maximise the clinical outcomes of our mothers and babies: - Ensure that, where possible, all women <27 weeks are able to give birth in centres with a neonatal intensive care unit (NICU). - Have clear guidelines for antenatal transfer in the event of impending delivery < 27 weeks, as part of the shared clinical and operational

governance being developed. - Aim to ensure at least 85% of all births at 23-26 weeks of gestation are at the level 3 unit at UHCW. - Ensure that all neonatal deaths are investigated using a standardised framework including root cause analysis and reported nationally to

support learning. - ‘Each Baby Counts’ (RCOG) initiative to review quality for term babies such that, in babies 23 weeks of gestation or more, every death (100%)

in the delivery room and neonatal unit is investigated, and that lessons are learned, implemented and shared though maternity Clinical Networks.

- Ensure that Neonatal services have the capacity to provide all neonatal care for at least 95% of babies who require admission for neonatal

intensive care and are born to women booked for delivery in the network (i.e. no more than 5% of babies requiring intensive care born to booked women should be transferred out of network for inappropriate reasons).

- Ensure that neonatal care services do not operate above the 80 percent occupancy averaged over the year. - Ensure that babies requiring neonatal services receive that care from a unit with the appropriate level of care as close as possible to the family

home. - Review the 2016 data received from the Neonatal Transport Group to: assess the reasons for babies being transferred because of lack of

capacity (space or staff); review the reasons why babies are transferred for more specialised care; and establish if any of the babies transferred in the first 3 days should have been born in an intensive care unit in the first place.

- Review the admissions by gestational age data to understand the local picture. - Ensure that the ATAIN scheme and action plan are implemented. - Monitor the levels of term baby admissions in neonatal units.

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STRATEGIC PLAN: HOW DO WE GET THERE? As previously described, the work of the LMS forms an element of the STP work-stream focused on Maternity and Paediatrics and its work programme is inextricably linked to that of acute paediatrics given the interdependencies that exist in relation to neonatal care. Our start point has been the refreshing of our LMS in January 2018 and, indeed, this LMS Plan. Our revised terms of reference (Appendix1) reflect a revised clarity of thinking and approach to how we transform our services in pursuit of our vision, benefits and outcomes. The LMS has identified three core work-streams to deliver its Better Births plan focused on:

• Health and wellbeing; • Quality and Safety; • Choice and Personalisation.

The detailed elements of each plan reflect the current position (strengths) of existing services and therefore focus on the weaknesses and opportunities that may be progressed to fully deliver the Better Births and Saving Babies’ lives requirements, as well as the recommendations of the West Midlands Neonatal Review. Work in support of neonatal safety and provision is interwoven into the work-streams focused on Quality & Safety, Choice & Personalisation.

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Health and Wellbeing

Perinatal and Postnatal Mental Health

Obesity

Smoking

Domestic Abuse

Quality and Safety

Saving Babies Lives Care Bundle

Maternity and Newborn Safety Collaborative

Shared Guidelines

Learning from Incidents and Complaints

Continuity of Carer

Perinatal Mortality Reviews

Care Pathways (including Pre-term)

Quality and Safety Dashboard

Personalisation/Choice

Future Clinical Model

Continuity of care model

Digital transformation

Personalised care budgets

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Detailed Plans in respect of each of these work-streams are outlined. In some instances, additional funding will be required which will be subject to business case approval by the STP Board. Health and Well-being: Core Aim: To optimise the health and wellbeing of mothers to be, mothers and infants through effective practice and integrated working

across the system. Anticipated Outcomes: Reduction in Maternal and Neonatal Mortality and Morbidity Reduction in smoking in pregnancy Reduction in maternal obesity and gestational diabetes Increased Breastfeeding rates – at birth and at 6 weeks Reduction in perinatal mental health issues, such as depression in the antenatal and postnatal periods Reduction in Neonatal care admissions and lengths of stay Work-stream Lead: Helen King, Deputy Director of Public Health, Warwickshire County Council Objectives Actions Leads Timescale Generic • Embed MECC for Mental Health & Wellbeing, Domestic Violence and

Abuse, Smoking in Pregnancy and Obesity via robust training in active observation and motivational interviewing for front-line professionals (midwives, health visitors, family nurses, GPs, 3rd sector practitioners, family support workers) and building on the Family Health Assessment tool in Coventry;

Heads of Midwifery (HoMs) PH Coventry and Warwickshire

2018-2020

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• Each midwifery team should have a public health midwife in every locality who leads on this work (one for each of the sub-streams: mental health, domestic violence and abuse, smoking, obesity) , plus protected hours to be able to sustain the focus and deliver on agreed outcomes (business case to be submitted to commissioners (CCGs));

• Continue with the integration of services via family hubs in Coventry and Children and family centres in Warwickshire.

• Improve compatibility of databases/ IT systems and information sharing; • A web-based directory of relevant services in Coventry and

Warwickshire to be developed to support referrals and pathways more effectively.

• Create clear metrics for service providers to support reduction in inequalities, which will be visible in their demonstration of increasing levels of resources being applied across the Index of Multiple Deprivation (IMD) gradient. Improve compatibility of databases/ IT systems and information sharing;

• Provide all staff with motivational training techniques, to help them support women to address issues such as diet, activity and smoking.

HoMs CCC and WCC Acute Trusts, CCGs, LAs CCC/WCC CCGs, Public Health CCC&WCC HoMs, LWAB, Public Health CCC&WCC

2018-2020 2019-2020 Now and on-going until 2020 2018-19 2018-2020 2018-2020

Improve antenatal • Monitor the effectiveness of the already established CWPT maternal Parent and In place now.

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and postnatal mental health

mental health team.

• Perinatal Mental Health Pathway to be enhanced to include fathers/partners, plus thresholds to be reviewed to enhance focus on early intervention e.g. Attachment and bonding.

• Introduce fast-tracking of expectant and post-natal parents into IAPT; recording of client data to be reviewed and improved to ensure effective fast-tracking; and training of IAPT staff on perinatal mental health.

• Strategic review of parenting support leading to a clearly defined universal and targeted offer of a range of support

o to include a group based parenting programmes based on Leksand approach

o Approach to be available in community venues/ family hubs as part of the universal offer/ pathway approach – programme to start at min 16 weeks of pregnancy;

o building community capacity and resilience/ work with the 3rd sector;

Mental Health & Wellbeing Steering Group, CCGs CCGs, CWPT, IAPT Warwickshire Children, Young People and Families business unit/Coventry City Council Children’s unit

2018-2020 Coventry in place now. Warwickshire in development 2018-2020

Address Obesity and Reduce

• Smoking status to be consistently assessed and recorded at booking. • Smoking cessation services & risk perception clinics

HoM Midwifery leads

2018-2020 In place now and

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Smoking • All women are monitored for CO at booking and at 36 weeks pregnant • Smoking Cessation Midwives to be established; • Introduce smoking/obesity navigators

HoMs HoMs HoMs, CCC PH and WCC PH, CCGs

to 2020 2018-2019 2018-2019

Reducing Domestic Abuse

• Continue to implement the IRIS programme in Coventry and Warwickshire, ensuring all healthcare professionals are appropriately trained to recognise abuse and support women appropriately, including signposting to community support and services.

Acute Trust Board leads for Safeguarding, HoMs, Medical Directors

Programme in place now

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Quality and Safety: Core Aim: To optimise health outcomes for mothers and babies through the provision of high quality, safe services Anticipated Outcomes: Reduction in Maternal and Neonatal Mortality and Morbidity Reduction in Reduction in Neonatal care admissions and lengths of stay Increase in continuity of carer Work-stream lead: Sarah Noble, Head of Midwifery, South Warwickshire Foundation Trust Alison Talbot, Head of Midwifery UHCW Objectives Actions Lead(s) Current Position/

Timescale for Delivery

Saving Babies’ Lives Care Bundle

• Fully implement all elements of the Saving Babies’ Lives Care Bundle in each Trust.

Heads of Midwifery

In place and on-going

Maternal and Newborn Safety Collaborative

• SWFT , GEH and UHCW to participate in Maternal and Neonatal Health Improvement Collaborative MANIC: GEH/UHCW Phase 1; SWFT Phase 2

• Multi-professional patient safety training (HEE funded in 2016/17)

Heads of Midwifery

In place for GEH/UHCW Completed

Shared Clinical Guidelines

• Review and revise Top 10 guidelines to ensure consistency across the LMS • Recruit audit midwife to undertake regular audits across the LMS

Heads of Midwifery

In place and on-going

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• Practice Facilitators to support embedding of guidelines amongst staff • Monthly collaboration meeting across providers to review implementation

and address issues

Learning from Incidents and Complaints

• UHCW to continue to implement Virginia Mason methodology (UHCWi) to improved incident reporting and learning from incidents

• GEH/SWFT implement their Serious Incident and Complaints policies • Coventry and Warwickshire SI Learning Forum (CCGs’ chaired) to have a

regular focus on maternity Sis

Heads of Midwifery

In place and on-going On-going In-place and on-going

Continuity of Carer • Complete birth rate plus for SWFT (undertaken in 2017 in UHCW and GEH)

• Pilot continuity of carer in 8 community midwifery hubs and evaluate • Share learning for wider Coventry and Warwickshire dissemination

Heads of Midwifery

March 2018 2018 2019

Perinatal Mortality Reviews

• Standardised perinatal mortality review process

Lead Obstetricians

2018

Care Pathways (including Pre-term)

• Work with the Neonatal Operational Delivery Network to review, revise and implement care pathways aimed at promoting the safety and well-being of mothers and babies.

LMS leads 2018

Quality and Safety Dashboard

• Design a new quality and safety dashboard to monitor KPI delivery in the three maternity units in order to track progress on addressing the objectives of this plan

Heads of Midwifery

Dashboard established for 2018/19

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implementation

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Choice and Personalisation Core Aim: To develop shortlisted future clinical model options for maternity and neonatal services across Coventry and Warwickshire to ensure an integrated care pathway.

Anticipated Outcomes: Getting the right people in the right place at the right time for the best outcome for mother and baby.

Reduced Maternal and Perinatal Mortality and Morbidity

The full requirements of Better Births, Saving Babies’ Lives and the West Midlands Neonatal Review (LMS related recommendations only)

Lead(s) Alison Walshe, Chief Nurse, South Warwickshire CCG Objectives Actions Lead(s) Current Position/

Timescale for Delivery

Produce the project plan to develop the short-listed clinical model options

• Work within the STP work-stream to develop a plan that aligns the LMS work with the paediatric work during 2018/19

• Develop links with the ODN and formal governance arrangements with NHSE specialised commissioners in respect of neonatal care

• Schedule workshop sessions over the summer to work up a range of clinical models

• Schedule an ‘options appraisal’ workshop to determine the clinically preferred model

LMS SRO LMS SRO Liz Haines Liz Haines

Jan-March 2018 Initial meeting held Jan 2018 May - August 2018 September 2018

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• Produce accurate medical workforce and midwifery figures to assist in the options appraisal and link to the Coventry and Warwickshire Local Workforce Advisory Board

• Gain an understanding of the location of community hubs across Coventry and Warwickshire

• Confirm the services to be established in the community hubs

• Undertake workforce modelling with the LWAB to ensure sufficient

medical workforce for the preferred clinical model, and appropriately skilled midwifery staff, particularly to support sonography

Trust leads Liz Haines Alison Talbot STP workforce lead

April 2018 February 2018 Initial ideas scoped (see Appendix 4); require confirmation by LMS. March 2018

Produce a personalised care plan format for use across the LMS

• Confirm the patient information sheets are established Alison Talbot March 2018

Personalised care budgets

• Make links with NHSE leads to gain enhanced understanding of Personalised Care Budgets and consider these as the clinical model work is implemented

Alison Walshe/Liz Haines

February 2018

Digital transformation

• Gap analysis of current provision and the vision set out in better Births • Assess the capability and functionality of existing maternity systems

Liz Haines On-going

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• Work in collaboration across the system to identify future models

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4. RISKS AND MITIGATION The LMS has undertaken a high level risk assessment of its current plan. All risks have been RAG rated and mitigating actions identified. Risk Likelihood Impact Rating Mitigating Actions Maternal and Child Health work-stream does not produce the inputs required for the clinical model options in a timely manner

3 4 12 = Medium

Programme Lead for the LMS is the Programme Lead for the Maternal and Child Health workstream and should support both the LMS Chair and the Maternal/Child Health SRO in producing a joint programme.

Difficulty in engaging users via Maternity Voices in shaping the LMS Plan, particularly the clinical model options

4 4 16 = High Programme lead to liaise with Maternity Voices to understand any constraints preventing full engagement in LMS activities and then work with the LMS Chair to overcome these.

Pilots (such as continuity of carer) fail to produce effective outputs/learning, compromising the ability to influence the shaping of the clinical model

2 4 8 = Low Heads of Midwifery and Programme Lead to stay abreast of best practice emerging from other LMSs. Utilise learning from the Better Births implementation hub and national leads meetings.

Activity modelling is not robust, compromising planning for the 2 4 8 = Low Utilise contract data and neonatal network

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future clinical model data for modelling purposes; and utilise, if possible, models used in other LMSs.

Difficulty in gaining clarity about community hubs being utilised by the Local Authorities

2 4 8 = Low Continue to pursue with Local Authorities, who are members of the LMS

Difficulty in sourcing robust medical and midwifery workforce data

2 4 8 = Low Continue to pursue through Trust members on the LMS; failing that, Directors of HR at the Trusts. Build on Birthrate Plus and HEE funded work and link to LWAB.

Difficulties achieving clinical agreement to implementing shared guidelines.

2 4 8=Low

Difficulties achieving clinical ‘buy in’ from the whole LMS to the short-listed options due to conflicts of interest

4 3 12 = Medium

Keep quality at the heart of the programme and ensure effective utilisation of the engagement activities with women during the options appraisal stage

The preferred clinical model cannot be delivered within the financial envelope

3 4 12 = Medium

Escalation to the strategic work-stream for consideration in the context of maternity and paediatrics

Clinical, managerial leadership and project management capacity to further develop and deliver the plan.

5 3 15=High Utilise funding allocated to the LMS (£75K in 2017/18 and £150K in 2018/19) to support dedicated clinical and managerial resource for the LMS – both to develop and deliver the plan.

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5. FINANCIAL OVERVIEW The most recent (May 2017) “Do Nothing” system wide deficit for this STP by 2020/21 is £318.1m. This reduces to £38.1m after planned solutions. The planned 2017/18 spend on maternity and neonatal services is as follows, noting that some commissioner spend goes to non STP providers, and vice versa STP providers receive income from non STP commissioners. Table 1 – break down of Commissioner spend Table 1: Break down of Commissioner Planned Spend 2017/18.

Inside the STP

Outside the STP Total

Inside the STP NHSE


Commissioners £000's £000's £000's £000's £000's £000's £000's

Coventry and Rugby CCG 28,990 88 29,078 98 0 1 99

North Warwickshire CCG 7,120 536 7,656 412 0 6 418South Warwickshire CCG 11,327 835 12,162 361 0 9 370NHSE Specialised Commissioning 0 0 0 0 12,248 0 12,248Total 47,437 1,459 48,896 871 12,248 16 13,135

Maternity Service Neonatology Service

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To note: NHS England commissions the majority of Neonatology Services provided within the STP and therefore is shown as a separate commissioner within the Table. Table 2 – break down of Provider income Table 2: Breakdown of Provider Services Income (Shown as a percentage)

Inside the STP


Inside the STP NHSE


Providers £000's £000's £000's £000's £000's £000's £000'sGeorge Eliot NHS Trust 7,810 700 8,510 0 1,271 0 1,271South Warwickshire Hospital FT NHS Trust 12,183 1,909 14,092 526 1,100 0 1,626

University Hospitals Coventry & Warwickshire NHS Trust. 28,505 1,382 29,887 1,014 9,877 1,014 11,905Total for all Providers 48,498 3,991 52,489 1,540 12,248 1,014 14,802

Maternity Service Neonatology Service

The underlying finance principle for the LMS has to be one of value for money and forward look financial sustainability. To achieve this, the plan should deliver improved outcomes for the same (or less) money on a per capita basis (i.e. spend could increase due to increased levels of activity but the equivalent cost per birth should be the same or less – with better outcomes). Should the preferred option not be deliverable within this assumption the

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strategic work-stream will need to consider whether additional funding may be found from elsewhere in the strategic Maternal and Child Health programme to support the unavoidable costs of maternity in delivering Better Births. There are key challenges in this assumption:

- the assessment of the baseline gap to achieve the key deliverables of better births. - the potential for reshaping of services and establishment of community hubs in a period of capital constraint.

Many of the improvement initiatives in Better Births are thought to have a low financial impact; however, there may be significant financial impacts if significant re-shaping of maternity care is required. As discussed in this plan, the preferred clinical model is yet to be agreed but there are some high-level considerations which will shape the financial impact assessment:

- analysis from NHSE Specialised commissioning indicates there is an excess of cots in Coventry and Warwickshire when modelled at an occupancy rate of 85% with a variation between sites. Rationalisation will have an impact upon workforce design and associated financial modelling.

- the options for the configuration and location of community hubs where there is a co-joined piece of work with the out of hospital STP work stream.

- the impact on outcomes of the continuity of carer models which could reduce overall levels and intensity of hospital based activity in maternity and neonatal services.

In lieu of the finalised clinical model and case for change, a high level set of principles has been agreed across the STP to underpin the case:

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• The Local Maternity System case for change will consist of weighted non-financial and financial metrics to be agreed in a transparent process with non-finance and finance professionals.

• A long list of all options will be considered relative to a do nothing position. • Business as usual savings will not form part of the case for change. • The financial sustainability of the STP will not be worsened by any option being taken forward. • The case for change will make consideration of those services outside the scope of the LMS, with any foreseen impacts being flagged through

the STP work-stream. • Commissioner efficiency savings derived from the case will be reinvested in maternity services to support other initiatives as per the LMS plan

where this clearly supports the case for change and is agreed as affordable to the STP. • Any individual organisational impacts will be managed across organisations with the understanding that it will not deteriorate performance

against control totals.

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6. COMMUNICATION AND ENGAGEMENT

INTRODUCTION

The communications and engagement activity for the LMS is currently being led by the strategic Maternal and Child Health workstream. Feedback from this engagement will strategically steer the work of the LMS and will build on work undertaken by the CCGs in 2015/16. Whilst no proposals have so far been put forward by the LMS to the strategic work-stream in relation to the future clinical model, it is likely that changes to services will be needed to deliver the expectations of Better Births. The process of co-producing this plan presents an excellent opportunity for the local population, partner organisations and other key stakeholders to come together to have conversations about how things could and should move forward, and to present their feedback, thoughts and ideas from the beginning of a service review in order to positively impact and direct the future of local maternity services – even if that involves making some difficult decisions.

WHAT’S ALREADY BEEN DONE?

To help inform planning for how services might be developed, some initial and targeted engagement was carried out across Coventry and Warwickshire (see Appendix 5). This took place between December 2016 and January 2017, and involved talking to mothers, mothers to be and their families about their current patient experience of maternity care. During interviews, local women discussed their antenatal care, labour and childbirth, and postnatal care. This has helped to inform how we start to develop local proposals at the earliest stage and engagement will be ongoing.

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All those interviewed had very similar expectations of maternity services, but these were not always met. The key themes in the discussions were around consistency of care, being listened to, personalised care, family friendly care, professional attitude of staff, being reassured, support with breastfeeding and other aspects of caring for a new baby, including antenatal classes and postnatal support groups, and access to information. Mums valued having the same midwife with them throughout the pregnancy. Where this was the case, experience of maternity services was much enhanced, particularly if the mum built a warm and friendly relationship with this midwife. All mums wanted to feel that they had reassurance and someone to turn to who would listen to them and give credibility to their concerns. Where there were frequent changes in midwife, this sometimes caused difficulty with different personalities and was unsettling for mothers. There were common themes around the mums’ expectations of care. They wanted first and foremost to feel that the people looking after them were professional, caring and knowledgeable, but there were also examples of where what constituted a good experience for one mother was a negative perception of another mum’s care. First time mums often lacked confidence and were worried about different aspects of their pregnancy and care after the baby was born. These mums craved reassurance and confidence giving and wanted to feel that their concerns were being listened to and not being trivialised. If they were made to feel that they were over reacting or worrying unnecessarily, they often became reluctant to voice concerns and ask questions and researched information themselves. Some mothers who had already had children felt they needed less support this time around, but there were some who felt that they were receiving less support because they were not first time mums and missed the extra support and appointments. Expectations were based on individual personalities and also past experiences such as miscarriages and traumatic births. In some cases mums felt that these past experiences were considered when care was provided, but in other cases they felt that they did not get the support and reassurance that they needed.

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This learning is already helping to shape thinking about how services need to change. Practice teams within community hubs, linked to wider health and social care services in particular, are being advocated to give mothers the best support from pregnancy through to the postnatal period, enabling them to make informed choices about their care and giving them support in caring for their new baby.

NEXT STEPS

A further, more wide-ranging exercise is planned to be procured in early Spring 2018. The aims and objectives of this exercise are to ensure:

• All those members of the population with an interest in maternity services, commissioners and service providers are aware of and informed about programme of work to improve maternity services;

• Those with an interest have an effective opportunity to inform and co-produce any improvements, and ensure their views on proposals and plans;

• Decision-makers have the benefit of a range of patient, public and professional viewpoints and expertise; • Clinical leads, operational managers and commissioners are supported to achieve a fair, transparent, well-informed and smooth-running

development programme for improving maternity services; • Opportunities are maximised for those seldom heard to have a say; • Opportunities are maximised for stakeholders to be involved in the development of the plan and any future associated proposals; • The proposed engagement and consultation plan is in line with legal requirements for NHS bodies to engage and consult their local communities

on health plans; • Actions include full consideration of equality issues as guided by the Equality Act 2010: we will make use of the Equality Delivery Systems that

were established in Coventry and Warwickshire in 2013/14; • Engagement and consultation supports the co-production and implementation of a local maternity system transformation plan;

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• Communications and engagement activity is aligned between local partner organisations, STP and Health and Wellbeing boards to ensure cross-system reach;

• Communications and engagement activity positively manages the reputation of the local maternity system transformation plan and the organisations involved with its development.

The full remit of this engagement exercise is detailed in Appendix 6.

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7. CONCLUSION

There is no doubt that there is a significant amount of work to do within Coventry and Warwickshire to achieve the outcomes set out in this place. We start however, from a strong place: committed obstetricians and midwives; collaborative working between three providers; a good choice of current services; vocal users who wish to engage to shape services of the future; and a strong track record of successful bids for funding to assist the transformation of services.

Whilst there remains much to do to refine the detail of our plan, particularly our work programme, there is a new clarity of thinking that should keep the LMS on track to deliver this plan to time and ensure the mothers and babies of Coventry and Warwickshire receive the maternity and neonatal services they deserve to ensure the best start in life.

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APPENDIX 1. LMS TERMS OF REFERENCE Purpose To improve health outcomes for mothers and babies in Coventry and

Warwickshire through a system-wide approach to transformation (reflected in a LMS plan) involving service users, and local communities, as well as relevant senior clinicians, NHS and LA commissioners, operational managers, finance managers and primary care. This will involve shared clinical and operational governance, the co-production of care pathways, a clinically and financially sustainable model of care for maternity and neonatal services, as well as policies, procedures, guidelines and protocols, across the LMS. To make recommendations to the Maternal and Child Health STP work-stream regarding clinically and financially sustainable future model(s) of care

Objectives To develop and implement a local vision for improved maternity services and outcomes based on the principles within the “Better Births” report, specifically:

- Improving choice and personalisation of maternity services so that:

• All pregnant women have a personalised care plan; • All women are able to make choices about their

maternity care during pregnancy, birth and postnatally; • Most women receive continuity of the person caring for

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them during pregnancy, birth and postnatally; • More women are able to give birth in midwifery

settings (at home and in midwifery units).

- Improving the safety of maternity care so that by 2020/21 all services have:

• Reduced rate of stillbirth, neonatal death, maternal death and brain injury during birth by 20% and are on track to make a 50% reduction by 2030;

• Are investigating and learning from incidents and sharing this learning through their local maternity system and with others;

• Are fully engaged in the development and implementation of the NHS Improvement Maternity and Neonatal Health Safety Collaborative.

Implement the ‘Saving Babies’ Lives’ care bundle. Implement the recommendations of the West Midlands Neonatal review. To deliver, through integrated working with Local Authorities on the broader determinants of health, local health outcomes, aligned to local Health and Wellbeing Strategies. To put in place the infrastructure that is needed to support services to work together effectively, including interfacing with other services that have a role to play in supporting women and families before, during

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and after birth.

Work-streams

Health and Wellbeing • Incorporating Perinatal Mental Health, Smoking, Obesity and

Domestic Violence

Quality and Safety • Incorporating Saving Babies’ Lives Care Bundle, Maternity

and Newborn Safety Collaborative, Shared Guidelines, Learning from Incidents and Complaints, Continuity of Care, Perinatal Mortality Reviews, Care Pathways, and Quality and Safety Dashboard.

Choice and Personalisation

• Incorporating Design of the Future Clinical Model Membership / Attendance

• Core membership: South Warwickshire CCG Lead Coventry and Rugby/Warwickshire North Lead (Vice Chair) Public Health Leads for Coventry and Warwickshire Lead Obstetricians: GEH, SWFT and UHCW Neonatologists: GEH, SWFT, UHCW Operational Managers: GEH, SWFT, UHCW Heads of Midwifery: GEH, SWFT and UHCW STP Programme Manager Specialised Commissioning Representative Neonatal Network representative CWPT Maternal Mental Health Lead NHS England DCO Lead

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Maternity Network Lead Maternity Voices Representatives for Coventry and Warwickshire Primary Care representatives from each CCG

• Other members (by invite): WMAS Lead Health Education England Lead

Chair Chief Nurse, South Warwickshire CCG

Quorum 5 core members, to include 1 CCG representative, 1 Public Health representative, 1 representative from each Acute Trust.

Reporting arrangements

The LMS reports into the Maternal and Child Health work-stream of the Coventry and Warwickshire STP.

Decision Making The group will have specific decision making abilities, focused on:

- Determination of recommendations/options for consideration by the Maternal and Child Health work-stream;

- Expenditure of designated LMS funds; - Sign off of LMS plan submissions prior to STP sign off.

Frequency of Meetings

• Monthly programme board meetings to track progress and take forward strategic work.

• Venues to be rotated across Coventry and Warwickshire.

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• Additional workshop meetings may be set up between programme boards or as an extension to programme boards to progress work.

Date Approved 8th January 2018

Date to be Reviewed

September 2018

0

APPENDIX 2: DRAFT LMS QUALITY AND SAFETY DASHBOARD

MONTH 17/18

NOV

DEC

JAN

Indicator Data Source

UHCW GEH SWFT UHCW GEH SWFT UHCW GEH SWFT

Mortality and Morbidity

Still birth rate. Trusts Neonatal mortality rate. Trusts

Brain injuries occurring during or soon after Birth.

Trusts

Proportion of singleton term infants with a 5 minute Apgar score of less than 7.

Trusts

Proportion of vaginal births with a 3rd/ 4th degree perineal tear.

Trusts

Proportion of birth episodes with severe PPH of greater than or equal to 1500 MLS.

Trusts

Proportion of term admissions to NICU, SCBU. Trusts

Number of intra uterine transfers within the LMS. Trusts

Number of intra-uterine transfers outside of the LMS.

Trusts

1

Clinical care and health promotion

Normal birth rate definition: birth without induction, caesarean, instrumental delivery, episiotomy, augmentation, epidural, spinal or GA.

Trusts

Spontaneous vaginal delivery rate.

Trusts

Total caesarean section rate. Trusts

Caesarean section rate Robson group 1 and 2 Robson Group 1: Nulliparous women with a single cephalic pregnancy, at greater than or equal to 37 weeks gestation in spontaneous labour Robson group 2: Nulliparous women with a single cephalic pregnancy, at greater than or equal to 37 weeks gestation who either had labour induced or were delivered by a caesarean section before labour.

Trusts

Proportion of infants who are small-for gestational-age (birthweight below 10th centile).

Trusts

Proportion of live born babies who are breastfed for the first feed.

Trusts

Smoking at the time of delivery Trusts

2

Percentage of women, who smoke during pregnancy, responding to ‘Yes always’ when asked if during antenatal check-ups they have been referred to the specialist Smoking in Pregnancy Service.

Trusts

Proportion of pregnant women given flu vaccine.

Trusts

Proportion of pregnant woman given pertussis vaccine.

Trusts

Number of women assessed for overweight/obesity in pregnancy.

Proportion of pregnant women assessed as overweight /obese signposted/referred to appropriate weight management and physical activity.

Number of women screened for BCG eligibility (of neonate), number/proportion identified as eligible, and number/proportion of those referred for BCG vaccination (given that the model works differently in Coventry and Warwickshire.

Trusts

Number of women who have stopped smoking whilst pregnant.

Trusts

Number of women who have stopped/ reduced alcohol/ drugs consumption during pregnancy.

Trusts

3

Number of pregnant women asked in private about domestic abuse concerns.

Number of women assessed as having domestic abuse concerns referred to appropriate support services.

Number of pregnant women advised as to the risks of alcohol and substance misuse.

Number of pregnant women referred to specialist services for alcohol and substance abuse.

Occupancy rate of NICU / SCBU. Trusts / Badgernet

Choice and continuity of carer

Percentage of women responding with ‘Yes, always’ when asked if their decisions about how they wanted to feed their baby were respected by midwives.

Trusts internal CQC style survey

Percentage of women responding with ‘Yes, always’ when asked if they felt that midwives and other health professionals gave them active support and encouragement about feeding their baby.


Percentage of women responding with ‘Yes, definitely’ when asked if they got enough information from either a midwife or doctor to help them decide where to have their baby.


4

Percentage of women that saw a midwife as much as they wanted at home or in a clinic after the birth.


Percentage of women not offered any choices about where to have their baby.

User Experience

Percentage of women responding with ‘Yes, always’ when asked if during antenatal care, they were involved enough in decisions about their care.


Percentage of women that were not left alone by midwives or doctors at a time when it worried them Percentage of women responding with ‘Yes, always’ when asked if they felt that midwives and other health professionals gave them active support and encouragement about feeding their baby.


Percentage of women responding with ‘Yes, always’ when asked if when thinking about the care they received in hospital after the birth of their baby, were they treated with kindness and understanding.


5

Percentage of women responding with ‘Yes, always’ when asked if they need attention while in hospital after the birth, were they able to get a member of staff to help them within a reasonable time?


Percentage of women responding with ‘Yes, always’ when asked if during their antenatal check-ups they were given enough time to ask questions or discuss their pregnancy.


Percentage of women who, having raised a concern during labour and birth, felt their concern was taken seriously.


Number of expectant and post-natal women/fathers diagnosed with a mental health issue/ or self-diagnosed.

Number of expectant and post-natal women/fathers receiving listening visit from health visitors because of mental health issue (identified at antenatal visit)

Health Visiting Service

Number of expectant mothers/fathers accessing IAPT (& self-referrals vs treatment offered)

IAPT?

6

Number of post-natal mothers/fathers accessing IAPT (& self-referrals vs treatment offered)

IAPT?

Number of women referred to Perinatal Mental Health service vs. a number of women receiving treatment/ support from the service (referrals by which professionals)

Trusts/IAPT/Health Visiting Service

Proportion of expectant and post-natal mothers who have completed the Solihull Approach guides (by geographical & demographic variables)

Trusts/Health Visiting Service

Proportion of expectant and post-natal mothers/fathers who have been able to access an antenatal 'parentcraft/ parenting' course/group

Proportion of expectant and post-natal mothers/fathers completed the Solihull Approach guides (by geographical & demographic variables)

Trusts/health visiting Service

Organisational culture

Proportion of midwives responding with 'Agree or Strongly Agree' on whether they would recommend their trust as a place to work or receive treatment.

NHS Survey (Annually)

7

Proportion of midwives responding with ‘agree’ or ‘strongly agree’ with the statement "When errors, near misses or incidents are reported, my organisation takes action to ensure that they do not happen again".


Proportion of specialty trainees in Obstetrics & Gynaecology responding with 'strongly agree or agree' on whether their working environment is one which helps build the confidence of doctors in training.


Proportion of specialty trainees in Obstetrics & Gynaecology responding with 'excellent or good' on how they would rate the quality of clinical supervision out of hours.

Deanery Survey (Annually)

Proportion of specialty trainees in Obstetrics & Gynaecology responding with 'agree or strongly agree’ with the statement 'handover arrangements between shifts in my post ensure continuity of care for patients'.

Deanery Survey (Annually)

Workforce Birth: Midwife ratio Trusts

Percentage of QIS nurses in NICU / SCBU (National recommendation 70%).

Trusts

Proportion of obstetric doctors covered by locums. Trusts

Proportion of neonatal doctors covered by locums.

Trusts

Could we also include some measures in relation to the recommended actions for inclusion in the LMS action plan, such as:

8

Proportion of midwives / health visitors trained in parent infant mental health (early identification of PMH problem, early identification of bonding and attachment problems, agreed screening and assessment tools (NICE guidance), CBT, specific training on how to work with parents/family unit to build attachment). Note: the Parent-Infant MH & Wellbeing Steering Group will need to look at workforce development requirements moving forward.

Trusts / Health Visiting Service/NHS EE

Proportion of expectant and post-natal women/fathers fast-tracked to IAPT (This requires inclusion of specific questions within first IAPT assessment - particularly important in relation to fathers who may be less likely to volunteer expectant or new parental status).

IAPT?

Proportion of midwives and health visitors trained to deliver effective MECC in smoking, obesity, DVA etc. 9this includes the motivational interviewing training).

Trusts/Health Visiting Service

KEY

UHCW = University Hospitals of Coventry and Warwickshire NHS Trust

GEH = George Eliot Hospital NHS Trust

SWFT = South Warwickshire Foundation Trust

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APPENDIX 3: NEONATAL REVIEW RECOMMENDATIONS The recommendations arising from the West Midlands Neonatal review are:

a) Specialised Commissioners will re-commission providers to plan for a specified volume of occupied cot days, based upon historic usage, and ensure that they plan their cot capacity to be occupied at 85% of full capacity. The Specialised Commissioners will support STPs to consider what their local cot base should be based upon historic and predicted volumes of activity and optimal occupancy rates. Specialised Commissioners, alongside STPs, will reconfigure neonatal services where units are agreed not to be sustainable, safe or efficient.

b) Consider, with STPs/CCGs and providers, identifying a pilot footprint to trial an Alliance or other New Care Model approach to

collaboratively commissioning a combined neonatal and maternity service.

c) Specialised Commissioners will establish a clinical workstream to develop protocols and specifications for the following: - Transfers and repatriation - Access and Egress criteria - Transitional Care - Outreach Services - Standardised communications

d) Specialised Commissioners will provide senior input into the West Midlands Maternity and Newborn Alliance Board. We will ask the Board

to provide strategic input to two Operational Delivery Network (ODN) teams (down from three) to deliver a work programme jointly agreed by NHS England and STPs. They will align ODN boundaries with STP geographies.

e) Specialised Commissioners will work jointly with CCGs to consistently commission Transitional Care and Outreach to reduce demand on

NHS England and CCG commissioned services.

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f) Specialised Commissioners will undertake a joint mortality assessment, alongside CCGs, factoring in the level of care a unit is designated for and the occupancy rate to identify and address causes due to clinical and capacity reasons

g) Specialised Commissioners will encourage networks and transport teams to develop real or near-time information sharing around cot and

maternity bed availability.

h) Specialised Commissioners will work with Health Education England to ensure that we have a joined-up approach to planning workforce as new models of care develop.

9. Specialised Commissioners will prioritise three improvements to the emotional and practical support made available to parents and negotiate with providers to deliver those. i) Specialised Commissioners will, alongside CCGs, agree five high impact changes to improve the interface between maternity and neonatal services

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APPENDIX 4: COMMUNITY HUBS – WORK TO DATE Better Births recommends bringing care together in community hubs where women can access elements of their care locally with different providers working together to offer midwifery, obstetrics and other services such as ultrasound, smoking cessation and weight reduction. The vision for in Coventry and Warwickshire is the provision of multi professional team working which aligns maternity care and sonography with health visiting, Family Nurse Partnership, specialist programmes that link into child health (such as MAMTA in Coventry – a 3rd sector organisation that provides specialist parentcraft for BME women, early help services social care and health promotion with Family Hubs. Coventry City Council and Warwickshire County Council (WCC) are currently proposing new ways to offer services and support to children and families. The proposal in Warwickshire includes converting a number of current children’s centres into Family Hubs with circa 12 located across the county. Within Coventry, a similar initiative would see services being provided through eight Family Hubs across the city. Team development across partners has commenced with the expectation that these will be led at a local level, incorporating the assets in their communities and ensuring these assets, e.g. schools, communities and families, have the opportunity to be partners in the further development of the Family Hub model. The diagram overleaf outlines the services we aim to provide in a Family Hub setting across Coventry and Warwickshire.

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APPENDIX 5: INITIAL BETTER BIRTHS QUESTIONNAIRE

Have your say about maternity services in Coventry and Warwickshire November – December 2016

Following a national review of maternity services, NHS England has recently published ‘Better Births – improving outcomes of maternity services in England’.

During the national review feedback from women, families and healthcare professionals was gathered and considered to inform the report and create a vision for maternity services in the future:

‘Our vision for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; where she and her baby can access support that is centred around their individual needs and circumstances.’

Better Births

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The National Maternity Review: https://www.england.nhs.uk/ourwork/futurenhs/mat-transformation/mat-review/

Achieving the vision

We want to continue this work at a local level. We want to hear from as many mothers, fathers, families and local healthcare professionals, so that together we can plan local maternity health services across Warwickshire, Coventry and Rugby. Listed below are key words and phrases taken from the vision. The interviewer/event lead needs to keep these in people’s minds as they listen to and record the antenatal, birth and delivery experiences of the mothers/fathers/families they talk to.

Once the written feedback from the face to face engagement has been captured on the following pages, these words will be mapped against what people have told us. This will help to inform the critical success factors for any proposed new models of care as plans are developed.

Please tell us about your experience of antenatal care (care before the birth)

https://www.england.nhs.uk/ourwork/futurenhs/mat-transformation/mat-review/

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What was good? Prompt - how did this make you feel?

What was bad? Prompt - how did this make you feel?

How could your experience have been improved? Prompt – how would this make you feel?

Please tell us about your experience of the labour and delivery of your baby




Please tell us about your postnatal care (care after the birth)


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Please tell us the five key factors of maternity care that are most important to you:

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2

3

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5

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APPENDIX 6: SPRING 2018 ENGAGEMENT EXERCISE

CONTEXT There are a number of priorities, both locally and at a national level, that need to be considered during any conversations about the future of maternity services. These are:

• “Better Births” 2016 – National Maternity Review • Five Year Forward View priorities • Better Health, Better Care, Better Value – the Coventry and Warwickshire Sustainability Transformation Partnership/Plan • Local health and wellbeing strategies • West Midlands neonatal cot review • CCG Improvement and Assessment Framework

WHAT QUESTIONS DOES THIS STRATEGY NEED TO ANSWER? In order to be successful, any communications and engagement work in support of the local maternity service transformation plan needs to address the following questions:

• What do we want to achieve? – Clear aims and objectives, a single vision and an agreed future state will all help to identify an end goal • Who do we need to talk to? – There are dozens of stakeholders and audiences that will be interested in or potentially affected by any

changes • What’s already been done? – For context and to ensure we’re aware of the bigger picture, utilising intelligence already gathered and

not reproducing work already done unnecessarily • What do we need to say? – What are the succinct, accessible, relatable messages to use to promote the work? • How shall we say it? – What are the best channels to use? How do we ensure we use the right language? How do we ensure we ask the

right questions in the right way at the right time, and with the right people?

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• How do we know when we’ve got it right? – We need to ensure we install a robust feedback loop for all communications and engagement to make sure the messages are resonating, we’re reaching the right audiences and using the best channels, as well as working to continuously improve everything we do.

WHAT DO WE WANT TO ACHIEVE? In order to support the objectives of the LMS in delivering Better Births the STP will lead a communications and engagement exercise, which seeks to keep informed and gather the views of as many people/organisations/groups that may be affected by the plan as possible. This will ensure future services are based on the requirements of those that need/use them most and that those groups are not only able to input into these discussions, but that their input is listened to, valued and utilised where appropriate (and where not appropriate, it is made clear why). Our communications and engagement work needs to be relatable, accessible and two-way. We need to be open, honest and transparent. The work cannot feel like a tick-box exercise and nor should it be; this is a real, positive opportunity to help drive change to local services and should be seen and treated as such. HIGH LEVEL CHANGE MANAGEMENT PROCESS

The communications and engagement work will play a critical role in the overarching change management needed for the local maternity system transformation plan. We want to positively influence behaviour to ensure that the goals set by the engagement, in this case, supporting the provision of maternity and neonatal services that are safe, kind, family friendly, personalised and with improved outcomes for children, young people and families, are adequately met. A change methodology, such as the change acceleration process below, will need to be used to ensure the change is effective.

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LEADING CHANGE For a change to be successful, it needs visible, genuine and committed leadership who “lead by example” throughout. A lack of influential leadership is one of the biggest contributors to change failure. The LMS needs to demonstrate that maternity is not just a national, nebulous priority, but that it is something that has been identified locally as needing to change and that all local health and care providers, third and voluntary sector groups and patients and the public are aligned with doing so for the benefit of those who use local maternity and neonatal services. SHARED NEED The desire to change must outweigh any potential resistance, and compelling reasons for change which resonate and appeal to each key stakeholder group must be presented. This must be tested, retested and informed by those who the change will affect, or it cannot be ‘real’. There may be many variations on this need: what patients want may differ to what is wanted by service providers, for example, but as long as there

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are consistent themes throughout that align with the overarching aims and objectives, it will help people see how these plans may go on to affect them and give them the desire to input and feed into the future. SHAPE VISION A desirable, engaging and compelling “future state” must be established – every journey must have a visible destination, or it will never end or become reality. The vision needs to be co-produced and in language that is accessible and relatable. It must demonstrate which behaviours will change and what individual outcomes will be, rather than simply listing expected organisational results. If people do not believe in the vision, they will not come on the journey and the change will fail – this is as true to patients and the general public as it is for local providers. GET BUY-IN Once clear and visible leadership, a strong desire for change and a compelling future state have been established, further buy-in can be sought. This is the period in which change needs to mobilise and build momentum: the use of advocates, champions and early-adopters will help test ideas with “critical friends” and trusted advisors, so that feedback can be taken on board, assumptions challenged lesson learnt. MAKING IT LAST Capitalising and celebrating early wins, using the knowledge gained during the journey and transferring it into new ways of working and demonstrable best practice will help the changes begin to stick with the core stakeholder groups. This could include changes to how maternity services are delivered at a strategic, operational and day-to-day level, and how this will look and feel different to patients. MONITORING PROGRESS Progress will need to be continuously monitored: is the change being accepted? Is it ‘real’ for people? What are the benchmarks? It is important to celebrate success and demonstrate accountability for lack of progress. CHANGING SYSTEMS AND STRUCTURE Consideration needs to be given to the wider inputs into successful change: IT systems, human resources, training and development, workforce and workflow, current processes and so on. All of these external inputs support the status quo and may need to also change to support the new way of working, or people will resort back to old habits. It is important to systematically identify where existing systems and structures impact and influence the things ware trying to change and what opportunities there are to use these to positively the local maternity service. THE LMSTP LOGIC MODEL

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On the next page is the local maternity service transformation plan logic model. This model demonstrates the inputs (i.e. resources), activities, audiences, outputs and outcomes/impacts the communications and engagement aspect of this work will have. The model is a “live” document and will be referred to and updated regularly as the work moves forward – this is just a current snapshot.

WHO DO WE NEED TO TALK TO? It is likely that changes to maternity services could affect a wide range of stakeholders. It is important that all communications and engagement, as well as any associated planning, is collaborative, with owners defined for each group and with absolute clarity over responsibilities and expected input. For this reason we are starting a first phase of work to develop a robust specification for engagement, working with our local Healthwatch leaders so as to ensure the approach is comprehensive and built on our best information and evidence.

Phase Activity summary Schedule

Phase 1 – Develop a specification for engagement with both Coventry and Warwickshire Healthwatch, use the early engagement and other insights on these services to inform the specification.

Ensures advice and guidance from Healthwatch at the initial stage of the work so that the engagement programme is robust

Sept 2017

Issue the specification to the market to commission an engagement provider to operate the programme

Manage recruitment of an engagement partner

Oct – Dec 2017

Phase 2 – Main period of engagement

Commence the programme of activities

Jan/ Feb 2018

Whilst it would be unreasonable and impossible to expect to be able to engage with every single person that may be affected by changes to maternity services, it will be critical to the success of the plan that we engage with as many people, from as many different backgrounds, organisations and interest levels as possible, in order to ensure any future proposals and decisions made are done so with public/patient needs, wants and outcomes at the heart. We need to understand what services people want, where they want them and how they wish to access them. In order to achieve this, we cannot rely solely on traditional methods of engagement, such as surveys, but instead will need to think more widely about the best ways in which to reach our target audiences in ways that are convenient to them. An example list of some of the groups we would wish to speak with (more details in the stakeholder section) would include:

• Service users – new or expectant mothers are one of the core stakeholder groups. What are their wants, needs and worries? What is their current understanding and expectation of maternity services? How can we involve them to design a future maternity service that meets and exceeds those expectations, where possible and appropriate?

• Local parenting bloggers – they have influence and reach that could support our engagement • Staff at local maternity service providers – any changes to service provision or delivery would directly affect this group, so it is important they are

engaged and informed throughout so they can be part of future developments and feel ownership of any eventual changes • Elected members – maternity service provision is a hot topic politically, so it is important that our local elected members are kept engaged and

informed as much as possible to bring them on the journey with us, so that they can contribute to developments, as otherwise it is likely they will oppose any future proposals

• Voluntary and third sector – there are a number of local community groups that offer support to parents, and working collaboratively with them will widen our reach and credibility with the target patient groups, help us to reach more seldom-heard groups and build on the excellent work already undertaken out in the local communities and neighbourhoods

STAKEHOLDER ANALYSIS, ENGAGEMENT AND MANAGEMENT Stakeholder management will be a very important aspect of ensuring the engagement process is successful through winning the support of influential or key people who have a direct impact on the success or failure of the programme. Stakeholder analysis is the technique through which these key people are identified. Stakeholder planning is then used to build the support and generate buy-in from these key people, or keep them informed and engaged with the programme. The benefits of using a stakeholder centric approach include:

• Using the influence of those in power can help to shape and improve the programme, once you have gathered their support; strong, visible leadership can also motivate employees and support them to embrace and adapt to new ways of working

• Enabling targeted communications early and frequently, ensuring that those affected by the programme understand what is happening, why it is happening, what it means to them and the benefits they are likely to see as a result

• It allows you to see what is important to and anticipate reactions from those affected by the programme and develop plans to win peoples’ support In essence, communications are developed to meet the needs of groups who are impacted by the programme, while stakeholder management strategies are designed to meet the needs of key individuals who are not only impacted by the programme but also have a high degree of influence over the success of the programme. Stakeholder management is very resource intensive, involving a high degree of face to face, two way communications and involving key members of the programme team. However, it is essential in order to build programme commitment and quickly identify issues or concerns which may affect the programme. Both stakeholder management and communications activities will need to operate throughout the life cycle of the maternity services review, and they should be continually monitored and evaluated to ensure they are meeting the needs of all audiences. An example high-level stakeholder plan can be seen below:

WORKING WITH PARENTING BLOGGERS Blogging has really taken off in recent years, giving the “average” person the ability and various platforms from which to share their views at-scale, with a wide range of like-minded people. The scale of blogging about parenting, in particular, has grown exponentially, and the most influential are being used in focus groups, on television and in campaigns across the country due to their influence and reach. The most influential have twitter followers in the tens of thousands. They provide content that resonates with ‘real’ people, who really engage with, respect and value the opinions of the bloggers. They cover a multitude of topics, from the lead up to birth

and what it is really like, to living with new born, sleepless nights, mental health, family support and more. They could be a key demographic to reach out to in order to spread our messages as widely as possible and add credibility to any engagement work. However, there are a number of things to consider when working with bloggers:

- Bloggers, particularly the more influential ones with the farthest reach, should not be expected to work for “free”. Often they will expect compensation or remuneration for their input. For example, asking for a sponsored post might cost £300, but will reach over 70,000 people.

- Bloggers are different from journalists, and need to be treated and respected in different ways. They write about their chosen subject(s) as it is something they are passionate about, rather than being told to write about by an editor, or paid to do as a job. This means they can, within the same boundaries as anyone writing anything for public consumption (i.e. they cannot write anything that can be taken as defamatory, libellous etc), write whatever they like, whether good or bad

- Some bloggers will actively engage with and write about/share stories or campaigns that interest them even if there is no reward offered - Any work with bloggers should be based upon an official agreement that clearly dictates what is expected of the blogger and any remuneration

agreed for their participation - Approaching bloggers should be done in a personable, succinct way that outlines how and why we wish to engage them and to what end.

Several mums said how much they valued the involvement of their partner in the pregnancy and birth and unrestricted visiting times enhanced the experience of giving birth in hospital. Having other children caused some access and childcare difficulties at the post and antenatal stages of care if appointments were not made around family routines or children were not allowed to attend appointments. One mum whose family came to visit from another area commented on the lack of facilities at the hospital. The TV did not work and there were no refreshments available after 4pm. Many mums appeared to benefit from antenatal classes where these were available. They found the information that they were given and he networking with other parents invaluable. Some mums had no or little access to antenatal classes depending on where they lived and how easy it was for them to get there. There appeared to be less in the way of postnatal support groups and many mums felt that these would have been beneficial to them after the birth. Breastfeeding support was on the whole good, but there were several cases where it had not been available or effective for individual mothers. Some mothers gave up breast feeding because of the lack of support.

WHAT DO WE NEED TO SAY?

CONTEXT We need to raise awareness of the following, which influences the context of why there needs to be a discussion around maternity services:

- There have been a number of reviews, both at a national and local level, which mean we need to rethink how we deliver maternity services in a safe, accessible, sustainable way across the area

- The safety component is particularly important to avoid unnecessary complications during birth - Local performance against a number of targets shows room for improvement.

OVERARCHING MESSAGE FOR THE LMS “Local health and care providers across Coventry and Warwickshire are inviting you to take part in initial conversations about the future of maternity services in the area. This is an opportunity to be involved from the start, help us design services that meet your needs and are safe, kind, family friendly, personalised and provide the best possible results for children, young people and families”.

SOUNDBITES FOR STAKEHOLDERS • The CCGs are leading the strategic commissioning of Maternal and Child Health services, working closely with Local Authority and Public Health leaders

and informed by expert clinicians • All local organisations will have the opportunity to engage with and contribute to the plan • A truly collaborative approach is required to achieve the aims and objectives

SOUNDBITES FOR PATIENTS AND THE PUBLIC • The Local Maternity System, comprising local NHS providers, is going to review maternity services to see how they can be improved to be safer, more

personalised, kinder, more family friendly and provide care that meets a person’s individual needs • This is the start of a long journey – no decisions have been made at this time • This is a great opportunity to be involved in and truly help shape and co-produce the future maternity services across the area from the very start • We need to know what is important to people, what their version of excellence looks like and value their ideas, thoughts and feedback

Once engagement begins, more key messages will be developed, reviewed and tested with target audiences to ensure they resonate. Some of the messaging may be generic (i.e. ensuring parents have a choice of where and how they give birth) and some may be more specific to particular pieces of work that develop as a result of the review (e.g. supporting mothers to give birth at home).

HOW SHALL WE SAY IT? It is wrong to assume that only expectant mothers will be affected by and interested with any changes to maternity services. It is also incorrect to assume all expectant mothers will be young, tech-savvy and able/willing to engage across digital media for the most part. Therefore, it is important that we are as inclusive as possible in our engagement to ensure as many people as possible have a chance to put forth their ideas and input into the conversation in a way that is convenient to them. Below is an example communications and engagement journey, which features ideas for the types of channels which could be used to build advocacy and support for change. This will be further developed as engagement begins around maternity services and opportunities for engagement begin to present themselves. COMMUNICATIONS AND ENGAGEMENT JOURNEY

COMMUNICATIONS AND ENGAGEMENT PLAN ON A PAGE

PARTNERSHIP WORKING

Many local organisations will need to be involved in the conversations about the future of maternity services, so it is important that the communications and engagement function integrates and aligns with each organisation. We will ensure a clear understanding of the target audiences through completion of audience segmentation and high level impact analysis. This information, as well as a data gathering exercise into existing communication channels across partner organisations, will enable the development of a robust communications and engagement plan, ensuring the most appropriate mechanisms and approaches are used for each audience, and that the language, tone and context is set correctly for each recipient. It is important that we work with existing communication experts at participating organisation to ensure effective identification of messages and content, as well as the timely delivery of communications to their audiences. PLANNING AN ENGAGEMENT CAMPAIGN

Some of these headings are covered within this document; others will be developed as part of a communications and engagement plan. It is prudent to put a lot of effort into the planning component of an engagement campaign, as it will result in a better end result, but the planning should not be so lengthy that it begins to negatively impact on the timescales for actual engagement.

A more specific example would be as shown below:

HOW DO WE KNOW WE’VE GOT IT RIGHT? It is important that evaluation is conducted at regular intervals to ensure the work is meeting expectations, hitting key milestones, within scope and still aligned to the overarching aims and objectives. Balanced feedback will be provided against strengths, areas for improvement and key learning. An engagement log will be held to monitor the reputation of the project externally. Key deliverables from communications will be monitored at a programme and project level. Engagement levels will be base lined and monitored throughout this programme. This plan will be monitored through the collaborative steering group and stakeholder meeting with commissioners. As the plan develops to reflect the scope of the programme the key deliverables will be monitored through the transitional board (or alternative governance structure to be agreed).

RISKS THE PURPOSE OF THE ENGAGEMENT There is a significant risk that some may see this as a tick box exercise and believe that ideas and plans have already been drafted. There is a risk that a misunderstanding of the programme will lead certain stakeholders to feel that a consultation is required. That is why use of the key overarching message detailed earlier in this section is important, particularly in the initial stages of the programme. If a consultation is required at any point during this programme a separate communications and engagement plan will be required. PACE OF CHANGE Developing any new model at pace will present a number of risks, including the potential to miss engagement opportunities with key stakeholders. Careful and thorough stakeholder management will be applied to minimise the risk of disengaged groups and delays to the programme. MESSAGING With so many organisations involved with this programme there is a risk to the delivery of timely consistent messages throughout the programme. A process for sign off will be agreed with partners to mitigate this risk and also with the design boards. CULTURAL CHANGE This programme will require organisational development to support the cultural changes that need to take place and where appropriate external support will be used in line with this plan. Internal communications through this period will be critical to support the changes in working practice required for the new model of care. There will also be change in partner organisations, therefore the communications and engagement support for these will need to be identified at design boards and additional support provided if required.

STP – BETTER HEALTH, BETTER CARE, BETTER VALUE The impact that other elements of the STP have on this programme from an engagement perspective need to be monitored as it could affect the reputation of the programme.

Local Maternity System Transformation Plan

Documents

Transcript of Local Maternity System Transformation Plan