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Highland Health Board NHS Highland Board 28 November 2017 Item 4.3 Implementation of midwife-led Community Maternity Unit in Caithness and the development of Hub and Spokes Model of Maternity and Neonatal care in NHS Highland Report by Mrs Mary Burnside, Lead Midwife North Highland, Dr Helen Bryers, Head of Midwifery and Dr Lucy Caird, NHS Highland Interim Clinical Lead for Obstetrics and Gynaecology on behalf of Dr Roderick Harvey, Board Medical Director. The board is asked to • Note the further progress made in the implementation of the Community Maternity Unit in Caithness • Note the progress made and proposal for future development of a Highland wide Hub and Spoke model of maternity & neonatal care in NHS Highland. 1. Summary On 29th November 2016 NHS Highland Board approved the recommendations of ‘‘Caithness Maternity and Neonatal Services – A Public Health Review’ including the move to set up midwife-led Community Maternity Unit (CMU) in Caithness and the designation changed on Monday 4th December 2016. An interim report on progress was presented to the board in May 2017. This paper provides an update on the arrangements as of the 1st November 2017, including a summary of clinical activity. 1.1 Number of Births. Transfers and Retrievals Over the eleven month period from 1st December 2016 to 31st October 2017 there have been total of 218 births to women resident in Caithness. Of these, 199 births were in Raigmore Hospital, and 18 (9%) normal births in the CMU, with one planned delivery elsewhere Transfers and Retrievals are lower than before the change in designation and this is an important indicator that the new arrangements are working as planned. 1.2 Clinical Services, Developments and Staffing • The midwifery team is up and running as a midwife-led service and there are positive signs of this team growing in confidence and working together • An interim NHS Highland clinical lead for obstetrics and gynaecology is in place with plans for a substantive appointment • Triage of calls to Raigmore consultants and Labour Suite at Raigmore Hospital is fully established and is working as planned • Arrangements for obstetric sonography outreach to Caithness from Raigmore Hospital are in place and have helped to make the local service more sustainable. • New algorithms to support the CMU have been developed and implemented • The consultant obstetricians who were based in Caithness have relocated their jobs to Raigmore Hospital and since 1st October 2017 have been working to a revised job plan with outreach input into Caithness. • One existing Raigmore based consultant also participates in the visiting service to Caithness, thus strengthening the link between the units, and provides leadership. • There is ongoing work to support early pregnancy assessment in Caithness using specific guidelines and clinical pathways. • There has been no change to the elective gynaecological service provision in Caithness • Enhanced out-patient gynaecology service in Golspie has been developed 1.3 Education & Training An extensive programme of training and skills updating has been available for staff in Caithness General Hospital including Emergency Department, theatres and emergency response team. 1.4 Recruitment Successful recruitment of an experienced midwife to the Caithness team plus one to the nursing/midwifery bank 1.5 Ambulance Provision Joint working and funding of circa £0.5m to develop a new staffing model and ambulance provision which will be in place in early 2018. In the meantime interim arrangements are in place to strengthen the service 1.6 Accommodation Enhanced arrangements and facilities for women and families to access accommodation in Inverness. This has included enhanced awareness and support through a dedicated liaison officer. 1.8 Communications and Engagement There is ongoing engagement with local community to keep abreast with new arrangements including the appointment of a Liaison Officer as a point of contact for Raigmore. A Local Maternity and Liaison Group has been established and continues to meet monthly. The Group members developed an approach and questionnaire to look at patient experience 2 Background On 29th November 2016 NHS Highland Board approved the recommendations of ‘‘Caithness Maternity and Neonatal Services – A Public Health Review’ that the small consultant obstetric unit in Caithness General Hospital should be reconfigured as a midwife led Community Maternity Unit (CMU) given serious concerns over the safety of the current configuration for a small but significant proportion of mothers and neonates Implementation of these recommendations bring Caithness arrangements in line with other CMUs in the North Highland Health and Social Care Partnership, namely those based in Dr Mackinnon’s Memorial Hospital in Broadford and the Belford Hospital in Fort William, both of which also support large geographical areas. In addition, the Board accepted the second recommendation that an integrated Hub and Spokes model for the delivery of maternity, neonatal and gynaecology services should be developed with further outreach from a central Hub in Raigmore Hospital (Inverness). It was recognised that this change would require additional clinical leadership, greater use of technologies such as videoconferencing, more streamlined access to accommodation facilities for mothers and families who have to travel significant distances, and closer liaison with Scottish Ambulance Service and neonatal retrieval services. 2.1 National Review of Maternity & Neonatal services The ‘Best Start’- A Review of Maternity and Neonatal Services in Scotland was published by the Scottish Government in January 2017. The main recommendations of the review are that every woman will have continuity of care from a primary midwife for the majority of their antenatal, intrapartum and postnatal care, and that obstetricians will be linked with midwives in multi-disciplinary teams. The implementation of the midwife-led CMU in Caithness and the further development of the ‘Hub’ and Spokes model of maternity and neonatal care is in line with the recommendations made in the national review. NHS Highland has been selected as an early adopter site for implementation of Best Start which will support further developments. 3 Operational Updates 3.1 Number of Births. Transfers and Retrievals Over the eleven month period from 1st December 2016 to 31st October 2017 there have been total of 218 births to women resident in Caithness. Of these, 199 (91%) births were in Raigmore Hospital, including 41 elective and 31 emergency caesarean sections (Table 1). During the same period there have been 18 (9%) normal births in the CMU. No mothers booked for birth in the CMU required to be transferred during labour and the outcomes for mother and newborn have been good. Table 1: Total births by mode and place of birth for Caithness Women 1st December 2016 to 31st October 2017 Mode of birth Caithness CMU Raigmore births to births Caithness Women SVD (normal birth) 18 + 1 local freebirth* 112 Instrumental (ventouse & forceps) 0 15 Elective caesarean sections 0 41 (EL LUSCS) Emergency caesarean sections (Em 0 31 LUSCS) Total 18+1 (9%) 199 (91%) *freebirth – birth, usually at home, without support (by maternal choice) from midwife or medical staff For comparison the number of births in the other CMUs in the Highland Health and Social Care Partnership (HHSCP) is shown (Table 2). The Lochaber CMU has a comparable caseload size and catchment area (Lochaber) and a similar SIMD deprivation profile. It has a similar number of local births to the Caithness CMU . Table 2: Total local births for Lochaber CMU and Skye& Lochalsh CMU 1st Dec 2016 to 31st October 2017 Mode of Birth Lochaber Skye CMU Births CMU births Maternity Caseload Maternity Caseload 220 (annual) 108 (annual) SVD (normal birth) 18 13 Breech 0 1 Total *18 (8%) *14 (13%) *percentage of local births (1st Dec – 31st October) out of total caseload 3.2 Transfers and Retrieval No mother who was booked for birth in the Caithness CMU required to be transferred during labour. There has been one neonatal transfer as a result of an unanticipated concern over the baby. This was managed according to agreed protocols and both mother and baby have had a good outcome. Both these transfer figures are lower than experienced in the previous model and are key indicators that the Unit, and new arrangement, are working as planned. The total number of maternal and neonatal transfers from the Caithness CMU and mode of transport over the past eleven months are summarised below (Table 3). Table 3 : Number of maternal and neonatal transfers to Raigmore Hospital, by mode of transport 1st December 2016 to 31st October 2017 (excludes mothers who travelled direct from home to Raigmore Hospital) Transfer mode number of women Own transport 55 Road ambulance (response within 1 hour) with 17 midwife escort Road ambulance (999) with midwife escort 5 Air ambulance (Helimed) with midwife escort 4 Taxi 4 Neonatal retrieval 1 Total 86 3.3 Hub and Spokes The remaining areas of work are mainly around the further development of the Hub and Spokes in order to have a fully functioning integrated North Highland maternity and neonatal service. A Hub and Spokes Implementation Group chaired by the Board Medical Director continues to meet to ensure identification and full implementation of the outstanding requirements The main aspiration of the Hub and Spokes group is to move towards a Highland-wide Women and Child Health Directorate with one management, clinical leadership and governance structure. This is to ensure that issues related to maternity and neonatal care are managed in a timely, seamless and safe way across North Highland and within a single financial budget. The current position on the Hub and Spokes is summarised as follows: • Agreement to implement an electronic maternity record, Badgernet Clevermed, which will ensure timely updates to women’s records during their pregnancy, birth and postnatal care. This will replace the current hand held paper record and will ensure that all clinicians and the women themselves have access to relevant information at all times irrespective of physical location.
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