NHS Board 28 November 2017 Item 4.3

Implementation of midwife-led Community Maternity Unit in 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 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 . 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 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 was published by the 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 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. • Improvement work is currently underway to put in place, test and evaluate a Highland wide model of maternity and neonatal services management and governance. This is in order to enable the Hub and Spokes model to function more effectively by removing artificial operational barriers to financial and clinical pathways of care. • Ongoing challenges remain at the Hub in terms of the physical layout and capacity for in- patients, appropriate space to manage triage and day attendees. This may be addressed via the Best Start work through proposals for increased space for maternity and neonatal services. In the meantime relatively minor physical changes to the information hub area in the labour ward at Raigmore Hospital are being pursued with the Estates Department • Historically there has been inadequate dedicated day time consultant anaesthetist cover for both emergency and elective caesarean sections at Raigmore Hospital, resulting in some elective operations being postponed to a later date and some anaesthetics provided by trainee or other non-consultant staff. The document “” 2015 states that “as a basic minimum for any consultant-led obstetric unit, there should be 10 consultant anaesthetic sessions per week”, and also “separate provision of staffing and resources should be available to allow elective work to continue uninterrupted by emergency work”. In order to meet the Royal College of Anaesthetists guidelines on the provision of obstetric anaesthesia services the Hub and Spokes group have agreed with the service lead for anaesthesia that full dedicated day time consultant anaesthetic cover will be provided from the 1st January 2018. This should ensure that all elective caesarean sections are performed on the planned date and that all operations performed during day time hours have immediate access to a consultant anaesthetist. • Improving and formalising current arrangements surrounding clinical risk management and patient safety through increasing the amount of dedicated time available for both medical and midwifery staff.

3.4 Accommodation for Women and Families

The external review of the Public Health report suggested that NHS Highland provide more homely accommodation for women and their families before and after birth. Family accommodation is available on the Raigmore site at Kyle Court, an additional two converted flats, The Ronald MacDonald centre and SCBU House. Free accommodation is provided for partners for up to three nights and depending on circumstances additional nights can be organised if required.

On occasions when there are no rooms available at Kyle Court, local Bed and Breakfast and hotel accommodation is used, with costs paid up front by the Board.

From 1st December 2016 to 31st October 2017 there have been 137 bookings submitted to Kyle Court Raigmore. Of these, 125 women stayed in Kyle Court for between one to six nights, with an average stay of two nights per couple/partner.

Consideration of accommodation is also covered in the Best Start recommendations. It remains a key component of the Hub and Spokes work and the views of mothers and their families are central to the developments. Questions on accommodation are included on the patient feed-back questionnaire.

The work with Estates Department in Raigmore is crucial to improving the Raigmore maternity environment with the aim of improving the capacity for partners to stay in the maternity unit without compromising the privacy of other women. Discussions are ongoing to look at possible future options.

4. Contribution to Board objectives

The new arrangements provide timely access to clinically appropriate safe care

4.1 Governance implications

• Staff governance

Embedding and strengthening the new arrangements has required significant engagement with staff across all units to ensure safe and consistent clinical care is in place.

The move to a Hub and Spokes model with appropriate enhanced training, support and 24/7 obstetric and neonatal advice provides a supportive and resilient environment for staff to provide safe and timely care. The transitional arrangements were overseen by a number of working groups which were guided by a Transformational Oversight Group co-chaired by the medical director and director of nursing.

There has been significant joint work with staff across all units to support training and development of guidelines and protocols. There is now rotation of Caithness midwives through the Raigmore Unit to ensure skills are maintained. In addition to updating clinical skills, this is engendering a positive team culture and a better understanding of roles in different areas of maternity care.

In the update paper to board in May challenges around recruitment to midwifery posts in Caithness were highlighted. Since May, the Caithness CMU has recruited one fulltime experienced midwife. Recruitment remains a challenge but the staffing levels have improved, and the on-call model is embedded and similar to that in the other CMUs in NHS Highland. Further development of the on-call model is being explored and will be included in a Highland wide review of midwifery workforce that is about to be undertaken with external support from a workforce planning expert.

Clinical

The new arrangements in place for Caithness are now in line with the current models elsewhere in North Highland and Argyll & Bute, and have been further strengthened by the development of the Hub and Spokes Model.

Financial

The recommended changes proposed were on grounds of clinical safety. Some investment has been required to support clinical leadership, with some new posts and an investment in technology.

Implementation of Best Start may have cost implications but will need to be considered across all parts of North Highland and Argyll & Bute

5. Risk Assessment

Good risk assessment, adherence to protocols and contingency planning is designed to ensure safe delivery in the CMU and as appropriate onward transfer.

NHS Highland in collaboration with the Universities of Aberdeen and Stirling is conducting a research study to understand how recent mothers in the area chose where to give birth, and how different obstetric and paediatric risks affected their choices. The focus groups for this study are currently underway. The information from the focus groups will be used to inform the development of a questionnaire which will be sent to pregnant women and new mothers across the North of Scotland.

6. Planning for Fairness

An Equality Impact Assessment was initially carried out and has been updated. It will be further considered as part of Best Start

7. Engagement and Communication

The Caithness Maternity and Gynaecology Group continue to meet monthly with the group chaired by a local GP, Dr Alison Brooks.

Work undertaken by the group includes appointment of the Liaison Officer post, input to local and Highland wide maternity information leaflets, input to policies, overview of accommodation and development and testing of service user questionnaire. The questionnaire has been tested with individual mums as well as with a small group. It will be issued to all Caithness women who have given birth since the beginning of the year (and ongoing) and it will be given out to new mothers in the postnatal period (around six weeks) with reminder prompts to support completion.

Greater degrees of deprivation are associated with a higher prevalence of obesity, smoking, and other factors that are known to increase the likelihood of complications of pregnancy and the birth of babies that require specialist care. Mothers and babies from the Caithness district are therefore more likely than average to require specialist care that cannot be provided locally and this seems unlikely to change in the foreseeable future.

On behalf of the Group Dr Alison Brooks wrote to Caithness Planning Partnership to highlight some of these concerns and to seek reassurances that the Partnership will be taking actions to address any inequalities.

The Terms of Reference and notes of meeting are all available on the NHS Highland website and are shared with Association of Community Councils, Caithness Planning Partnership and Caithness Programme Board. This also includes who has attended the meeting and any apologies.

A number of stakeholders, including NHS Highland were interviewed about the review by a medical student from Aberdeen University, as part of a Medical Humanities Project.

Dr Roderick Harvey Board Medical Director

17th November 2017