The best start: five-year plan for maternity and neonatal care

Chapter Seven: Supporting The Service Changes

Delivering the new model of maternity and neonatal care will require some fundamental changes to the way in which services are provided in the future. A wide range of support services provide essential elements of the care to women and their babies and, thus, it is essential that they are considered in detail and addressed appropriately if the full benefits of their significant contribution is to be realised to maximum effect.

7.1 Transport

Patient transport is a key issue for service users within NHSScotland, particularly in relation to neonatal transport.

ScotSTAR provides a national service for the transfer of some of the sickest patients within NHSScotland and is responsible for the Scottish Neonatal Transport service, which is an integral part of the neonatal community. It is operated by the Scottish Ambulance service.

There are occasions where babies are transferred to a different unit following birth. Effective communication and information around the transfer of their newborn were highlighted as key issues for families when babies (and their parents) require transfer and, thus, it is vital that these areas are viewed as a high priority.

'The transfer of my baby was excellent, and the nurse was really helpful. It was nice to get this one on one time with her to discuss the whole experience and how I was feeling at the time - especially with someone who understood. Being allowed to travel with my baby during the transfer was really appreciated.'

Maternity and Neonatal Review: Neonatal Survey 2016

Whenever possible, the need for neonatal specialist care should be anticipated antenatally and the mother moved to an appropriate perinatal care centre prior to birth. Normally this transfer would be by ambulance, and these must be equipped to deal with maternity transfers. Unnecessary maternal transfers should be minimised, with best available evidence used to identify mothers at risk of imminent preterm birth. The development of a standardised risk assessment tool, used appropriately and consistently across Scotland should minimise unnecessary or late transfer in utero. The tool should be regularly reviewed and updated to take account of the rapidly changing evidence around transfer.

This principle must be underpinned by a robust system for the identification of an available cot. This would be greatly facilitated by a standardised real-time information technology-based system for all Scottish neonatal units to declare cot status. Based on a National Framework for Practice, all units should develop clear and agreed pathways for newborn care, referral and repatriation. These pathways should be available to parents to enable fully informed choice with regard to place of birth.

Maternity services should be able to accommodate an expectant mother in the maternity facility adjacent to the neonatal facility appropriate for her baby, and the mother should receive her care in that setting.

When an unexpectedly unwell or preterm infant is moved to another neonatal unit soon after birth, the mother should be transferred at the same time as the baby to minimise separation. If the mother is too unwell to be moved immediately, she must be offered an opportunity to see her baby before transfer. Use of telemedicine/babycam systems should be considered to allow her to continue to have visual contact with her baby, and she should be transferred as soon as she is well enough to travel, and any further care required delivered in the same place as the baby.

The transport team must continue to be an integral part of the neonatal community. Effective communication and liaison between neonatal unit and neonatal transfer teams should be routine. When babies are transferred, in some instances (e.g. repatriation of stable babies) the most appropriate person to accompany the baby and his/her parents may be a member of the local neonatal care team, with the accompanying benefit of face-to-face handover. Effective communication between the transport team and despatching/receiving units will include discussion and agreement on the most appropriate staff to accompany a baby in transfer. It is anticipated that the repatriation of babies should be provided seven days a week.

7.1.1 Education, training and staffing

Staffing of the neonatal transport team has been challenging in recent years, and needs to be more flexible and integrated into neonatal unit staffing to support the transport service. In future there is likely to be more transport of babies who require the most complex and specialised care and there needs to be provision of consultant support for these transfers made in future workforce planning.

A further, detailed review of transport services should be undertaken, led by the neonatal transport service, to examine the best model for staffing of the service.

This should include:

• Consideration of a more flexible deployment of medical and nursing staff across neonatal services to cover both transport and units at peak periods, supported by additional staff training where required.
• A strategic medical and nursing workforce plan for neonatal intensive care units that is integrated with neonatal transport services.
• A plan for the support of consultants for complex transfers.
• Consideration of rotation through transport being integrated into the grid training programme for neonatal trainees.

RECOMMENDATIONS
55	A standardised risk assessment tool should be developed in relation to any decision on in utero transfer. This development should be led by ScotSTAR, the neonatal transport service, in close cooperation with maternity and neonatal staff.
56	A robust national system for the prompt identification of neonatal cot availability should be developed which is accessible through a single point of contact.
57	Nationally agreed pathways for declaring cot availability should be agreed and formal processes should be in place for the management of periods of unusually high activity.
58	All staff involved in neonatal transfers must have appropriate training, with neonatal transfers being subject to regular review and audit processes.
59	A further, detailed review of transport services should be undertaken, led by the neonatal transport service, to examine the best model for staffing of the service, including the potential for integration with neonatal unit staffing models.

Informed Choice And Control

Mrs S, from Orkney was pregnant with her third baby. After complications with her first two pregnancies, she was feeling anxious.

Pamela, the Senior Charge Midwife at Balfour Hospital in Orkney spent time with Mrs S and her husband, talking through her concerns, discussing her preferences and ensuring that she had all the necessary information to make informed choices for her and her baby.

'Pamela gave us many options so we could feel more in control during this pregnancy whilst also making sure the approach taken was always the safest option for me and the baby.'

Through her support and encouragement, Mrs S managed to successfully breastfeed for the first time, something she had been unable to do for her first two children.

Pamela's approach has even inspired Mrs S to enrol at college with a view to eventually becoming a nurse.

7.2 Remote and rural care

Many of Scotland's 14 NHS territorial Boards deliver services to populations living in remote and rural locations. Different models of care have been established in these areas, determined by the local geography and population needs.

During the course of the Review, there were three obstetric-led units in rural general hospitals (Caithness ^[56] , Kirkwall and Stornoway), one GP/midwife-led service in Lerwick, and 12 midwife-led units that are more than 30 miles from larger units.

Pregnant women in these remote areas are risk assessed throughout their pregnancies to determine the safest place for them to give birth. Many island women will travel to be located in closer proximity to a larger mainland unit in the later stages of pregnancy where the need for additional maternal or neonatal care is anticipated.

7.2.1 Views on the current model

A number of service users and staff in remote and rural areas contributed to the Review. Women reported that, currently, they receive a high quality of personal care, usually delivered by a small local team of midwives, with whom they have built relationships of trust and support.

One of the most common challenges cited by families was the need to travel, often some distance, to access care, frequently in an unfamiliar environment with an unknown care team. Parents of babies in neonatal care from remote and rural areas highlighted the personal challenges associated with long stays in hospital, including separation from their families and the financial aspects of having to live away from home for some time.

Staff in remote and rural areas highlighted the following issues:

1. Skills: A broader range of general skills is required in remote and rural areas. There is less additional support available to staff and, thus they have to be able to react to urgent situations and provide first line support in an emergency situation. It is, therefore, essential that staff can access high quality training in order to have the required skills to respond to such situations.

2. Support: Some rural NHS Boards described good relations with, and support from, larger NHS Boards. However, others found that this could be improved. It was generally noted that there would be benefit in formalising these arrangements to ensure that there is a systematic, and agreed approach to ensure staff can enhance and maintain their skills in a planned and consistent manner, with appropriate, dedicated resources to ensure this routinely occurs.

3. Workforce: There are recruitment challenges in remote and rural areas and staff retention was highlighted as a significant problem across all professions.

4. Home birth: This is particularly challenging for island and very rural settings due to the extended travel time for staff to remote areas.

5. Transport: The timely support of the neonatal transport service is critical, and the training they provide to staff is very valuable in remote and rural settings.

In order to address these issues, a number of areas can be considered. A systematic review of the key competencies and skills that are required for remote and rural staff should be undertaken to ensure tailored support, education and training is provided to staff. This should include examination of structured opportunities for rotation to larger units for skills development and maintenance.

Dedicated time and resources are required to support staff in maintaining and enhancing their skills, with a particular focus on the identification of the deteriorating patient and emergency situations. Structured arrangements should be in place between remote and rural NHS Boards and an urban NHS Board to ensure that formal training and development packages are in place, with all staff receiving annual updates and training in identifying the deteriorating patient and the management of obstetric and neonatal emergencies.

Where NHS Boards are facing particularly acute recruitment and retention challenges in nursing, midwifery and medical staffing, consideration should be given to the development of incentives or bursaries to encourage staff to work in those areas.

7.2.2 Telehealth and telemedicine

All telehealth and telemedicine should be utilised in a more comprehensive manner, across all remote and rural areas to support contact and consultations, the provision of clinical advice from other NHS Board areas, as well as being utilised for training and development purposes. Telemedicine has great potential to support keeping care local, through use of eConsultations.

In particular, in remote and rural parts of Scotland, this could avoid the need for women and babies to travel, but it has uses in virtually every part of Scotland. However, this change would require investment and support from both the smaller, and the larger, NHS Boards to maximise its potential. A systematic review of the possible impact and use of telehealth/telemedicine initiatives should be undertaken to maximise its impact across all NHS Board areas and a working group should be set up to explore the potential in this area.

RECOMMENDATIONS
60	A systematic review of the additional key competencies and skills that are required for remote and rural staff should be undertaken and training developed and provided. This should include consideration of a structured rotation to larger units for skills development, maintenance and update.
61	Structured arrangements should be in place between remote and rural NHS Boards and an urban NHS Board for training and development in the identification and management of the deteriorating patient and obstetric and neonatal emergencies.
62	A working group should be set up to explore the potential for enhanced use of telemedicine in maternity and neonatal services.
63	Consideration should be given to the development of incentives or bursaries to encourage staff to work in remote and rural areas.

7.3 Planning and supporting the workforce to deliver

The Review vision describes services that are delivered by staff who are empathetic, skilled and well supported to deliver high quality, safe services.

7.3.1 Workforce planning

Workforce planning is an essential part of delivery of the new model of maternity and neonatal care.

The current workforce is already highly skilled, flexible and committed. A wide range of available training programmes and modules are already available, and undergraduate training programmes for nursing, midwifery and medical staff are fully subscribed at present. Workforce planning tools are well established and are widely used and these can be adapted to the new model of care.

It is, however, vitally important that NHS Boards plan for, and incrementally build, the workforce capacity across all maternity, neonatal and ancillary disciplines over the next five years to deliver the new model.

Workforce planning needs to consider current, and future, influences on the workforce, including demographic changes, changing working patterns (such as increased part-time working and demand for more flexible working), recruitment and retention challenges in some areas and the absolute need for new roles to be developed, supported and implemented.

In addition, the implementation of multi-professional team working has been highlighted during this Review and this aspect of workforce planning will need to be addressed in order to ensure that teams have the range of skills required to deliver the new model of care.

Workforce planning will require to take place at local, regional and national levels. This planning work will involve all disciplines and will need to shape the future training of all professions. In relation to medical staffing, it will assist in informing and influencing the Shape of Medical Training Review to reflect the new and adapted roles, in particular to develop paediatricians with a special interest in neonatology.

To deliver the current range of services in remote and rural areas it will be important to ensure all staff have the competence to support the level of care being delivered. This should include exploring the different roles staff may play in the future.

RECOMMENDATIONS
64	NHS Boards will require to undertake comprehensive workforce planning-based on the new model, including an assessment of current and future supply and demand, and new roles, and this should be fed into national level work including the Shape of Medical Training Review.

7.3.2 Education and training

Accessible, available and relevant education and training is vital to support the new roles and to build capacity in the workforce to deliver them. The new roles described in this report will need to be underpinned by planned and managed changes in training and education provision for registered and non-registered staff. These changes will be required across the spectrum of education and training packages from undergraduate through to continuing professional development. This needs to reflect the range of roles and skills needed for staff, for example in both urban and rural settings. The provision of clinical supervision for midwives will support the transition to the new continuity of carer model.

In some parts of Scotland, nurses and midwives have highlighted the challenge of securing release for training. Consideration should be given to the provision of protected training time for all staff to ensure training is given the appropriate priority.

RECOMMENDATIONS
65	In parallel with workforce planning, planning for education and training capacity should take place with NHS Education for Scotland and the universities, colleges and other training providers, to enable NHS Boards to build capacity where it is needed in time to deliver the new model.
66	Consideration should be given to the provision of protected training time for all staff to ensure training is given the appropriate priority.

7.4 Continuous quality improvement

7.4.1 Quality improvement - learning from data and audit

In order to ensure services are as safe as possible and to create a culture of continuous improvement, it is critically important that up to date and easily accessible data and audit systems are used to drive change.

Readily accessible information about maternity and neonatal care in Scotland is vital for policy, for professionals and for the public. This will inform choice, improvements in health, healthcare and services. It will be used to facilitate benchmarking, to learn from adverse events and to reduce variations in care outcomes.

The improvement and audit landscape in maternity and neonatal care has expanded rapidly in recent years with the introduction of:

• MBRRACE
• Each Baby Counts
• MCQIC
• National Neonatal Audit Programme
• Bespoke local datasets of clinical information ('Dashboards')
• Scottish Maternity Care Experience Survey

The development of a National Maternity and Perinatal Audit, and a Standardised Perinatal Mortality Review tool, jointly with other UK Health Departments has also been commissioned.

To harmonise data collection and presentation at a national level, maternity and neonatal dashboards should be developed to examine key quality indicators and outcomes. This will help to facilitate benchmarking and reduce variations in care.

Healthcare Improvement Scotland have developed a national framework to capture learning from adverse events through reporting and review, published in April 2015 ^[57] . NHS Boards should ensure that the systems and processes in place within their Board to report, record and review all adverse events are relevant to, and applied to, adverse events in maternity and neonatal care. Boards should also ensure they share and act on learning from adverse event reports. This approach will be complemented by the awaited Standardised Perinatal Mortality Review tool which will build on existing tools to promote collective national learning from cases of stillbirth and neonatal death.

RECOMMENDATIONS
67	National level maternity and neonatal dashboards should be developed to facilitate benchmarking and reduce variations in care.
68	NHS Boards should ensure that the systems and processes in place within their Board to report, record and review all adverse events, are relevant, and applied to, adverse events in maternity and neonatal care, and that systems are in place to share and act on learning.

7.5 Information technology, data and telemedicine

7.5.1 Data and audit

Up to date and readily accessible information about maternity and neonatal care in Scotland is needed to inform improvements in services, to monitor equity and inform strategies and to help reduce inequalities. Staff currently view the complexity, variability and time commitment to the current data collection process as being of concern.

The range of routine data collected at local and national level should provide information of adequate detail and quality to allow robust surveillance of population health determinants, health service planning and monitoring of the quality of service processes and outcomes. This data should be analysed and reported regularly to provide answers to any key questions raised by the public, health professionals and national decision-makers.

The potential to use the new National Maternal and Perinatal Audit tool to provide focused audits on key issues should be explored. In addition, a national data hub, led by Information Services Division, part of NHS National Services Scotland, should be developed to coordinate collection and verification of all Scottish related neonatal and maternity data, to streamline data collection and reduce duplication of data entry.

7.5.2 Information technology and systems

Currently women hold their own maternity record, the Scottish Women's Hand Held Maternity Record ( SWHHMR) ^[58] . This goes with them to all appointments and different members of the care team can access this record

Information technology systems spanning the whole care spectrum are viewed as essential by staff to deliver streamlined care with the new proposed model. Most NHS Boards have an electronic maternity system in place, or are in the process of procuring or installing a system. In neonatal care, almost every unit is Scotland is operating on the Badgernet system. Badgernet records data about the baby and the care received.

Electronic maternity care systems

The benefits of having a uniform electronic care system across Scotland for neonatal care are apparent. To simplify data entry and sharing, it would be preferable to have one maternity care system across Scotland, which will interface with systems across healthcare settings (e.g. primary care) and be accessible in all these settings. This will improve sharing of vital information and reduce duplication of data entry across Scotland. This system should be capable of interfacing with the electronic women's maternity record.

Electronic women's maternity record

An electronic women's maternity record would be an important tool in maternity care, to promote co-production of care plans and birth plans, and for shared decision-making.

A Scotland-wide initiative to develop an electronic women's maternity record should be developed. The features of this system will include readily accessible information for women and all professionals involved in her care, wherever the setting. It is intended that this system will replace the existing paper-based system of maternity records.

RECOMMENDATIONS
69	The potential to use the new national Maternal and Perinatal Audit to provide focused audits on key issues should be explored.
70	A national data hub should be developed to coordinate collection and verification of all Scottish related neonatal and maternity data.
71	A single maternity care system across Scotland should be developed, which will interface with systems across healthcare settings and be accessible in all these settings.
72	A Scottish electronic women's maternity record should be developed, that is readily accessible to women, and all professionals involved in her care.