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

Every woman will have continuity of carer from a primary midwife who will provide the majority of their antenatal, intrapartum and postnatal care and midwives will normally have a caseload of approximately 35 women at any one time. Where women require the input of an obstetrician in addition to midwifery care, they should have continuity of obstetrician and obstetric team throughout their antenatal and postnatal care. Midwifery and obstetric teams should be aligned around a caseload of women and should be co-located for the provision of community and hospital-based services. Early adopter NHS Boards should be identified to lead the change in practice. Implementation should ensure appropriate education, training and development and realignment of resources is achieved, recognising the potential for additional resources to be required during implementation.

Every woman will have a clear birth plan developed for her needs which is updated regularly throughout her maternity journey.

GP practices should nominate a link GP for the practice to provide a liaison point between the midwifery/obstetric team, the health visiting team and the practice.

Parents of babies in neonatal care should be involved in decisions about the care of their baby and in providing as much care for their baby as possible.

Maternity and neonatal services should be redesigned to ensure mothers and babies stay together.

All units should take a flexible approach to the presence of partners, to ensure that families can stay together, with suitable accommodation being provided and facilities to enable kangaroo skin-to-skin care and breastfeeding/breast milk feeding.

All neonatal facilities should provide emergency overnight accommodation on the unit for parents, with accommodation available nearby for parents of less critically ill babies.

To reduce variation, an urgent review of the approach to expenses for families of babies in neonatal care should be undertaken to develop a nationally agreed policy.

High quality prenatal and antenatal education must be available to all, and NHS Boards should continue to promote and improve early access to antenatal education.

The redesign of Ready Steady Baby should reflect the new model of care and provide unbiased, consistent, evidence-based information about maternity and neonatal care.

The 2009 Pathways for Maternity Care should be revised at a national level to facilitate an individualised approach to the management of risk through the development of a personalised care plan which is regularly reassessed.

The new model of care is based on the absolute requirement to have high performing, multi-professional teams in place, and all NHS Boards should ensure that these teams are developed, and supported, to operate effectively and that this team development is afforded the highest priority at NHS Board level. Multi-professional team education and training opportunities should be explored and should include all levels of staff within NHS Boards.

A directory of third sector services, available to maternity and neonatal service users, should be created, in partnership with third sector providers in order that all staff are aware of local and national level third sector support for families.

NHS Boards should redesign maternity services with a focus on local care, built around the concept of multidisciplinary community hubs, with the majority of women being offered routine care and services through these hubs. Each NHS Board should undertake a local assessment of the viability, scope and potential impact of hubs identifying local needs balanced with maximising benefit from resources. A review of the functioning of these hubs should be conducted , following an agreed national framework, after a defined period of operation.

Each NHS Board should ensure that they are able to provide the full range of choice of place of birth within their region. National, standardised core information should be made available on the range of safe birth settings to support women's choice.

All NHS Boards should aim to provide a range of pain relief for all women.

Caesarean delivery should only be provided if clinically indicated and factors contributing to the rising caesarean section rate should be examined, from both the clinical, and women's, perspective, with optimal levels of intervention that balance risk and potential harm being identified.

In conjunction with service users, NHS Boards should undertake an assessment of the viability, and scope, of freestanding midwifery units against an agreed national framework to ensure consistency, with a view to balancing access needs with the need to ensure resources are used to their maximum impact.

Options for postnatal care should be discussed with women throughout pregnancy and a plan agreed which takes account of their unique circumstances.

For the majority of women, all key processes should be aligned and streamlined to ensure early discharge is the norm.

The provision of high quality postnatal care should be afforded a high priority, with staffing models being reviewed in conjunction with the introduction of the continuity of carer model.

Well, late preterm infants and term infants with moderate additional care needs should remain with their mothers and have their additional care needs provided on a postnatal ward by a team of maternity and in-reach neonatal staff. Clear pathways of care, admission criteria, discharge planning and clinical guidelines would be required, underpinned by education and training.

The routine examination of the newborn can, in most cases, be undertaken by appropriately trained midwifery staff, with an appropriate audit and governance mechanism in place to evaluate the outcome.

The new model of continuity of carer, community hubs and enhanced community care will provide an environment to support breastfeeding. Community-based care will include a role for support staff to assist midwives in the provision of baby care, including breastfeeding support and parenting skills, along with care and support for women who formula feed.

The general midwifery workforce should receive refresher education and training in core skills including supporting normal birth processes and providing care across the whole care continuum, and in examination of the newborn.

Consideration should be given to development of clinical midwifery roles across the career framework as part of national work to transform nursing, midwifery and allied health professional roles.

A revised staffing profile for inpatient postnatal maternal and neonatal care should be developed collaboratively by maternity and neonatal care providers, underpinned by staff education and training in relation to postnatal maternal and neonatal care.

Where a woman has a medical condition which requires additional specialist medical input, this should be provided in a timely manner from an identified named physician in that medical speciality, with an interest in pregnancy, and may need to be managed at a regional or national level. Midwifery care should continue throughout from the primary midwife, as part of the multi-disciplinary team. Units providing the most specialised maternity and neonatal care should be co-located.

Where women present outwith maternity settings they should be reviewed by the maternity team in a timely manner to ensure pregnancy-appropriate medical care occurs at all times, in all locations. Standards for this should be agreed nationally.

Each unit must identify a lead obstetrician who has or who will develop appropriate expertise in fetal medicine. There must be good ongoing communication with and information for parents as well as robust referral pathways in each Board to ensure strong links between local and regional/ national centres.

To ensure high quality and consistent information is given, it is recommended that standardised information leaflets are given to parents during antenatal discussions on fetal abnormality.

Staff providing critical care in theatre, recovery or high dependency must comply with national standards, be appropriately trained and regularly maintain competencies. Adequate staffing levels must be in place within theatres, recovery and high dependency areas.

Maternity theatres should have dedicated theatre staffing, and these staff should be appropriately educated, trained and managed.

All NHS Boards should conduct a systematic needs assessment focused on the pattern of vulnerable women of childbearing age in their area and develop specific, targeted services for women with vulnerabilities, with team care constructed around women's needs.

All staff should receive a level of training to support them to identify and support vulnerable women as part of routine care, and women with the most complex vulnerabilities should have access to a specialist team. Midwives in these roles will continue to provide continuity of carer, should have a reduced caseload in recognition of the complexity of the women, and will act as the co-ordinator of team care for the woman and baby.

GPs and health visitors must be involved as part of the team in pre and postnatal care, and GP practices should identify a named link GP for vulnerable childbearing women and their babies.

All NHS Boards should review their current access to perinatal mental health services to ensure early and equitable access is available to high quality services, with clear referral pathways. NHS Boards should ensure adequate provision of staff training to allow staff to deliver services to the appropriate level. Primary midwives, in partnership with primary care colleagues, should play a proactive and systematic role in the identification and management of perinatal mental health care.

The Scottish Government should ensure that Perinatal Mental Health is a key focus in the forthcoming Mental Health Strategy, and that appropriate connections are made with the new models of care described here in that strategy.

NHS Boards should ensure all neonatal staff can refer parents of babies in neonatal care to local psychological services.

All staff in maternity and neonatal units should be aware of third sector support organisations operating in their area and be able to signpost them to women and families in their care.

In every case where a family is bereaved they should be offered access to appropriate bereavement support before they leave the unit, and each maternity and/or neonatal unit should have access to staff members trained in bereavement care. Families should also be provided with appropriate information about bereavement services locally, both in hospital and third sector services, and also information on follow up care.

Inpatient and community services should integrate end-of-life care pathways to support families in their choice if they would like to spend time with their baby at home or in a hospice.

Parents should be involved in decision-making throughout and involved in practical aspects of care as much as possible. This includes the provision of facilities for overnight accommodation, encouraging kangaroo skin-to-skin care and early support for breastfeeding.

New models of neonatal care should be based on the BAPM definitions to increase consistency of practice and facilitate benchmarking with other neonatal units across the UK.

The new model of neonatal services should be redesigned to accommodate the current levels of demand, with a smaller number of intensive care neonatal units, supported by local neonatal and special care units. Formal pathways should be developed between these units to ensure that clear agreements are in place to treat the highest risk preterm babies and the sickest term babies in need of complex care in fewer centres, while returning babies to their local area as soon as clinically appropriate. Three to five neonatal intensive care units should be developed, supported by 10 to 12 local neonatal and special care units.

Excellent communication processes should be developed between neonatal units and with parents to ensure a full understanding of the care pathways for babies. Consistent, standardised information will also be developed to ensure all parents are aware of the options for their baby, in particular for those parents whose babies might have all, or part, of their care outwith their local unit.

A national Framework for Practice should be developed which outlines clear pathways for newborn care and referral. This framework should also support the development of consistent and equitable specialty paediatric and allied health professional support for local neonatal units.

A national model for a seven-day neonatal community service should be developed, with appropriate skill mix, robust guidelines and medical support to support early facilitated discharge and ongoing care pathways.

Robust guidelines and follow up processes should be developed for post-discharge babies across Scotland.

The role of ANNP staff should be reviewed to ensure their skill set is maximised, with a clear training and development support mechanism to retain and develop staff,

Neonatal Nursing Qualified in Speciality and Advanced Practice education should continue to be available and quality assured to ensure it meets course requirements and the demands of the new models of care.

Non-registered neonatal staff should have a clear role definition, competency framework, training and skills pathway to ensure they can work flexibly across all aspects of care.

Workforce planning processes should be reviewed to ensure adequate numbers of general paediatricians with a special interest in neonatology are being trained to deliver this service in the future.

A formalised and structured approach to rotation and skills maintenance for staff in smaller units should be developed and resources through the appropriate Managed Clinical Network.

A standardised risk assessment tool should be developed in relation to any decision on transfer. This development should be led by the Neonatal Transport service, in close cooperation with maternity and neonatal staff.

A robust national system for the prompt identification of neonatal cot availability should be developed which is accessible through a single point of contact.

Nationally agreed pathways for declaring cot availability should be agreed and formal processes should be in place for management of periods of unusually high activity.

All staff involved in neonatal transfers must have appropriate training, with neonatal transfers being subject to regular review and audit processes.

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.

A systematic review of the additional key competencies and skills that are required for remote and rural staff should be undertaken and training and provided. This should include consideration of structured rotation to larger units for skills development, maintenance and update.

Structured arrangements should be in place between remote and rural NHS Boards and an urban NHS Board for training and development in identification and management of obstetric and neonatal emergencies.

A working group should be set up to explore the potential for enhanced use of telemedicine in maternity and neonatal services.

Consideration should be given to development of incentives or bursaries to encourage staff to work in those areas.

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.

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.

Consideration should be given to the provision of protected training time for all staff to ensure training is given the appropriate priority.

National level maternity and neonatal dashboards should be developed to facilitate benchmarking and reduce variations in care.

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.

The potential to use the new national Maternal and Perinatal Audit to provide focused audits on key issues should be explored.

A national data hub should be developed to coordinate collection and verification of all Scottish related neonatal and maternity data.

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.

A Scottish electronic women's maternity record should be developed, that is readily accessible to women, and all professionals involved in her care.

A single Maternity Network Scotland should be created to promote sharing of experience and expertise and to create regional or national protocols, for example to manage the most complex conditions at a national level.

There should be a single Neonatal Managed Clinical Network for Scotland with the new model to ensure integrated working across NHS Board boundaries, including input from service management and clinical staff. The maternity and neonatal networks should come together formally on at least an annual basis to promote integrated services.

Consideration should be given to developing research capacity to carry out research to inform implementation of the model of care and to funding of a national programme of maternity and neonatal health service research.

The recommendations and their implementation should be evaluated for impact on outcomes and experiences of women, babies, families and staff, and resources.