Continuity of carer and local delivery of care: implementation framework

Chapter One: Frameworks

Background

Five Early Adopter Boards (EAB) were agreed by the Best Start Implementation Programme Board (IPB) further to a process of selection from a large number of Boards who volunteered. These are: NHS Forth Valley, NHS Glasgow & Clyde (Clyde only), NHS Highland, NHS Lanarkshire and NHS Lothian.

EABs agreed to lead the way in implementing a suite of recommendations including:

• the midwifery continuity of carer model for all women;
• a new model for hospital based maternity services, including transitional care; and the associated core workforce;
• aligned and co-located midwifery and obstetric teams;
• enhanced roles for support workers in the community and in community hubs;
• Community Hubs for the delivery of maternity care and, in-time, neonatal outreach; recognising that different models of neonatal outreach care will be suitable for different contexts across Scotland and may include being delivered in the family home.

Funding was allocated in 2017/18 to support planning for implementation, and in 2018/19 and 2019/20 to support the transitional work required for local service redesign. The EABs were identified in September 2017 and have been taking forward implementation work since then.

EABs are core members of the Best Start Continuity of Care and Local Delivery of Care Subgroup, driving national work required, reporting progress, sharing experiences and committed to sharing learning across NHS Scotland (NHSS) to inform national roll-out.

The implementation learning resource is structured in stages that will be familiar as they are based on the strong foundations of using improvement methodology across Scotland. The specific stages best reflect the learning from the early adopter boards as it emerged and borrow from Audit Scotland (2016) and the Health Foundation (2017) in design and terms used.

Aims of the Implementation Framework

This framework is designed to enable maternity services to access useful tools, resources and information to implement continuity of carer and local delivery of care, and track progress.

This document includes:

• Agreed framework: this defines the agreed parameters for consistency across Scotland;
• An acknowledgment that implementation across Scotland can involve innovation in how that is applied;
• Implementation lessons collated from the EABs;
• Monitoring and Evaluation Toolkit; (as part of Chapter 3 which will follow);
• Links to resources.

Continuity of Midwifery Carer Framework

Best Start Recommendation 1

Continuity of Midwife and Obstetrician: 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.

With regard to implementing continuity of carer, the following parameters have been identified. These incorporate evidence from the Best Start, as well as learning from the EABs.

Every woman will:

• have a recorded primary midwife;
• receive the majority of scheduled antenatal and postnatal midwifery care from her primary midwife;
• meet/get to know the primary midwife's buddy midwife, who may also provide some scheduled care;
• meet/get to know the members of their defined team;
• receive care during labour and birth from her primary midwife or buddy midwife; with the support of the wider team to cover leave and days off;
• know the midwife who cared for them during labour and birth.

Every caseload midwife will:

• be the primary midwife for a defined caseload of women, approximately 35 women at any one time. This may be lower if the midwife is caring for vulnerable women with medical, social or psychological needs, or due to rurality and distance;
• manage her caseload of women, at whatever points the women books with the service;
• undertake the initial booking history, and plan and provide most of the woman and baby's care throughout the maternity care journey;
• work in a small team with a buddy midwife;
• may be the primary caregiver for women having elective caesarean sections;
• work in partnership with the wider health and social care team as required to coordinate care around the woman;
• provide care for women in either a community setting, or in the woman's home or hospital setting.

Every team will:

• test the optimum team size to ensure an effective balance which ensures achieving continuity of carer and service cover, with all leave built into the modelling;
• consider the skill mix to support the team;
• work together effectively to provide support for each other and facilitate continuity of care;
• develop mechanisms to provide triage that enable continuity, access to the service and mitigate against risk;
• have access to a team leader;
• use/access clinical supervision to support team wellbeing and reflection.

Each Team Leader:

• should ensure that midwives in their teams have access to and utilise clinical supervision;
• may oversee one or more teams in an area;
• may hold a small caseload;
• will make use of local arrangements to oversee quality and safety of care and feedback from service users, based on their own data;
• will ensure rotas and leave are well planned.

Every Hospital based (Core) midwife:

• may provide support to caseload midwives accompanying their women in labour;
• may provide support for the antenatal and postnatal wards;
• may provide a triage service and/or day care;
• may be the primary caregivers for women having elective caesarean sections;
• may be part of a caseload team to provide support for medically complex women, or where geographical distance is a factor.

EABs found it was important to:

• ensure that midwives have the equipment, Information Technology (IT) and transport they require;
• ensure that midwives have access to the learning and clinical supervision they require to effectively manage a caseload or work in the core hospital based team;
• ensure that Human Resources (HR) processes and nationally agreed terms and conditions are adhered to;
• work in partnership to plan and monitor the move to the new model;
• ensure there is cover 24 hours a day, 7 days a week, using either an on-call rota which is part of contracted hours, or a rostered model;
• develop a plan for implementation that meets the principles described in this document;
• support implementation by facilitating access to the necessary stakeholders: planning, eHealth, IT, estates, HR;
• ensure that caseload teams have suitable community based accommodation/hub from which to work;
• ensure that there is the right level of support infrastructure in place to support the new model of care;
• support culture and behaviours that prioritise the wellbeing of all staff at every level of the organisation based on mutual respect; and encourage devolved decision-making and autonomy with agreed parameters;
• support staff and managers to implement the change recognising that at times a level of organisational change may be required.

Each EAB found the support of Executive Director Leadership at Board level important for successful implementation.

Continuity of Obstetric Care Framework

Best Start Recommendation 1
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.

The Best Start recommends that:

"Women who need the input of an obstetrician, will have continuity of a primary obstetrician throughout their antenatal and postnatal care. For most women antenatal care will be offered in their local community. For some women the most appropriate place to have their antenatal care will be in hospital-based clinics."

Every linked Consultant Obstetrician will:

• be aligned with a caseload of women and team(s) of midwives;
• provide support and advice to midwives within their linked area;
• provide direct care to women in their caseload during the antenatal and postnatal period.

Obstetric services are currently structured with obstetricians working with trainees who take clinics as part of their training. In addition, obstetricians have, and will continue to have a significantly higher caseload than midwives in the new model.

The Best Start recommendations will result in a significant but proportionate change to the way obstetric services are delivered. This change is necessary for the transformation required for the multidisciplinary continuity of carer model. In the new model under Best Start:

• There will be a named link Consultant Obstetrician for every midwifery caseload team in order to implement the mutlidisciplinary continuity of carer model;
• There will be a named primary Consultant Obstetrician for all women who require obstetric care during their antenatal and postnatal care;
• Women who require the input of an obstetrician and require multiple (more than 2) scheduled antenatal and/or postnatal obstetric clinic appointments, should receive direct care from their primary obstetrician at least 50% of the time;
• If a woman's care requires a specialist high-risk clinic, the named primary Consultant Obstetrician may change but the expectation remains the same, i.e. that the women should receive direct care from that primary obstetrician at least 50% of the time.

Community Hub Framework

Best Start Recommendation 14

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.

NHS and other public sector community services are continually evolving and are likely to change more rapidly over the next few years as a result of the integration of health and social care. Families have indicated that routine services should be delivered as close to home as possible, to minimise disruption to normal family life and separation from social networks. This is consistent with national policy direction to shift the balance of health and social care close to home where possible.

In maternity and neonatal care, it is intended that integrated team care will, over time, take place in local community 'hubs'. These hubs would be local care settings for a range of services, designed around the needs of the local community. A community hub would become a facility where people feel they can identify with the services delivered from the hub, in an environment where they feel comfortable.

Services provided in the Hubs could include maternity services and a range of community support services according to local need. These could include, but not necessarily all, of the following according to local context:

• Day assessment, antenatal care;
• Providing women with the majority of their antenatal care;
• Postnatal care, including support for well babies after discharge;
• Scanning facilities;
• Diagnostic services;
• Obstetric and specialist clinics; physically or virtually;
• Neonatal outreach; physically or virtually;
• Wider community support such as breastfeeding support and other infant care support;
• Antenatal parenting classes held during extended opening hours at the weekends and evenings;
• General Practitioner (GP), Health Visitor, Perinatal Mental Health, Immunisation, Sexual Health services, Local Authority support and third-sector services;
• Early years' support;
• Birthing facilities.

Neonatal Transitional Care Framework

Best Start Recommendation 22
Well, late-preterm infants and 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 neonatal staff. Clear pathways of care, admission criteria, discharge planning and clinical guidelines will be required, underpinned by education and training.

Best Start Recommendation 27
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.

The greatest proportion of babies currently admitted to neonatal units comprise late-preterm (34–36 + 6 weeks' gestation) and term infants with moderate additional care needs. Late-preterm infants commonly require a moderate additional level of support to maintain temperature and establish breast, or formula feeding, and more commonly require treatment for jaundice.

Currently, many babies in these groups are admitted to neonatal units, but most of them could be cared for with their mother on postnatal wards, or even at home, with additional support. This type of transitional care arrangement would keep mother and baby together and reduce neonatal unit admissions of both late-preterm and term infants.

Boards may want to consider how effectively their current service pathways ensure that mothers and babies are able to stay together, as much as possible, throughout the postnatal period.

Services currently providing Neonatal Transitional Care (NTC) may consider how effectively their model is working to keep mothers and babies together, and identify any additional pathways and/or clinical guidance required to further reduce admissions of term and late-preterm infants to the Neonatal Unit.

Services that do not currently provide NTC should bring together Maternity and Neonatal care teams to plan jointly the establishment of a NTC service that will minimise separation of mothers and babies. It is helpful if such planning addresses:

• Pathways of care to minimise separation of mothers and their babies throughout the postnatal period;
• Criteria for NTC;
• Clinical guidelines for the safe delivery of effective NTC;
• Discharge criteria from NTC;
• Escalation policy and pathways of care for babies developing additional care requirements beyond those that can safely be delivered by NTC;
• Review of education and training requirements for Maternity and Neonatal staff relating to the delivery of NTC;
• Where mother and baby have additional needs, care should be flexibly provided, in any care setting, according to individual circumstances.

Boards already report on National Neonatal Audit Programme (NNAP) audit measures which include specific measures relating to maternal infant separation for late-preterm and term infants so this can be used to establish movement to transitional care to assess the impact that the establishment of transitional care has on admissions to neonatal units. In addition, the impact that this policy has on maternity beds will also be monitored to understand the consequences.

Resources from Boards –

Transitional Care Information leaflet – NHS Forth Valley

https://drive.google.com/open?id=18MKXnWlGIBuBT6Fk3PNGdkFdcDx3h9iW

Transitional Care Parent Feedback poster – NHS Forth Valley

https://drive.google.com/open?id=1XpHLEk7jQLVHgc2KTNENYK3yYgK9Fv4w

Resource document – ‘A Framework for Neonatal Transitional Care’ (BAPM: 2017)’.