Publication - Advice and guidance

Coronavirus (COVID-19) delivering maternity and neonatal services through the pandemic: beyond Level Zero - guidance

Published: 24 September 2021
Directorate: Children and Families Directorate, +2 more … Chief Medical Officer Directorate, Chief Nursing Officer Directorate
Topic: Children and families, Health and social care
ISBN: 9781802013740

Guidance for NHS Boards for the management of maternity and neonatal services in Scotland in their continued response to COVID-19 and to aid health boards with local service planning.

Supporting documents

Annex One – Workforce Planning Guidance for Midwifery Services during COVID-19 and Beyond Level Zero

Version control	changes	date
V1.1	Updated PJ template	11/01/2021
V1.2	Updated text in sections to reflect learning from earlier phases in COVID-19 pandemic. Inclusion of the real time staffing resource. Acknowledgement of reduced availability of other staff i.e. students in paid employment, redeployed staff and returner midwives. References.	27/07/2021
V1.3	Reference to phases and levels of the pandemic removed with changes to reflect service pressures	18/08/2021
V2.0	Amendments approved as above and clarity around ratios in intrapartum	31/08/2021

This guidance applies during COVID-19 emergency and period of remobilisation, it should not be used when the emergency is over. Please note this should be used in conjunction with Board’s local escalation policies.

Aim

To provide clinical reference guidance to support decision making in maternity services during the extreme circumstances of the COVID-19 pandemic and remobilisation. This professional guidance should be used in conjunction with the nationally developed professional judgment template (appendix 1) and real time staffing resource (appendix 1) to inform midwifery staffing requirements.

Driver

During the COVID-19 pandemic it has been recognised that changes have been required in service delivery / clinical models as a result of a number of factors, varying according to specialty and local context. These include increasing demand, reduction in staff availability due to absence, requirement to implement social distancing measures and the protection of pregnant women, high risk groups and staff. It is therefore highly likely that current staffing models and in particular skill mix may no longer be achievable or appropriate. A planned approach to changing staffing models and skill mix is required to ensure that associated risks can be mitigated in a consistent way and that the best possible care can be provided.

Maternity is an essential acute and community service with no anticipated or identified reduction in need throughout the course of the pandemic. Midwives and the wider maternity workforce have been required to continue care for pregnant women, babies and families and, as an essential service, midwives should not be deployed out with maternity services.

This clinical guidance has been developed to support clinicians identify where changes may be required to service and clinical models, and the risk mitigating factors which should be considered as we move beyond level zero, when services may be required to adapt in response to local COVID-19 pressures, acuity of women and the availability of staff.

The professional judgement staff modelling template was developed in the first wave to provide a consistent approach for clinical and workforce managers. This allowed them to quickly calculate the whole time equivalent (wte) staffing requirement based on the professional judgement of the user in line with the clinical guidance, whilst recognising variation in clinical settings and models of care. In wave two there was a recognised need for a consistent system wide approach to inform identification, recording, mitigation and escalation of risk. The maternity real time staffing resource was developed as part of the COVID-19 system wide approach to real time staffing. The balance must seek to prioritise safe, person-centred care that considers the physical and mental wellbeing of women, their families and staff, within a service where the ability to reduce demand is minimal.

Clinical Guidance for Maternity and Neonatal Care During COVID-19 Pandemic and Beyond Level Zero.

The Scottish Government has issued guidance to Boards related to maternity care during the pandemic ‘Delivering Maternity and Neonatal Services: Moving Beyond Level Zero’.

In addition, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) joint guidance outlines specific advice related to adaptations to services for both midwifery and obstetric care provision.

Midwifery Staffing During COVID-19

Midwifery staffing requirements are normally determined using the Healthcare Staffing Programme workload planning tool as part of the common staffing method. This is accompanied by professional guidance regarding one-to-one care in labour and a caseload size as outlined in the ‘Best Start Forward Plan for Maternity and Neonatal Services’ (2017). Full implementation of Best Start was not in place in all Boards prior to the pandemic.

The impact of the coronavirus pandemic is unprecedented, it has become evident that availability of midwifery staff who usually work in specific clinical areas has reduced due to staff absence. The NHS Scotland Test and Protect contact tracing programme has had a positive impact on reducing community transmission of COVID-19 however this has resulted in high numbers of clinical staff being notified, subsequently requiring maternity staff to isolate and significantly depleting the available workforce. When considering available staff those midwives who were self-isolating or shielding due to COVID-19, in many cases, provided care via telehealth, Near Me or other remote means. As the numbers of staff isolating or absent with COVID-19 increased this significantly reduced the staffing required for direct clinical care. This guidance was updated to included exemptions for critical staffing in July 2021. The guidance for self-isolation was further updated and can be found here.

In some situations, midwifery staffing has needed to be altered, to ensure staff with relevant experience are utilised in the most effective way. During wave one there were opportunities for returner midwives, other available staff from stepped down services and paid employment for students to support the delivery of midwifery care under the direct or indirect supervision of substantive midwives. In the subsequent waves many of these staff were no longer available. To date, details of midwives on the temporary register continue to be shared with boards, with the most recent data being circulated in the week of the 9^th of August.

When considering deployment of staff with or without a midwifery registration from other areas a comprehensive risk assessment must be made to ensure that there is a whole system approach to risk assessment and that movement of staff does not have the unintended consequence of disabling other services. Therefore, it is necessary to prioritise access to different staff groups dependent on pressures being experienced across the system, whilst ensuring the most effective use of transferrable skills in different clinical settings. All registered midwives can delegate tasks to others in accordance with the NMC code.

A flexible, pragmatic and staged approach with an emphasis on team-working rather than a ratio approach will need to continue to be considered in order to utilise maternity skilled staff effectively, ensuring the most effective care to women and babies.

Purpose

The professional judgement template will assist Boards to scenario plan staffing requirements based on absence and the real time staffing resource will provide a consistent approach to identifying risk. These resources provide the operator with the function of calculating the number of staff required on each shift whilst considering the optimum skill mix within the context in which the service is operating at the time. Skill mix will need to alter dependent on availability of staff and changes to acuity within the clinical setting.

How: The maternity real-time staffing resource will allow the user to enter the staffing number required per reporting period and to identify the minimum number of substantive midwives per reporting period, the number of registrants available from other sources and the number of support staff required. This resource informs identification, mitigation and escalation of risk associated with staffing challenges in a consistent way in real time. This identifies the number of staff required at that time or census point.

The professional judgement template will allow for scenario planning as the skill mix and absence alters. This calculates the WTE staffing requirement as calculated over 7 days.

Scenario Planning for Care Provision

A risk assessment approach should be taken to introducing skill mix and new staff groups to the relevant clinical environment. Some scenarios are provided below for antenatal, postnatal, labour ward and high dependency categories which are intended to provide guidance on the level of risk. When staffing in each stage is no longer sustainable movement to the next stage is advised. The moving through each level will be dependent on local availability of staff and should be applied taking account of the local context in which the service is delivered. Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to normal service provision. Boards may concurrently be at different stages for antenatal, intrapartum and postnatal care.

It is also essential, when considering staffing requirements using these scenarios, to consider the clinical leadership required to support staff working out with their normal scope of practice and those who are supervising and delegating to them. Resources for clinical supervision and delegation can be found at the bottom of this document. These examples are intended as guidance and should be used in conjunction with local escalation policies at all times.

Antenatal Care

Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to normal service provision at all times with the full schedule of care appointments provided.

Risk level Zero: Normal Service Provision

Service:

Full range antenatal services

Staffing:

Maintain numbers and skill mix of registered to unregistered staff
Care by midwife
Student midwife has direct or indirect supervision depending on need (recognition that students retain supernumerary status which differs from wave one)

Risk level One: Moderate Pressures with Contingencies

Service:

Minimum 8 appointments with minimum of 6 face–to-face appointments
Consider alternative care delivery methods
Consider joining up appointments
Stop antenatal group sessions

Staffing:

As above with additional consideration on the following:

Through risk assessment and decision-making processes allocate women to other available staff matching skills to women’s need
Midwife has support of midwifery team dependent on need
No change to students

Risk level Two: Highest Pressures Managed Locally

Service:

Consider alternative care delivery methods

Staffing:

As above with additional consideration on the following:

This stage carries increasing risk in ensuring appropriate supervision of students and delegated roles

Risk level Three: Corporate Escalation

Service:

The highest level of risk

Staffing

As above with additional consideration on the following:

This stage carries increasing risk in ensuring appropriate supervision of students or other available staff in the delegation of roles.
Students retain supernumerary status but in extremis, consider as part of the clinical workforce with appropriate supervision

Note: students should have normal experience alongside a midwife as part of the practice learning environment.

Intrapartum Care

Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to stage one (pre-COVID-19). Women will have 1:1 care at all times, however provision may not be by a midwife dependent on the service stage.

Risk Level Zero: Normal Service Provision

Full range of intrapartum options available
Maintain numbers and skill mix of registered to unregistered staff
1:1 care by midwife
Students are supernumerary

Risk Level One: Moderate Pressures with Contingencies

Service:

Consider reducing care options ensuring mix of midwifery and obstetric led care

Staffing:

As above with additional consideration on the following

Through risk assessment and decision-making processes allocate women to other available staff matching skills to women’s need

Risk Level Two: Highest Pressures Managed Locally

Services:

Unable to sustain full range birth options. Centralise to AMU/OU
BBA covered by community

Staffing:

As above with additional consideration on the following

One midwife oversees the care of 2 women, providing care to one and the other woman cared for by student midwife with indirect supervision
This stage carries increasing risk in ensuring appropriate supervision of students or other available staff in the delegation of roles.

Risk Level Three: Corporate Escalation

Service:

Unable to sustain level 2 or 3. Highest level of risk, restricted birth options without deployment of staff from other clinical specialties or diverting to other locations

Staffing:

As above with additional consideration on the following

One midwife oversees the care of 3 women; the 3 women cared for by student midwife or staff from other available/redeployed specialties
Students retain supernumerary status but in extremis consider as part of the clinical workforce with appropriate supervision

Risk Level: Existing HDU

Service:

Maintain services

Staffing:

Maintain numbers and skill mix of registered to unregistered staff

Risk Level: Additional HDU

Service:

Plan for surge capacity as required

Staffing:

As above with additional consideration on the following

Through risk assessment and decision processes upskill proportionate number of staff to ensure skilled staff on every shift

Note: students should have normal experience alongside a midwife as part of the practice learning environment.

Postnatal Care

Boards should revert to the previous stage as soon as local context allows, with the ultimate aim of returning to stage one (pre-COVID-19).

Risk Level Zero: Normal Service Provision

Service:

Full range of postnatal services.

Staffing:

Maintain continuity of carer where possible with numbers and skill mix of registered to unregistered staff.
Care by midwife.
Students are supernumerary.

Risk Level One: Moderate pressures with contingencies

Service:

Home visiting based on need
Minimum contacts day 1,5,10
Prioritise face to face contact based on need
Consider other care delivery methods
Stop postnatal group sessions

Staffing:

As above with additional consideration on the following

Student midwife has direct or indirect supervision dependent on need recognition that students retain supernumerary status.

Risk Level Two: Highest pressures managed locally

Service:

Home visiting based on priority need

Staffing:

As above with additional consideration on the following:

This stage carries increasing risk in ensuring appropriate supervision of students or other available staff in the delegation of roles.

Risk Level Three: Corporate Escalation

Service:

Highest level or risk and extremis

Staffing:

As above with additional consideration on the following:

Students retain supernumerary status but in extremis consider as part of the clinical workforce with appropriate supervision

Note: students should have normal experience alongside a midwife as part of the practice learning environment.

Clinical Supervision and leadership

At a time of significant pressure, it is essential that roles, responsibilities and accountability is clear. Clinical supervision will be particularly important at this time for all staff to support their health and wellbeing. All NHS organisations in Scotland have in place a range of clinical and psychological support services in place to support staff including wellbeing hubs and access to support services. Links to the some of the national resources are available below

All registered midwives can delegate tasks to others in accordance with the NMC code. Further support for decision making in relation to delegation can also be found in the decision support framework produced by the Northern Ireland Practice and Education Council which has been adopted for use in the 4 countries of the UK. This may be helpful to midwives when delegating or supervising staff who have been deployed to maternity services as a result of COVID-19.