A Refreshed Framework for Maternity Care in Scotland: The Maternity Services Action Group

3. THE POLICY CONTEXT

This section gives an overview of the health and social policy context and extrapolates its key messages for maternity care practice. The approach driven by the national policy frameworks can be summarised as follows:

• Prevention of problems in the first place
• Early intervention if problems have started to manifest themselves- so as to prevent them getting worse
• An increasing emphasis on partnerships and outcomes to realise a transformational change in public sector service delivery
• Building capacity in communities, families, parents and children to help them tackle their problems

The focus of this approach is to identify the key inputs and actions needed to improve outcomes for children and families. For NHS staff this requires work across sectors and in multi-disciplinary teams, adopting key worker roles and being able to facilitate access to other services, in a way that is not merely signposting.

3.1 NHSSCOTLAND

HEALTHCARE QUALITY STRATEGY

The Better Health Better Care ( BHBC) Action Plan (2008) made a commitment to strengthening the role of NHS healthcare in giving all children the best start in life: it was specific about developing the contribution of maternity services by updating the national framework for maternity services in Scotland.

'NHSScotland's antenatal services mean that it is uniquely placed to develop early relationships with Scottish families and to identify risks and offer a preventative approach to health care. We need to strengthen antenatal care so that we get better engagement with families who are at higher risk of poor outcomes, paying particular attention to the needs of teenage mothers who have traditionally started antenatal support later and had less of an engagement with elements of the service such as antenatal classes.'

The NHSScotland healthcare Quality Strategy ¹⁴ builds on the momentum of BHBC; recognising that healthcare quality is 'built from the ground up and is dependant on the effects of millions of individual care encounters'. Care encounters that are consistently person centred, clinically effective and safe for every person, every time'.

The healthcare Quality Strategy has been built around what people in Scotland have said they want from healthcare services. They said they wanted:

• Caring and compassionate staff and services
• Clear communication and explanation about conditions and treatment
• Effective collaboration between clinicians, patients and others
• A clean and safe environment
• Continuity of care and
• Clinical excellence

Delivering this quality of care is at the heart of clinical values and the motivation for all healthcare staff, including staff providing maternity care. Three high level Quality Ambitions have been developed to incorporate these aspects and the internationally recognised six dimensions of healthcare quality- healthcare that is; person centred, safe and effective, efficient, equitable and timely into the Quality Strategy.

All work within NHSScotland and with its partners will be aligned to the three healthcare Quality Ambitions. The table below demonstrates how these ambitions apply to maternity care.

Quality Ambitions	Maternity care- examples
Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making	Use of strengths based approaches in promoting health and behaviour change Effective communication, translation and interpretation services are in place Inequalities sensitive practice is promoted
There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of health care services at all times	Reductions in healthcare acquired infections during antenatal, labour, birth and postnatal periods
The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated	Reductions in inequalities in access to antenatal and postnatal care services Reductions in inequalities of care quality experience

HALL 4 GUIDANCE

A New Look at Hall 4 - the Early Years - Good Health for Every Child ¹⁵ (the refreshed Hall 4 guidance) highlights the importance of early assessment and planned support for the baby and family. In some cases, this may mean agreeing the baby's health plan indicator with the family before the baby is born. This will need effective communication, referral and liaison processes to be in place between public health nursing, maternity services and primary care services.

MATERNAL AND INFANT NUTRITION FRAMEWORK

A framework to improve maternal and infant nutrition has been developed for Scotland. This framework sets out a clear set of actions to be taken across public service sectors in Scotland. ¹⁶

3.2 THE SOCIAL POLICY FRAMEWORKS

The Scottish Government's purpose is to focus government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth. This commitment is at the heart of the National Performance Framework- Scotland Performs ¹⁷. Maternity care services have a contribution to make to at least four of the Scottish Government's 15 National Outcomes. These are:

• Our children have the best start in life and are ready to succeed
• We have improved the life chances for children, young people and families at risk
• We have tackled the significant inequalities in Scottish society
• We live longer health ier lives

The Concordat between the Scottish Government and local government and the new outcomes-focussed relationship that has emerged places significant expectations across the public and third sector to work in partnership, and align resources and priorities where possible.

In addition over the last 10 years a legal framework for the promotion of equality has taken shape. The Scottish Government and public bodies are working to ensure that no one is denied opportunities through factors such as race, gender, gender identity, disability, sexual orientation, religion or belief, or age. All public services are required to carry out Equality Impact Assessments in relation to the services they plan and provide. Alongside these legal frameworks, the Scottish Government has produced three key social policy frameworks which, taken together, form a coherent approach to addressing disadvantage and inequalities in Scottish society:

• The Early Years Framework - http://www.scotland.gov.uk/Topics/People/Young-People/Early-years-framework
• Equally Well (health inequalities)- http://www.scotland.gov.uk0cd55c8b-d5d6-4b5d-aac8-ea28400f15d7
• Achieving our Potential (poverty and income inequality)- http://www.scotland.gov.uk05d01a7c-3458-44dd-b457-73731ae3199d

Equally Well and the Early Years Framework highlight the key role antenatal care has in contributing to reducing health inequalities and improving health in the early years. The Equally Well Task Force concluded that:

'Effective action in the early years to address future inequalities in health, and linked aspects of people's lives, includes high quality antenatal care that identifies and addresses risks early' (Equally Well page 29)

Achieving our Potential acknowledges the compelling evidence that exists which shows that despite the best efforts of government, local authorities and many others, some children are still held back by social and economic barriers which hamper their development and make it much more likely that they will experience poverty in later life. Interventions which address inequalities in maternal and infant health can provide critical support in ensuring children have the best possible start in life.

The Equally Well Task Force stresses that if services are to respond effectively to the range of circumstances that contribute to a person's health and wellbeing, a collaborative approach across different public services is required, along with the active engagement of service users and the communities they live in. The following is a summary of key messages for maternity care from the Equally Well review and the recent Marmot review. ¹⁸.

Health inequalities closely follow a social gradient -affecting all groups in society. Improving population health and reducing the gap between groups therefore requires a public service response that is universal, tailored and proportionate to need. Neither a solely targeted nor a one size universal approach will do - a 'progressive universalist' approach is required.

International research and expert advice indicate a number of approaches that are likely to be effective in improving health outcomes whilst also reducing inequalities in outcomes between groups; those most pertinent to maternity services include:

1. High quality, evidence-based antenatal care that identifies risks early and takes effective action to deal with them- capitalising on the evidence that the antenatal period is an optimum point at which most women are highly motivated to do what is best for their baby,

2. Continuity of care and carers

3. Schemes to improve maternal nutrition during pregnancy,

4. Measures to alleviate poverty in families, including income maximisation and employability services.

GETTING IT RIGHT FOR EVERY CHILD ( GIRFEC)

GIRFEChttp://www.scotland.gov.uk/Topics/People/Young-People/childrensservices/girfec/programme-overview is a central part of the Scottish Government's commitment to improving outcomes for all children and clearly articulates the need for transformational change across all public service systems, practice and culture to drive these improvements. The GIRFEC approach applies across the spectrum of need, whether there are early indications of additional needs within universal services or in higher risk situations involving the need for more complex interagency plans. It provides a common, co-ordinated approach which is relevant to all agencies and services working with families.