Moray Maternity Services Review: report

8 Findings and Conclusions

8.1.1 Findings

The above sections summarise the evidence the Review Group has received.

From this, the Review Group believe that:

• It is right to be more ambitious with the scope of maternity services currently provided for the Moray population. Similar populations across Scotland have a more extensive local provision, and this would be in line with the "Best Start" and "Realistic Medicine" framework.
• It must be recognised that, regardless of investment and the development of alternative maternity service models in Dr Gray's, a proportion of women will choose, or will need, to give birth in a larger and more specialist unit. This should be seen as a positive step in ensuring women and babies are safely and appropriately cared for. This is likely to mean that transfers in labour, while this should be minimised through effective risk assessment, may still be required.
• Maternity services are key to the wider economic and community wellbeing of a population, and this should be factored into the decision making.
• The provision of maternity services in Moray is inextricably linked to the long term development and success of all the services within Dr Gray's.
• The Review Group heard that, at times, the staff in Dr Gray's felt unsupported by NHS Grampian as an organisation. While there will always be different perspectives, it is important that this is acknowledged.
• In discussion with staff, the Review Group also heard that relationships between the service in Dr Gray's and the wider maternity services in Aberdeen and Raigmore require to be strengthened and developed, promoting collaborative working to improve safety.
• The Review Group also heard about specific actions being taken to strengthen and support the leadership in Dr Gray's (NHS Grampian's new portfolio leadership approach). This is also acknowledged, and should be supported and encouraged.
• The Review Group received considerable testimony from women, families and women's advocacy groups. These included "Maternity Voices Partnership" groups in Moray, Grampian and Highland, and "Keep Mum" who have had a long history of supporting and campaigning in relation to the maternity services in Moray. It was clear that, while "Keep Mum" is understandably an influential group on public views around Moray maternity services, that it will be beneficial to develop engagement through the MVP groups who are making positive progress in developing relationships with maternity services representatives and extending the input from women, families and wider stakeholder groups. This should continue to be encouraged.

8.1.2 Conclusions

The Review Group carefully considered the extensive evidence heard and reviewed, the desire to widen the scope of the service, and the careful balance that has to be struck in relation to patient safety and the deliverability of any future model of service provision for Maternity Services in Moray.

As described above, the evidence and testimony provided by a wide variety stakeholders allowed the Review Group to consider the many factors and influences which will have an effect on the ability of NHS Grampian to stabilise and further develop Maternity Services on the Dr Gray's site.

The six models considered were:

• Model 1: Status Quo
• Model 2: No Intrapartum Services at Dr Gray's
• Model 3: Community Maternity Unit* linked mainly to Aberdeen
• Model 4: Community Maternity Unit* linked mainly to Raigmore (Moray Networked Model)
• Model 5: Rural Consultant-supported Maternity Unit*
• Model 6: Consultant-led Maternity Unit*

*this unit to be located in Dr Gray's Hospital in Elgin

Both Model 1 (Status Quo) and Model 2 (No Intrapartum Services in Moray) were considered inappropriate and undesirable by the Review Group. The remaining four models of service provision were considered individually by Review Group members based on a set of pre-agreed scoring criteria. Of these, Model 6 (a Consultant-led Maternity Unit in Dr Gray's) was recognised as the most desirable model of service provision when considering 'Patient Safety and Quality', 'Service User and Stakeholder Experience', and 'Policy Alignment'. However, the Group is clear that, when set within the current service and workforce context, this is not deliverable within any reasonable timescale (2-5 years), and unlikely even within the next 10 years. As a result, continuing to focus on this model is not recommended.

The Review Group therefore focused its attention on: Model 3 (a Community Maternity Unit linked mainly to Aberdeen); Model 4 (a Community Maternity Unit linked mainly to Raigmore); and, Model 5 (a Rural Consultant-supported Maternity Unit).

The Review Group believe that all three of these models are realistically deliverable. It is acknowledged that whilst Model 5 is similar to the model provided in the Scottish Northern Isles (which is not considered 'standard' for mainland obstetric services) it remains a sensible, pragmatic model supported by robust safety data from other units.

8.1.3 Conclusions – Short-term

Following careful review and consideration of the evidence gathered the Review Group agreed that Model 4 was the best model to be established within a reasonable time-frame (up to two years) in order to provide a safe, high-quality Maternity Service to women residing in Moray; particularly given that Raigmore is significantly closer to Dr Gray's than Aberdeen.

Model 4 is described as a "Moray Networked Model", and includes a Community Maternity Unit (midwife-led) in Dr Gray's, with access to consultant intrapartum care in Raigmore or Aberdeen. This would see an increase in the proportion of births taking place in Raigmore which is geographically closer to home for a percentage of women in Moray. Emergency and urgent transfers would also go to Raigmore. It is expected that the CMU would be able to deliver approximately 20% of babies in Moray (all of which would be "low risk"), and potentially an additional 20% with the repatriation of women having elective caesarean sections. There would be local consultant-supported antenatal care, potentially supported by an increase (where appropriate) of digital and virtual care, but no in-hours or out of hours' medical provision for intrapartum care.

This model is in line with the Health Boards' plans for "Best Start North", and will require an appropriately formalised Clinical Accord/Service Level Agreement (SLA) regarding ongoing service development with NHS Highland. NHS Highland has indicated it has a two-year plan to enhance its infrastructure and staffing levels, and this will allow expansion of the facilities in Raigmore. It is recognised that NHS Highland's plan for Raigmore are co-dependent on further changes within NHS Highlands maternity services, including appropriate capacity with the Special Care Baby Unit, the development of the Invergordon Community Midwifery Unit, and the Inverness Community Hub. This plan will support women from West Moray giving birth in Raigmore, and will support intrapartum transfers to Raigmore in urgent and emergency situations. This will, in turn, offer further choice for women in Badenoch and Strathspey who may wish to choose to give birth in Dr Gray's in Elgin.

8.1.4 Conclusions – Medium-term

The Maternity Services at Dr Gray's are inextricably linked to the vitality of the hospital as a whole, and it is recommended that careful consideration is required around the overall role of Dr Gray's Hospital. The size of the catchment area and rurality are sufficient to justify and sustain a vibrant hospital with a range of consultant-led services; however, development of the hospital has not continued in line with other comparable Scottish hospitals (e.g. NHS Borders, NHS Dumfries and Galloway), and it may not be possible, for either practical or financial reasons, to reach a full "District General" position. NHS Scotland and NHS Grampian need to consider how best Dr Gray's should be supported to serve the population of Moray as a whole.

If NHS Grampian concludes that the hospital should be a functioning District General Hospital, then it would need to commit to a revitalisation plan for secondary care covering an appropriate range of hospital departments. This is likely to require additional recurring funding. It would also require a dedicated and pro-active leadership and change management team who could focus on the positives of the revitalisation plan and the benefits of living locally. The recruitment and retention of staff will be a key element of delivering this model. The Scottish Government, both of the Health Boards, NES and the Deanery, must also all commit to finding solutions for staffing rural areas of Scotland. Indeed, it could be argued that if NHS staff in training are not exposed to rural working, they are missing a key element of required training; as it is often emphasised that trainees are not in units to provide service but to be trained for the future. Allocation across Scotland, however, can appear to be based on sustaining middle grade rotas for service delivery in the larger centres.

If moving towards a more fully functioning district general hospital is the preferred plan for Dr Gray's as a whole, then the Review Group would favour moving to Model 5 for maternity care i.e. a Rural Consultant-supported Maternity Unit aiming to deliver 50-70% of babies in Dr Gray's (based on the Scottish Northern Isles' Model).

NHS Grampian may envisage, however, that Dr Gray's would best serve its medical services in Moray by providing valuable outreach care from the specialist units in Aberdeen and Raigmore. This may be the most appropriate model when considering the population of NHS Grampian as a whole; and moreover, this may be more sustainable from a service, workforce, and financial perspective. If this were to be the preferred strategic plan for the area, then the Review Group would favour continuing with Model 4.

In setting out these models in this way, it is recognised that this is dependent on strategic considerations that are outside the remit of this Review.

8.1.5 Recommendations

NHS Grampian and NHS Highland should, as a matter of priority^[24]:

• Progress in the short-term with setting up Model 4 (Community Maternity Unit linked mainly to Raigmore ("Moray Networked Model").
• Consider, in the medium-term, the role of Dr Gray's Hospital as a whole; and, if a more fully functional District General Hospital is favoured and achievable, to then consider what steps can be put in place to deliver Model 5 (a Rural Consultant-supported Maternity Unit) in Dr Gray's.

It must be recognised that the development of any new model of service provision will take time; and the Review Group has, therefore, set out a number of recommendations that should also be progressed immediately, as a matter of urgency, to be established as soon as possible and at least within the next 6 months.

8.1.6 Summary of Recommended Actions

A number of key actions are set out below:

1) Immediate measures

It is accepted that implementing the preferred short-term model (Model 4) will take some time, with the development of increased physical and staffing capacity in the Raigmore Maternity Unit likely to take up to two years to achieve. It is, however, important that steps are taken now to improve the current situation in Dr Gray's, and to address a number of the current potential safety and public concerns with the Maternity Services in Moray:

• The Review Group would suggest that the terminology "Life and Limb support" is withdrawn and ceases to be used; and that the offer of this service is discontinued with immediate effect. The nature of 'Life and Limb support' is unclear, and has been the source of considerable concern and discontent amongst staff at Dr Gray's as well as causing confusion to women and their families.
• Enhance the support from the existing local Obstetrics and Gynaecology (O&G) Consultants to the midwifery team so that they have agreed multi-disciplinary guidelines and protocols.
• Encourage and support the appropriate "autonomy" of decision-making by midwifery staff at Dr Gray's, working within their scope of practice.
• Agree clearly defined transfer protocols, transfer criteria and associated triggers between Dr Gray's and the maternity units in Aberdeen and Raigmore.
• Ensure that when managing potential transfers, within these agreed criteria/triggers, that those transfers are accepted in a proactive manner, so that the Maternity Team at Dr Gray's are appropriately and adequately supported.
• Agree and support Emergency Transfers in labour being directed to Raigmore.
• Consider the use of staff with advanced skills to minimise the dependence of the service on junior doctors i.e. pharmacists / midwives, ensuring that skills are kept up to date.
• Ensure that an effective and supportive multi-disciplinary "debrief" process is in place for any incident or "near miss", so that a culture of learning and improvement is developed and embedded throughout.
• Re-introduce elective caesarean sections to Dr Gray's under the care of current O&G consultants.

2) Culture

The importance of culture to quality and safety in any service has been clearly articulated. The following recommendations are made, and should be progressed as a matter of priority:

• Identify opportunities for staff to work across all sites (i.e. Dr Gray's, Raigmore and Aberdeen) to enhance relationships and improve understanding between staff groups. This should include at least Midwives and Obstetricians from all sites.
• Commission the delivery of a Cultural Safety Programme aimed at the multi-disciplinary team working in Dr Gray's. This should include the relevant team members at Raigmore and Aberdeen so that the ownership of this work, and the relationships between Dr Gray's, Raigmore and Aberdeen, and the services they work with are addressed as part of this work. Involvement of all senior clinical staff in this work should be mandatory.
• Invest in and protect time for the creation of a whole team focus at Dr Gray's, and between Dr Gray's, Raigmore and Aberdeen, so that the service at Dr Gray's becomes embedded as part of a Networked Maternity Service between NHS Grampian and NHS Highland.

3) Leadership

Effective leadership of any service, including good Clinical Leadership and management support, is essential if a service is to thrive. There has been a gap in leadership to the Maternity service in Dr Gray's in recent years and good future leadership will be a critical success factor going forward. Progress has been made with the overall leadership for Dr Gray's and this must be supported and encouraged in the future:

• Invest in the clinical leadership of the obstetrics and gynaecology service at Dr Gray's. The service should look to identify an experienced and respected Senior Clinician who can lead the service for at least the next five-year period as the service goes through continued change and development. This post would require extended managerial sessions and be given appropriate management support;
• NHS Grampian should build on the recent development of Hospital management at Dr Gray's and the focus and responsibility for Dr Gray's within the Moray Health and Social Care Partnership;
• NHS Grampian, with local clinical leaders and the community, should develop a clear strategic plan and vision for the future of Dr Gray's. This has the potential to be a key component of the Acute services in Grampian and provide significant support to the service's recovery from the Pandemic;
• NHS Scotland should provide clear support for the ongoing sustainability of Dr Gray's as a key part of the NHS Scotland estate, including capital investment where required;
• NHS Grampian should work closely with NHS Highland to ensure a clear programme plan and support arrangements (including Governance) are in place to support the ongoing delivery of an Improvement Plan for Maternity Services in Moray.
• NHS Scotland should consider arrangements for ongoing oversight of the development of Maternity Services in Moray. This is ultimately the responsibility of NHS Grampian, but public confidence may be enhanced by a level of objective external oversight.

4) Workforce and Recruitment

The recruitment and retention of the workforce will be the main driver of success for the sustainability and improvement of maternity services in Moray. This recognises the ongoing challenges associated with recruitment and retention in rural areas of Scotland, that are exacerbated in the North of Scotland.

• NHS Grampian should take a focused approach to the ongoing recruitment of staff to Dr Gray's, and for the maternity services in particular. This should include a specific workforce development plan for the site and service, and a recognition that this will need to be creative and to explore alternative approaches.
• NHS Highland should take a similar focused and creative approach to recruitment for the development of the Raigmore Maternity Service.
• These workforce and recruitment plans should include consideration of the opportunities to maximise links from the transfer of staff into the Ministry of Defence (MOD) facilities at Lossiemouth and Kinloss. Both sites employ a significant number of staff of working age and opportunities for identification of MOD personnel with appropriately skilled partners willing to transfer to work in the NHS in Moray should be explored.
• Any recruitment plan should be based on the "strengths" and "benefits" living and working in Moray provide, as well as the opportunities for joint appointments and cross-service working with Aberdeen and Raigmore Hospital; this plan will require dedicated investment.
• NHS Grampian and senior staff in Dr Gray's must focus on the training experience of all junior doctors working in Dr Gray's, so that this becomes a placement of choice based on the excellence of teaching and support. This will require investment in the teaching time, leadership and skills of relevant senior staff.
• NHS Scotland (Scottish Government) should ensure the National Workforce Strategy and future National Workforce Plans clearly prioritise the challenges associated with rural recruitment and retention.
• NHS Scotland (Scottish Government) should develop a 'National Maternity Services Workforce Plan' that recognises the future workforce needs to sustain maternity services in rural areas that are consistent with the "Best Start" Strategy.
• NES should develop and agree with relevant stakeholders a clear framework for Advanced Midwifery practice, that recognises the challenges and needs of all Maternity units.
• Further consideration should be given to how student intake to midwifery and medical school can be appropriately managed to ensure adequate successful applicants from remote and rural Scotland (recognising that individuals from these areas are more likely to return to work in these areas in due course).
• Following the development of an updated Maternity Services Workforce Plan, consideration must be given to the required junior doctor and midwifery training numbers necessary to support the future workforce across the whole of Scotland. This will need to include additional trainee numbers for the North of Scotland in Obstetrics and Anaesthetics, without reducing numbers elsewhere in Scotland.
• Consideration should be given to the future role and scope of Maternity Care Support Workers within the Maternity Services' workforce.

5) Infrastructure

• An up–to-date and appropriate infrastructure is important both in relation to the service provided to our communities but also supports the recruitment and retention of staff. As a result: NHS Grampian, supported by the Scottish Government, should ensure appropriate ongoing capital investment in Dr Gray's to sustain this as a vibrant hospital for the local Moray area.
• NHS Highland and the Scottish Government should urgently complete and agree the business case process for the re-provisioning of the Maternity Unit at Raigmore Hospital, including the wider implications for NHS Highland's maternity services. This is imperative, so that the unit has adequate capacity to accept urgent transfers from Dr Gray's, along with providing an appropriate unit of choice for women and families from Moray who may wish to choose Raigmore as a consultant-led maternity unit of choice.

6) Engagement

The support of the community to the future of maternity services in Moray will be essential. There is a developing Maternity Voices Partnership^[25] (MVP) group in Moray, and this should be encouraged and supported so that this becomes the main vehicle for constructive engagement with the local community:

• NHS Grampian should invest time and energy to the ongoing development of the MVP group across Moray.
• NHS Grampian should ensure this includes a clear engagement of next steps in the development of local services, with regular updates and explanations of progress to the local community.
• The MVPs in Moray, Grampian and Highland, as well as other community groups are encouraged to support the recommendations in this report as the most appropriate way of developing Maternity Services in Moray, recognising how important their voices are in providing support to staff and the right climate for the recruitment and retention of key staff.
• Elected representatives are encouraged to support the recommendations in this report as the most appropriate way of developing Maternity Services in Moray, recognising how important their voices are in providing support to staff and the right climate for recruitment and retention of key staff.

In conclusion, the Review Group, while recognising the desire for changes to the service, believe our conclusions and recommendations are balanced, deliverable, and will support the continuous development of Maternity Services in Moray.

The Review Group, therefore, commend these recommendations for Maternity Services to the women and families of Moray, the wider community and their political representatives. The delivery of these recommendations will require the support and commitment of the managerial and clinical staff across NHS Grampian and NHS Highland, as well as their Executive Leadership Teams and the Scottish Government. This will be essential to promote and champion this model, and to support all parties to work collaboratively to ensure it is delivered within the indicative time-frames laid out within this report.