Moray Maternity Services Review: report

Appendix D: Scottish Approach to Service Design (SAtSD)

Approach

The Scottish Approach to Service Design (SAtSD) informed the design approach considered when the Moray Maternity Services Review was set in motion. User research is "a methodology that connects the people designing a service with the people who use it".

The "Double Diamond" model (below) is a visual diagram showing the design stages of the service design approach. The Double Diamond shows the importance of taking time to understand the problem before designing solutions. Each diamond shape illustrates the process of creating or exploring many possible ideas before refining these to the best or most appropriate idea. The first diamond does this to confirm the problem (through user research) and the second to design the solution.

This Review focused on discovery and defining potential models for NHS Grampian to take into the second diamond to then develop and deliver the proposed model.

Research Methods

As informed by the SAtSD, user research was undertaken to understand the experiences and "pain points" of those interacting with Moray maternity services.

User research was necessary to ensure that the needs of the service users were understood and considered when making recommendations regarding the proposed future model for Moray maternity services. The user research consulted a range of stakeholders:

• Mothers
• Family and Partners
• Patient Representatives
• MSPs
• Other clinicians
• Management
• Transport and Transfer
• Professional groups

Evidence sessions were conducted by the Review Group between May and October 2021. Written evidence was requested via public engagement communications channels which also contributed to the themes identified.

It is recommended that NHS Grampian Health Board use a Service Design Approach when implementing the proposed recommendations. This will ensure that users are fully engaged in the design of the new service.

Synthesis

Data from the research was analysed by thematic analysis using the POPI framework which categorises responses into:

• Pain points – areas of improvement;
• Opportunities – opportunities in the system that could contribute to improvement;
• Principles – elements of an ideal service;
• Insights – key insights from the review.

Following this analysis, insights were synthesised into cross-cutting themes, which are the areas on which there was common agreement. Personas were created for each user group to highlight the 'needs' that are specific to that group, based on the evidence alone. The cross-cutting themes and personas were validated with the Review Group, and used to inform the development of potential models of service delivery, accepting that it would be difficult to meet everyone's needs.

Cross-cutting themes and user needs

User research and thematic analysis identified the following cross-cutting themes:

• Communication and procedures across NHS Grampian lack consistency
• Desire for a safe more local maternity service
• Paucity of available resources and staff increases transfer
• Precarious intrapartum transfer should be minimised
• Wider public engagement in the region would build back trust
• Unclear expectation setting for delivery and recovery causes anxiety for mothers

Full user personas and individual user group specific insights can be found in Appendix E of this report.

Mothers

"There was little to no 'consultation' about induction and no explanation as to what that would entail. Poor communication also between Dr Gray's Hospital and Aberdeen."

Mothers described the need for upfront communication and attentive care to enable them to make a more informed decision about their birthing pathway, and to focus on giving birth.

Other key user needs included:

• I need maternity care closer to home.
• I need better planning around bed availability and ambulance transfers.
• I need better communication around the reasons and risks behind the transfers and delays to feel safer and reassured.
• I need consideration and assistance for my partner and my family to enable them to visit and support the baby and I throughout the birth.
• I need to feel like I have been consulted and involved in the decisions made around my birthing pathway.
• I need accessible communication and information on the process, the decisions, and the risks associated with my birthing plan, so I don't feel anxious.
• I need a clear understanding of who is taking responsibility for my care.

Midwives

While also part of a clinical multi-disciplinary team, midwives were singled out due to their unique supportive role for mothers.

"What guideline are you following? Depending on who you are speaking to in Aberdeen, you're getting told "yes, you can put them through", or "no, you'll have to deal with that."

Midwives described the need for more guidance, recognition and autonomy to enable them to feel like a valued part of a multi-disciplinary team and advocate for mothers' needs.

Other key user needs included:

• I need clear guidance on midwifery protocols such as triage and escalation.
• I need recognition of and workforce support to advocate for mothers' needs throughout the birthing process.
• I need to be informed on the planned roadmap for maternity care going forward.
• I need a safer more consistent transfer process for women.
• I need greater collaboration with consultants so that my specialist skills as a midwife are better recognised and utilised within the MDT.

Family and Partners

"There were limited facilities available for partners."

Family and Partners highlighted the requirement for more consideration around their role as a support network to their partners and newly born baby.

Other key user needs included:

• I need mothers to have the highest quality care experience regardless of the location of birth.
• I need local maternity services that minimise transfers so mothers feel safer.
• I need clear communication on birth procedures to support my partner.
• I need more shared decision making on where the mother will give birth.
• I need more consideration for the mothers' emotional wellbeing.
• I need staff, procedures and infrastructure to be aligned with partners and families' practical needs.

Patient Representatives

"We have to be actively trying to engage a diverse group of people to fully understand the issues mothers face"

Patient representatives needed greater dialogue with NHS Grampian to co-design a service that is fit for purpose.

Other key user needs included:

• I need NHS Grampian to be more transparent about the future plan's co-design it with us.
• I need more support for the mother's mental and physical wellbeing.
• I need NHS Grampian to engage with more diverse audiences in their public engagement.
• I need more robust feedback mechanisms for the public to enable continuous improvement.
• I need more local maternity services which reflect the needs of the growing population.

MSPs

"You've heard of senior decision makers in Aberdeen who did not visit the hospital until this crisis emerged. So, in charge for several years and did not walk the floor of Dr Gray's hospital. That's decision makers in Aberdeen, medical decision makers"

MSPs advocated for clarity on the future of Dr Gray's, and independent oversight on the outcome of the review, so that women can continue to get quality care.

Other key user needs included:

• I need women to feel safe and supported by maternity care in Dr Gray's.
• I need independent oversight of agreed changes by NHS Grampian to ensure quality.
• I need consistent patient care and less clinical risk caused by transfer for women in Elgin.
• I need less medicalisation of the pregnancy pathway and greater compassion for mother and family needs.
• I need more innovative recruitment in the area to create a sustainable service for the North.

Other Clinicians

This user group was made up of responses from pharmacists, anaesthetists and obstetricians

"If this is an exercise to set up the service without any investment, then we are wasting time because somehow people want to reconfigure the service without putting in any money"​

Clinicians described a need for investment training and recruitment so that more people are attracted to work in the area to build capacity of a multi-disciplinary team

Other key user needs included:

• I need trusted multidisciplinary teams
• I need career development and cross-skilling of midwives
• I need more creative recruitment in the region to support the growing demand
• I need reconsideration of the infrastructure available to maternity
• I need less subjectivity around 'life and limb' and a reduction in the medicalisation of birth
• I need a better understanding of the risks of transfer with tighter protocols when it does happen
• I need more shared data intelligence in the region for better prescribing and a reduction in antibiotic use

Management

"Things have to be spelt out explicitly as to what is required to run the service model the public want and state this is what it's going to cost"

Management required a clear decision on the roadmap for Dr Gray's with investment to support it to continue delivering sae patient centred service

Other key user needs included:

• I need a resourced service with the right infrastructure to deliver a safer service.
• I need more collaboration in the North to share resources and learning.
• I need a decision on the future roadmap of service to return quality of care.
• I need engagement with the public to continue, building a dialogue and trust.
• I need more innovative and creative models for Dr Gray's to be considered that tackle the unique challenges of the North.
• I need sustainable and clearly defined solutions with roadmaps within reasonable timeframes.

Transport and Transfer

"So, I really feel for front-line crews in these circumstances, as they are often portrayed as being unnecessarily rigid about things. They need a very clear, supportive framework if we are going to change that process from just 'taking to the nearest place"

Transport and transfer staff require clearer protocols on transfer and resources available to provide safe and timely transport across the region.

Other key user needs included:

• I need greater resources and staff, in the short term, midwives could provide additional support.
• I need greater consideration of the risks of intrapartum transfer.
• I need greater collaboration between hospitals in the region around transfer and bed availability.
• I need a decision on the future for Dr Gray's.
• I need there to be clearer communication with mothers on the timings and realities of current infrastructure.

Professional groups

"Staff feel they are under the spotlight again with yet another review"

Professional groups needed some transparency around the future plans for Dr Gray's, dialogue in its design to create an innovative service with attractive career paths and a sustainable service for the North.

Other key user needs included:

• I need more innovation in the North around the routes of development available to trainees.
• I need more creative recruitment to resource services for the growing population.
• I need more support for development time so that staff can grow and deliver a higher quality service.
• I need more consideration of the pressure the reviews have put on staff at all levels.
• I need more collaboration with NHS Grampian over the future of the service.