Moray Maternity Services Review: report

2 Background to the 2021 Review

Moray, situated in the North East of Scotland covers a population in the region of 100,000 residents, many living in remote and rural areas. Overall, Moray is one of the least deprived areas in Scotland, as defined by the Scottish Index of Multiple Deprivation (SIMD), having no data zones in the 15% most deprived areas in Scotland, and two data zones in the 20% most deprived areas; both of which are in Elgin.

Dr Gray's is the only District General Hospital in Grampian. Its catchment includes the RAF base at Lossiemouth and the Army's 39 Engineer Regiment base at Kinloss; these, by their nature, are shifting populations, often bringing a younger demographic to the region.

The Review Group recognises there is intense interest in the outcome of this independent review from the people of Moray, the staff involved, NHS Grampian and NHS Highland, and the political representatives of the area. One of the key messages heard by the Review Group is the desire for a clear decision to be made and then implemented. The Review Group has made a great effort and taken considerable care to understand the current position and perspectives of all stakeholders. The Review Group makes its independent and professional view based on the most realistic approach to providing and developing maternity services at Dr Gray's.

An obstetric service has been provided at Dr Gray's since 1995 when this was established following an extended and committed public campaign on the development of Dr Gray's Hospital; this strong public and community commitment continues to this day.

Over the last 10 years, there have been difficulties in the recruitment and retention of appropriately trained clinical staff. This is not unique to Dr Gray's, and has been the case for much of rural Scotland, and indeed the UK as a whole. This reflects the increased specialisation of medical, nursing and midwifery careers, and the overall workforce demographic and supply, amongst other factors.

As a result of these issues, the future of Dr Gray's Maternity Services has been under scrutiny since the services were "temporarily" changed in August 2018 following staffing issues in the paediatric service. This change recognised that running an extended obstetric service requires a range of other support services, such as paediatrics, anaesthetics and access to theatres to be in place to provide a safe service.

While most antenatal care continues to be provided locally, intrapartum and inpatient care in Dr Gray's is currently provided through a midwifery-led model with "Life and Limb" support from the consultant obstetrician and gynaecologists who are on-call (from home) for gynaecology emergencies. Expectant mothers who require more complex care, or who choose to deliver in a consultant-led maternity unit, receive their care in Aberdeen Maternity Hospital (Aberdeen), with a very small number transferring care to the maternity unit at Raigmore Hospital in Inverness (Raigmore). Over time, this has resulted in a reduction in the number of women who can safely deliver their babies at Dr Gray's.

Following the introduction of these changes, Dr Gray's Maternity Services have been the subject of two previous reviews. The first review, in 2018, following the above mentioned changes to the service, was carried out by a small Expert Group reporting to the Chief Medical Officer at the Scottish Government. The Expert Group was established to provide insight and guidance on the measures proposed by NHS Grampian to maximise the maternity care which could be provided in Dr Gray's Hospital.

The second review, undertaken in 2019 and led by Professor Alan Cameron, was commissioned by NHS Grampian due to ongoing issues of recruitment and retention of medical staff, and the inability to provide sustainable medical out of hours' cover for the maternity service at Dr Gray's.

The high level outcome of each of these previous reviews is summarised below.

2.1 Chief Medical Officer's (CMO) Expert Group

The service provision in place at the time of this review had been primarily driven by the lack of available paediatric cover at Dr Gray's. This led to the need to rapidly change the service to ensure it remained safe; a change which was, at the time, expected to be a temporary arrangement.

1. The Expert Group were asked to provide independent assessment of the feasibility and likely success of the 6 priorities for service proposed by NHS Grampian to maximise maternity care at Dr Gray's, which were: Reinstating elective caesarean sections at Dr Gray's.

2. Increasing the number booked for birth at the Community Maternity Unit (CMU) to 35% of total bookings (currently 25%).

3. Reducing unnecessary transfers to Aberdeen by reviewing reasons for maternal transfer.

4. Increasing antenatal care delivered at Dr Gray's, by reviewing what specialist antenatal and postnatal services currently provided in Aberdeen can be delivered locally.

5. Working with NHS Highland to increase capacity in Raigmore to allow more women from Moray to receive care there in addition to the emergency transfers which have already been agreed.

6. Working to improve historically poor experience of trainees in obstetrics, gynaecology and paediatrics at Dr Gray's.

The 2018 CMO Expert Group recognised the difficulties staff and service users were facing at that time with the current service; they commented:

"At present Obstetric staff remain on call for "Life and Limb" emergencies as per the paediatric model in place and described by local staff. This creates a difficult model to describe to women, so that they can make an informed choice of place of birth."

Despite work to progress the outcome of the CMO Expert Group, in 2019, the Maternity Unit at Dr Gray's continued to be midwifery-led with obstetric support for antenatal care and the provision of "Life and Limb" support, which the CMO Expert Group had previously commented was "difficult to describe". This continued to create confusion for women as to whether or not they met the criteria to give birth to their baby in Dr Gray's.

Under the arrangements currently in place, midwives risk-assess women whilst they are in labour. Depending on the nature of any complications in labour, they will also consider referring to the Dr Gray's consultant obstetrician and gynaecologists for "Life and Limb" support. In order to make these decisions and arrange transfer, the midwives have been required to discuss and gain agreement from staff in the Maternity Hospital in Aberdeen (NHS Grampian, 65 miles away) or at the Maternity Unit in Raigmore (NHS Highland, 37 miles away).

This has led to confusion with staff groups as to which obstetric service to contact, and whether "Life and Limb" support is necessary, which has left women and midwives potentially vulnerable, and delayed decision-making at a critical time in labour. Women have described how, on arrival at Raigmore or Aberdeen, they have felt that their arrival was unexpected, their obstetric information was unavailable, and the units were too busy to provide the level of care they had anticipated. This in turn has, on occasion, led them to feel unwelcome in the unit to which they were transferred - the section on 'Mothers' and Families' Voices' within this report (Section 7.2) shares some of these women's experiences. The Review Group felt it was important to hear and capture as evidence these experiences in the women's own words.

Because of its relative proximity, there has been a desire for urgent transfers to be supported by the Maternity Unit at Raigmore in Inverness. However, due to the current capacity of this unit, Raigmore has only been able to accept transfers from Dr Gray's on a limited basis. As a result, most women in labour requiring transfer to a consultant-led unit are being transferred 65 miles away to Aberdeen.

2.2 The Alan Cameron Report 2019

The Alan Cameron report was received by NHS Grampian on 11 November 2019. This report detailed seven key findings in its Executive Summary, and made seven recommendations:

2.2.1 Alan Cameron Report - Executive Summary Findings

• There is no evidence of a trend in adverse outcomes for patients of the Dr Gray's Maternity Service.
• Clinical Governance in the Dr Gray's Maternity Service is not fully functional and presents a risk to patient safety.
• Working relationships in the Dr Gray's Maternity Service are dysfunctional and damaged to the extent that they may impact upon patient safety.
• There are increasing concerns regarding safety with the current hybrid model within the Dr Gray's Maternity Service.
• Circumstances have changed such that it is now not possible to revert back to the previous model of care.
• There are a number of significant concerns regarding the proposed enhanced Multi-Disciplinary Team (MDT) model of care.
• A Best Start Hub Model of Midwifery-led care could provide a safe and sustainable Maternity Service for the population of Moray.

2.2.2 Alan Cameron Report - Recommendations

• NHS Grampian transitions from the current hybrid model of care to a Best Start Hub Model of Midwifery-led care as soon as it is safe to do so.
• NHS Grampian undertakes a full and detailed review of clinical cases to assure themselves of the historical outcomes for individual patients within the Dr Gray's Maternity Service.
• NHS Grampian timeously utilises appropriate employment policies in relation to any findings that result from the detailed case review referred to above.
• NHS Grampian adopts robust clinical governance arrangements within the Maternity Service that fulfil the requirements of the Clinical and Care Governance Framework.
• NHS Grampian clarifies the management arrangements for Dr Gray's.
• NHS Grampian develops a clear vision for Dr Gray's Hospital and the Maternity Service there.
• NHS Grampian develops a full package of support for all staff who have been adversely affected by the issues within the Dr Gray's Maternity Service.