Introduction

The purpose of this document is to brief NCAT visitors on the guidance and evidence available to help make a judgement when clinically assuring reconfiguration of maternity and children’s services. In addition it should help commissioners and providers when considering reconfiguring services and should enable them to meet the standards expected by NCAT. Maternity and children’s services have been considered together in view of their close linkage and dependence on each other. This advisory note is not intended to be exhaustive and is neither pre nor proscriptive. Its evidence base was reviewed by a NCAT advisory group (see Appendix 1) who are either NCAT visitors (senior clinicians in paediatrics, neonatologist, obstetrics and midwifery) and others with expertise in reconfiguration (SHA leads, NHS Confederation).

Guidance and evidence basis

The following national and College reports were reviewed by the NCAT advisory group and thought to have significance. They often build on previous work which is referenced. Those of particular importance to reconfiguration are starred***.

• Birth Centres Resource: A Practical Guide, RCM, 2010.***
• Toolkit for High Quality Neonatal Services, DH, 2009.
• High Quality Women’s Healthcare: A proposal for Change, RCOG 2011.***
• Neonatal National Quality Dashboards 2012.
• NICE Quality Standards – Specialist Neonatal Care, NICE 2010.
• Responding to a proposal for merger or reconfiguration of Maternity Services provision in England: A good practice guide, RCM, 2010.***
• Facing the Future: Standards for Paediatric Services, RCPCH, 2011.***
• Socioeconomic Value of the Midwife, RCM, 2010.
• Standards for Birth Centres in England, RCM, 2009.
• Sustainable Maternity Services in Scotland.
• Birthplace in England Study report, NIHR SDO, 2011.***
• Delivering Quality Imaging Services for Children, National Imaging Board, 2012.

Group members have advised that the additional reports are pertinent to any service review.

• Quality and Safety standards for small and remote paediatric units RCPCH 2011.***
• Short stay Paediatric Assessment Units – advice for Commissioners and Providers, RCPCH 2009.***
• You’re welcome quality criteria, making health services young people friendly DH 2007.
• Right care, right place 1st time – joint statement by RCGP, RCN, RCPCH, CEM on the urgent and emergency care of children and young people RCPCH 2011.
• Standards for providing a 24 hour interventional radiology service, RCR 2008.***
• Safer Childbirth, Minimum standards for the organisation and delivery of care in labour, RCOG, RCM, RCA, RCPCH;RCOG 2007.***
• RCPCH guidance on the role of the consultant paediatrician in providing acute care in the hospital, 2009.
• Standards for Maternity Care – Report of a Working Party – page 30 relates to staffing 2008.
• A Charter for Paediatricians 2004.
• General paediatric Surgery – Guidance for Commissioners, RCS England 2010.
• National Confidential Enquiries: Maternal Deaths, Stillbirths and Neonatal Deaths, Perioperative Deaths.
• Safe Births; Everybody’s business. King’s Fund 2008.
• Making sense of commissioning Maternity Services in England – some issues for Clinical Commissioning Groups to consider. NCT, RCM and RCOG 2012.
• The Mandate: A mandate from the Government to the NHS Commissioning Board April 2013 to March 2015.
• Department of Health Choice Framework 2012–2013, 2013–2014.

Commentary

The advisory group has supported many of the conclusions and general recommendations of the above reports and advises that visitors and those involved with delivery and/or reconfiguring maternity and children’s services should acquaint themselves with their recommendations. The advisory group has suggested that NCAT visitors should be informed by sufficient information on which to make a safe judgement. The following is a list of desirable documentation:

• NCAT visits should be informed by appropriate locality based data and information. Ideally this should be data collected and recorded on a Maternity Dashboard: Clinical Performance and Governance Score Card.
• NCAT visitors require the following information:
  • The case for change which should include demographics of patient population and the strategic needs assessment, methods of public engagement including children and young people.
  • Numbers of births at the unit(s) under scrutiny and whether the birth rate is rising or falling. Births activity should be broken down into those in hospital unit, freestanding midwifery unit (FMU) if available, alongside midwifery unit (AMU) and, home birth.
  • What choices are offered to women for antenatal care, intrapartum care and postnatal care?
  • Description of the normal care pathway and analysis of the reasons that women leave the pathway in that particular population.
  • Numbers of births overall under midwifery led care.
  • Caesarean section rate (emergency and planned), assisted delivery rate (including failed instrumental delivery), theatre capacity.
  • Normal care pathway and analysis of the reasons that women leave the pathway in that particular population.
  • Numbers of 1 : 1 care in labour, and birth to midwife ratio – suggest changing this to – How does the service ensure every woman has a named midwife responsible for ensuring she has personalised 1 : 1 care throughout her AN, labour and PN care?
  • Transfer rates during labour (FMU or AMU to hospital and Home to hospital).
  • Number of instances of labour ward beds blocked by postnatal women.
  • Duration of any temporary closures of a maternity unit.
  • Percentage of women with episiotomy or tear sutured.
  • Percentage of women readmitted within two weeks of discharge.
  • Average number of contacts with midwife after going home.
  • Normal delivery rates.
  • Complications (Serious Untoward Incidents and Adverse Incidents) including perinatal mortality and morbidity, meconium aspiration, hypoxic-ischaemic encephalopathy, maternal mortality and morbidity including intensive care admissions, severe post-partum haemorrhage [requiring ≥ 4 unit blood transfusion], third degree tears, shoulder dystocia, surgical site infection, surgical never events.
  • Complaints and compliments about maternity and children’s services – What are the results of the ‘friends and family test’ and how will reconfiguration improve on these?
  • Description of facilities available (e.g. inpatient beds and/or paediatric assessment unit).
  • Medical work force (number of consultants, trainees, vacant posts and evidence of locum use for consultants and trainees over past year.
  • Nursing and midwifery and perioperative workforce with breakdown of grades, number of supervisors, students, agency/bank usage.
  • Relationship of the paediatric service with the emergency service.
  • Paediatric surgical services (emergency and unplanned – inpatient/day case).
  • Child Adolescent Mental Health Service provision.
  • A description of the clinical network arrangements between units.
  • Availability of multidisciplinary diabetic clinics, multiple pregnancy clinics, early pregnancy units, bereavement services.
  • Paediatric admissions (cold cases, acute, paediatric assessment unit activity).
  • For both services geography and distance to adjacent units and availability of tertiary care with evidence of patient flows within the locality.
  • Ambulance protocols for maternity and children’s services.
  • CQC and other reports from regulatory bodies.
  • Postgraduate Deans and GMC reports, Nursing and Midwifery Council educational reviews and local midwifery training HEI reports and other evidence about training.
  • NHS Staff Survey results.
  • Evidence of the contribution that general practice makes to the delivery of the maternity care pathway locally, including early pregnancy assessment and urgent care services.
  • Any other local plans for realignment of other services (e.g. Trauma centres, A&E and urgent care provision, hot/cold surgery sites, diagnostics, etc.), which may impact on availability of support such as critical care and imaging for women, babies and children.
  • Trend analysis of local midwifery good practice and conversely practice of concern, drawn from Local Supervisory Authority Midwifery Officers statutory annual audit visit report.
  • What initiatives do the services have in place to reduce the incidence and impact of post natal depression in terms of early diagnosis and intervention?

Conclusions of the advisory group

1. The NCAT supports Informed choice – maternity services should offer low risk women where appropriate the choice of home birth and a midwife led service (alongside or free-standing midwife led unit). Low risk women should be given full information and advice including the known small risks of neonatal mortality or serious morbidity associated with all birth settings. Nulliparous women should be informed of their increased likelihood of transfer if they plan birth in an environment other than an obstetric unit.
2. Commissioners of maternity and neonatal services should aim for a significant increase in low risk women accessing maternity services and giving birth outside of obstetric units in any of the alternatives (AMU, FMU or home birth). There is good evidence that such an aim will improve outcomes and be cost-effective. High transfer rates of nulliparous women is to be expected and this will need to be considered in any new service specification. The majority of the transfers are for pain relief in labour. Commissioners should consider commissioning services targeted at vulnerable and disadvantaged groups, and services that provide safe effective care with a better quality experience for women. One of the most successful models of care NCAT has encountered is that of the obstetric unit with an alongside midwife led birthing unit, which can keep the benefits of providing midwife led care but has the capability of seamless transfer of women in labour if clinical intervention is required.
3. Obstetric units should be readily available to all women choosing a birthing unit. Their main function is to provide the care for high risk mothers to be, and the management of complicated labour (including pain relief). There should be a consultant presence on the labour unit commensurate with unit size and in accordance with the recommendation of ‘Safer Childbirth’ (published 2007). This will often favour the creation of obstetric units with more than 2500 births to be clinically sustainable and affordable (see RCOG report). Trainee rotas should ensure the necessary exposure to an appropriate case load and with appropriate consultant supervision and formal assessment of competence.
4. The NCAT visitors will need to understand the impact on the provision of gynaecological services when consultant obstetricians also provide the local gynaecological services; conversely there is a need for appropriate gynaecological skills and experience in management of some obstetric emergencies (notably massive post-partum haemorrhage).
5. The NCAT supports the life course approach to women’s health care (RCOG 2011). This means that women have access to women’s health and maternity services close to their homes. In remote and rural areas this can create challenges to service provision and departure from this norm may be acceptable to both commissioners and service users. The place where women give birth is one part of overall maternity services, most of which can be provided locally (e.g. antenatal clinics, breast feeding support services). These services may not necessarily be co-located with the birthing unit.
6. The advisory group noted that there is still much work to be done in the area of risk assessment and identification of women who may develop complications. Better processes will help clearer risk stratification and enable better informed maternal choice with the expectation of that will increase the proportion of births not requiring medical assistance.
7. Large obstetric units (e.g. > 8000 births) can be advantageous in creating a large obstetric workforce but can cause organisational problems. They may be perceived as impersonal to women and their families. There is anecdotal evidence that the midwifery workforce is less happy working within large centres.
8. FMUs are often very small. Most support less than 400 births year. They are unlikely to be cost-effective unless other services are offered on the same premises (e.g. antenatal care and/or the midwifery team has flexible working patterns). Some FMUs can be supported by teams of community based midwives who provide antenatal and postnatal care and are then on call for any births within the unit.
9. Obstetric units should always be co-located with neonatal units capable of resuscitating the flat or blue baby. Whilst the skills of midwives and others continue to be developed, the availability of advanced care neonatal nurse practitioners (ANNPs) remains limited and as yet the sustainability of units relying on ANNPs has not been widely tested in England. Hence most obstetric units will continue to depend on paediatricians (and dedicated neonatologists) for resuscitation and stabilisation of babies, for the foreseeable future. Higher level neonatal units (level 2 and 3) will continue to be designated by the regional neonatal network and are not further discussed here. The NCAT strongly supports the development of ANNPs, this should be a priority for the Workforce Intelligence Unit and should address the problem of backup requirements (medical cover).
10. The NCAT acknowledges the workforce pressures addressed in the RCPCH report (Facing the Future). There will be a continuing need to rationalise paediatric inpatient services to maximise the effectiveness of the available paediatric medical workforce and provide better access to paediatric subspecialty services. The NCAT supports this direction of travel as it will improve the overall quality of care by improving access to senior opinion and creating robust trainee rotas. Wherever possible, children’s services should continue to be provided locally, but this will mean considering other service models. Paediatric assessment units (with or without observation beds) can provide an effective service. Standards for PAUs have been agreed (see Facing the Future – RCPCH). The withdrawal of continuous inpatient paediatric care from a hospital will often mean the loss of on-site 24/7 paediatric medical cover and this can cause problems for smaller hospitals that have obstetric units (and neonatal units). A number of solutions have emerged to this problem (other than moving the obstetric provision) – these may challenge the affordability, sustainability and quality of the service (e.g. overnight on site consultant paediatricians, advanced resuscitation skills for nurses and midwives) and need careful analysis.
11. Commissioners should recognise that if maternity services reconfigure staff may require education and training which supports them to work confidently in the new model. This may be particularly true in areas developing homebirth services or FMUs. It is also important that training in dealing with emergency situations is tailored appropriately to the setting in which the situation will occur.
12. It is very important that, where a range of homebirth, FMU, AMU and obstetric services are provided, the commissioner assure themselves that governance, communication and team working especially in relation to referrals and transfers is of high quality and ensures safe and effective care. Wherever possible training should be multidisciplinary. It will be particularly important that commissioners consider these issues if purchasing maternity and neonatal services from a range of providers. Local maternity and children’s services networks are one way to achieve effective liaison between services and consider clinical outcome objectives.

Summary

The NCAT’s intention is not to prescribe or proscribe different service models but to encourage creative solutions to tricky issues which may be driven by the need to create a sustainable, affordable workforce which is appropriately located and deployed to meet the needs of the local population. The principle remains that of putting patients at the centre of everything, localising services where possible but centralising when necessary. Effective early engagement with patients and the public is the single most important factor for successful reconfiguration. One of the intentions of this briefing note is to highlight some of the more contentious areas and to suggest possible solutions that will need to be openly discussed with the public.