Enhancing safety in women’s healthcare: does the NSF for Children, Young

People and Maternity Services offer new opportunities?

Heather Mellows FRCOGConsultant Obstetrician and Gynaecologist Doncaster and Bassetlaw Hospitals NHS

Foundation Trust

ENTER Conference, Manchester

28 April 2005

Enhancing Safety

Safe Maternity Services

WomenStaff

BabiesCommissioners

Maternity Services – enhancing safety

Best possible outcomes for mother, baby and family

Best possible, high quality Maternity Services for all

Number of CNST Claims by Specialty

0500

1,0001,5002,0002,5003,0003,5004,000

Specialty

Cerebral Palsy

• Birth related brain damage accounted for 5% of cases and 60% of expenditure 02/03

• Between 3 and 20% of cerebral palsy may be related to birth asphyxia

• “most cerebral palsy is not due to birth asphyxia”

Dr Karen Nelson – quoted in Making Amends, DH June 2003

Cerebral Palsy –cause not clear-cut

• Infection, Jaundice, Rh blood group incompatibility, birth asphyxia

• Risk factors:– Low birthweight– Premature birth– SGA– Multiple birth– Poverty/deprivation

Making Amends, DH, June 2003

Claims - Obstetrics• cerebral palsy

• brachial plexus injury

(see NHSLA Journal Summer 2003)

• perineal injury

• failure of pre-natal diagnosis

• anaesthetic awareness

• retained swab

An organisation with a memory –Report of an expert group on learning from

adverse events in the NHS: DH, 2000

• By 2005, reduce by 25% the number of instances of negligence in O & G which result in litigation

What “Old Opportunities”?• CEMDBegan in 1951 and aims to assess main causes of,

and trends in, maternal deaths; to identify avoidable or substandard factors; to recommend improvements (including audit) to health commissioners and professionals, and to suggest directions for future research and audit locally and nationally.

A First Class Service – quality in the new NHS DH Sept 1998 page 20

An organisation with a memory –Report of an expert group on learning from

adverse events in the NHS: DH, 2000

“The CEMD has helped to bring about dramatic improvements in the safety of some aspects of maternity care, but an audit of specific recommendations reveals that there are still areas in which key findings have not been universally acted upon.”

Page 68

CEMD

“A recurring theme of CEMD reports has been the dangers of inadequate senior supervision and problems with delegation. A report in 1995 concluded that both were still factors in a number of maternal deaths.”

A First Class Service – quality in the new NHS DH Sept 1998 page 20

Standards for service

“Towards Safer Childbirth – Minimum Standards for the Organisation of Labour Wards” RCOG and RCM: Feb 1999

• Organisation

• Staffing levels and roles

• Training , Accreditation and CME

• Facilities and equipment

CNST Standards

• “During the working week, there should be 40 hours of dedicated specialist medical cover on labour ward, by a consultant or equivalent….”

Where do we start?

• Do you know what an NSF is meant to do?

• Did you know that the “Children’s NSF” included Maternity Services?

• Has your Trust/PCT done anything yet towards implementation?

What are National Service Frameworks (NSFs)?

• Government Policy• Designed to help people get fair access to high

quality care wherever they live• Set national standards and define service models• Driven by implementation plans and measures to

assess progress• Monitored by Healthcare Commission

A First Class Service, Quality in the NHS Sept 98

The Children’s NSF Prompted by Kennedy and Laming

• Personalised service for children

• Earlier diagnosis and intervention

• Integration of health, social care and education

• To engineer a cultural change in the way children are dealt with

NSF for Children,Young People and Maternity Services

Standard 11:

“Women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies”

Changing Childbirth – 1993Indicators of success

• Hand-held notes• Named midwife• 30% midwifery led care• 75% know the midwife who delivers them• 30% deliver under care of a midwife• Ambulances have paramedics• All women have access to information about local

services

Changing Childbirth

“There are factors beyond the scope of the maternity services, such as low incomes, poor housing and inadequate nutrition….restricting access to services and increasing risks to her and her baby”

The National Service Framework for Children, Young People and

Maternity Services

A holistic approach

• Recognition that healthy mothers have healthy babies that grow into healthy children and have an impact on the future Health of the Nation

The Children’s National Service Framework

is a 10 year strategy to improve the lives and health of children

The provision of the infrastructure and use of resources to enable best practice through use of evidence based clinical guidelines

Maternity EWG members• Co-chairs

– Heather Mellows (RCOG) & Meryl Thomas (RCM)

• User reps– Mary Newburn (NCT)– Sue Eardley (MSLC and

Trust)– Lady Sarah Riddell

• Midwives– Jean Duerden (LSA)– Dame Lorna Muirhead

(RCM)– Lynne Leyshon (HoM)– Yana Richens (RCN –

inequalities)

• Obstetricians

– Prof. Bill Dunlop

– Prof. James Neilson

• GP – Dr David Jewell

• Anaesthetist – Griselda Cooper

• Paediatrician – Prof. Sunil Sinha

• Psychiatrist – Margaret Oates

• Public Health – Jean Chapple

• Researchers – Jane Sandall

– Jo Garcia

• PCT – Toni Horn

Maternity EWG

Holistic approach to maternity services:

• Pre-birth

• Birth

• Post-birth

• Inequalities

• User involvement

Why Mothers Die

Social disadvantage

Single mothers

Ethnic (other than white)

Black African

Poor communities

Risk of dying:

x 20

x 3

x 3

x 7

45% higher death rate

Inclusive Maternity Services

• Multiple social problems

• Homeless• Travelling people• Asylum seekers• Refugees• In prison

• Disabilities• Teenage parents• Involvement of fathers• HIV/AIDS• Drug abuse• Alcohol abuse• Domestic violence

Maternity Services – the context• NICE Clinical Guidelines

- Antenatal Care

- Caesarean Section

- (Intrapartum Care)

- (Post natal Care)

• National Screening Committee

recommendations

Maternity Module - Standard: All women should have an

individualised AN care programme…

Rationale: Women presenting late or poor attenders generally have poorer health outcomes

Evidence: 25% of maternal deaths occurred in women who were poor AN attenders

Possible Interventions: Accessible and acceptable provision of care, prepregnancy information and education

Maternity Standards

• Service provision – infrastructure, choice

• Clinical care provision – access, normality

• Information – women, families and carers

• Communication – women and all agencies

• Quality - care, carer and environment

• Training and education – carers and women

• Data collection, audit, research - planning

Establishing Standards: service provision

NHS Maternity care providers and PCTs ensure that:

• the range of ...care services available locally constitutes real choice…

• local options for midwifery care will include MLUs in the community or on a hospital site

page 28

Standards: clinical care provision

All NHS maternity care providers, PCTs and Local Authorities ensure that:

• Preconception services are available page 16

• Every woman .. has access to EPAU page 26

• Staffing levels .. on delivery suites comply with CNST standards page 28

• Consultant-led services have adequate facilities…including transfer to ITU page 30

CEMD recommendations

• Further long-standing recommendations concern the availability of on-site blood banks and Intensive Care Units. In 1994, 21% of units in England still had no on-site ITU and 12% had no on-site blood bank.

An organisation with a memory, DH 2000

Page 69

Standards: information

Maternity service providers should ensure that all pregnant women are offered clear information on:

• the full range of screening tests page 8

• what becoming a parent might be like page 17

• healthy life style page 17

• assistance with choice including risks and benefits page 19

Standards: quality of care

• Evidence based care - NICE guidelinesAll maternity care providers and PCTs ensure

that (there is):• Learning from mistakes: critical incident

reporting• Participation in CEMACH• Research

pages 40-41

Standards: training

• Multi-agency health promotion page 14

• Competence to assist in choice page 19

• Need for specialist services page 20

• Skills to support pain relief page 28

• On-site training for emergencies page 30

• Neonatal resuscitation page 36

The Concepts of Care

• Managed Maternity and Neonatal care networks

• Individualised Care Pathways

“[a woman will] understand exactly how to access additional services should the need arise.”

Managed Maternity and Neonatal Care Networks

“These are linked groups of health professionals and organisations from primary, secondary and tertiary care, and social services and other services, working together in a co-ordinated manner, to ensure an equitable provision of high quality, clinically effective care”

para 4.3

woman

Voluntary care

Social services

Perinatalpsychiatry

Secondary care

Tertiary maternaland neonatal care

Midwifery care

Woman andfamily

National Action for Implementation

• Developing managed networks

• Developing tools for use locally

• Untangling workforce issues

• Facilitating strategies for service redesign

• Prioritising National data collection plans

• Enabling on-going research to fill the gaps

The Children’s NSF-the challenge

• No targets

• No (direct) funding

• In ten years for NHS Trusts and local authorities must bring in standards

• Progress monitoring by the Healthcare Commission

• And star ratings may be affected

What can we do to enhance safety?

• What is missing from our service?

• What could we develop?

• What standards do we not meet?

• Which areas are most important for our women and families?

• How can we persuade the PCT to invest in maternity as a priority?

Implementation – bite-sized chunks

Plan change

Implement and audit

Assess local needs

Assess local services

NSF for Children,Young People and Maternity Services

Standard 11:

“Women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies”

Enhancing safety in women’s healthcare: does the NSF for Children, Young

People and Maternity Services offer new opportunities?

Yes, I think so, do you?