The update on maternity and neonatal services was
provided by Rachel Lissauer, Senior Responsible Officer, Chris
Caldwell, Chief Nurse for NCL ICB and Executive Lead for Maternity
& Neonatal services, David Connor, Group Director of Midwifery
at the Royal Free NHS Trust and Co-Chair of the Local Maternity
System, Sumayyah Bilal, Head of
Maternity Services & Commissioning for NCL, Nicole Callender, Associate Director for Midwifery at
NMUH, Barbara Kuypers, interim
Divisional Director of Midwifery and Nursing at NMUH, Dhruv Rastogi,
Divisional Clinical Director & Consultant Paediatrician at
NMUH, and Isabelle Cornet, Director of Midwifery at Whittington
Health NHS Trust.
Rachel Lissauer began by explaining that, while
accountability for services remained with the NHS Trusts, the Local
Maternity and Neonatal Service (LMNS) within the NCL ICB had a role
in considering elements such as safety, using data and insights,
ensuring a supportive infrastructure for services, using the voices
of pregnant women to inform how maternity services were run and
equality of outcome and access. The Service worked alongside the
Start Well programme which was looking at structural issues in the
Case for Change. The role of the LMNS had really changed over the
past 3-4 years with stronger role and closer working with
Head/Directors of Midwifery, including on staffing, recruitment,
training and demand pressures.
David Connor said that the Care Quality Commission
(CQC) had been revisiting Trusts across the sector as part of its
national response to the Ockenden
report. The CQC’s report on the Whittington NHS Trust had
been published while the North Middlesex University Hospital (NMUH)
and University College London Hospitals NHS Trust (UCLH) had been
inspected and the reports were currently being awaited. An
inspection of the Royal Free Trust was expected soon. Through the
LMNS Board, the action plans from inspections were monitored with
feedback and learning shared across the system.
Asked by Cllr Connor whether there were any
particular areas of concern as part of this process, David Connor
said that triage assessments were an area where improvements could
be made and that this was a common issue nationally so best
practice models were being looked at.
Sumayyah
Bilal provided an overview of the Women’s CQC
Survey, which was a national survey that covered all aspects of the
maternity journey and was conducted annually. The responses
received in NCL were not representative of the diversity of survey
users and so further work was planned on reaching those community
voices with a recently recruited independent senior advocate, as
recommended by the Ockenden report.
Area for improvement across NCL including monitoring of mental
health in pre and post-natal periods, infant feeding support and
the ability of partners to visit in hospital (where there had
previously been some restrictions due to Covid).
Sumayyah
Bilal also explained that all NCL Trusts were asked
to provide assurances to the LMNS Board of how they were
implementing the recommendations of the Ockenden report. Ockenden assurance visits were also carried out
with all NCL Trusts in 2022 and the feedback was mostly positive.
An area that required improvement was collaboration/co-production
with Maternity Voices Partnership (MVP). She added that the
Ockenden and East Kent reports had
resulted in additional funding being provided for safety. NHS
England had recently published a 3-year delivery plan for maternity
and neonatal services which had consolidated the overlapping
recommendations into four key themes.
Sumayyah
Bilal said that the Ockenden report had included a focus on workforce
and there had been work on recruitment and retention in NCL,
including an expansion of student placements, international
recruitment and all Trusts signing up to a pan-London consortium
providing recruitment and retention advice. The main priorities in
NCL were to work on a recruitment strategy, focus on why staff were
leaving, exploring staff wellbeing and development and linking this
to EDI (Equality, Diversity and Inclusion) initiatives and flexible
working and how staff can escalate concerns. There was a particular
challenge around the cost of living for staff in London.
The NHS officers then responded to questions from
the Committee:
- Asked by Cllr
Connor about the most significant challenge in the points she had
mentioned, Sumayyah Bilal said that
they complemented each as the workforce was needed to enable
service improvement so the workforce needed to be
supported.
- Asked by Cllr
White for further explanation of the key finding from the
Ockenden report that found “lack
of compassion and kindness by staff”, David Connor said that
the recent CQC report on the Whittington, complaints themes and
feedback from the Maternity Voices Partnership had not identified
lack of compassion as an issue locally and that he found the staff
to be a caring motivated workforce.
- Cllr White
expressed concerns about levels of understaffing and low pay for
some staff. David Connor responded that making sure that staff had
the resources required to do their jobs was something that they
were striving for and that there had been a reduction in the
vacancy rate across the system over the past year. The recruitment
and retention work had been key in ensuring that staff were
developed and looked after, but he acknowledged that the current
cost of living was a real concern. Sumayyah Bilal added that a working group,
including patient experience leads, was being established to
address the recurrent themes emerging from the Women’s CQC
Survey.
- Asked by Cllr
Connor about national workforce policy, Chris Cordwell said that a long-term Workforce Plan was
due to be published shortly and was expected to say that a lot more
midwives and nurses were required. However, it was not yet known
known how this would be achieved (e.g. more training or more
international recruitment) or what funding would be provided to
support this. Sumayyah Bilal added that
there was currently some ongoing work to upskill Maternity Support
Workers.
- Cllr White
noted that rates of stillbirths were higher in Haringey, as
highlighted on page 38 of the agenda pack, and that this coincided
with higher levels of deprivation. He also referred to inequalities
of outcomes relating to ethnicity. Rachel Lissauer said that there
was a strong evidence base on continuity of care. She acknowledged
that the findings for Haringey were concerning and that, while
stillbirths were higher in the east of the Borough (where
deprivation levels were higher), the issue was not exclusive to the
east of the Borough. She added that the report on this was expected
to be available in September/October 2023 and could be shared with
the Committee. (ACTION) Sumayyah
Bilal added that a working group on continuity of care had been set
up and was focusing on personalisation, deprivation and ethnicity
issues. The Trusts were aiming to improve continuity of care
through teams of midwives providing end-to-end care but there were
some workforce challenges associated with this. Nicole Callender highlighted the role of the Magnolia
Midwives service which provided multi-disciplinary support for
pregnant women with mental health issues and that continuity of
care through this model had better outcomes, so this model was
being rolled out to other community teams. Isabelle Cornet said
that the Whittington Hospital had one continuity of care team,
reduced from two teams, based on the workforce recommendations from
the Ockenden report. The active team
was based in the deprived areas of Islington and the team that was
no longer in place had been based in Haringey. Other community
teams were working on a continuity of care model for ante-natal and
post-natal care (excluding labour care), including a team for
higher-risk women.
- Cllr Milne
queried the extent of problems associated with those not engaging
with ante-natal care. David Connor said that it was rare for women
not to receive any antenatal care whatsoever and that access to
care was good, including through self-referral. Chris Cordwell commented that, based on the initial
findings of the report (referred to in the above paragraph), the
range of factors were quite varied and often related to a
person’s background, understanding of health seeking
behaviours, housing and education.
- Cllr Clarke
referred to evidence linking smoking to stillbirths. David Connor
said that the Saving Babies’ Lives national care bundle
covered smoking cessation in pregnancy, including through carbon
monoxide testing and signposting to support. In NCL, consideration
was being given to bringing smoking cessation advisers into
maternity units rather than having to refer people to a separate
appointment. Sumayyah Bilal added that
there were KPIs on smoking cessation and a focus on opting out of
smoking cessation services rather than opting in.
- Cllr Clarke
asked whether current staffing issues were impacting on the ability
of women to have home births. Isabelle Cornet explained that the
Whittington’s home birth service was still running but the
shortage of staff meant that this service was covered around 80% of
the time and this was currently being reviewed. She added that the
Birth Centre had recently been completely refurbished with five
rooms and that around 25% of births over the last couple of months
had taken place at the Birth Centre.
- Noting that
CQC reports were expected for the other NHS Trusts soon, Cllr
Connor referred to page 45 of the agenda pack which included a
summary of previous inspections and asked how the “requires
improvement” sections were being addressed.
o
Royal Free - David Connor explained that, following
an inspection of maternity services at the Royal Free Hospital in
2020, the CQC had rated the service as “inadequate” and
it entered the national maternity safety programme as a consequence
of this. It had successfully exited the programme last summer and
it was recognised that work had been carried out to address
identified issues and the rating of the service was now
“requires improvement”. The Trust Board and the LMNS
continued to monitor progress. He added that the last Ockenden peer visit, in October 2022, had been
complementary about the robustness of the governance processes,
focus on safety culture and good relationship with the
MVP.
o
NMUH - Nicole Callender
explained that the last CQC inspection had been in 2021 and that
there had been no “must dos” flagged in terms of safety
but there had been some “should dos” which had since
been implemented. Actions had been taken on staff
development/wellbeing/training and also on interpretation and
translation given the high number of different languages spoken in
the local area. Dhruv Rastogi commented that, because of the delay
between the CQC inspection and the report, it was important for the
Trusts to triangulate on the key current issues which had included
triage. He added that the recent Ockenden visit had been complementary.
- Asked by Cllr
James why Barnet Hospital had not had a recent inspection, David
Connor explained that, although Barnet Hospital had last been
assessed in 2016, elements of the maternity services were
cross-site with the Royal Free as part of the same Trust and
governance processes which had been assessed more
recently.
- Cllr Clarke
highlighted the upcoming cuts of 30% to the NCL ICB budget and said
that, while the Committee had been told that this would not impact
on services, this change needed to be carefully monitored. Chris
Cordwell commented that the cost
savings were linked to national requirements and did not relate to
the money spent on services. However, she acknowledged that there
were financial challenges across the system overall.
- Asked by Cllr
James for further explanation about the reasons for the significant
inflow from non-NCL residents to Barnet Hospital and UCLH,
Sumayyah Bilal explained that this was
not unexpected because women had the right to book antenatal and
labour care in any hospital of their choosing while post-natal care
was provided in the closest hospital to their place of
residence.
Cllr Connor summarised the main concerns of the
Committee, where further information would be welcome in a future
report (ACTION), as:
- poorer
outcomes for those from more deprived areas or from BAME
backgrounds, including greater understanding of causes and risk
factors;
- continuity of
care, including progress of the Magnolia team;
- workforce
issues, including cost of living/housing issues and improving
support for staff overall;
- training for
staff, including the development of the maternity support workers
role.
- the findings
of future CQC reports in the areas which are currently rating as
requiring improvement;
- monitoring
the statistics on smoking cessation;
- cuts to the
running costs of the NCL ICB;