Agenda item

For the Committee to receive an overview of maternity and neonatal services in NCL including Ockenden Review assurance/compliance and the role of the Local Maternity Services Network.

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;