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1 LMS plan v18
Local Maternity System Board Plan
Fay Baillie on behalf of the Herefordshire & Worcestershire LMS Board
September 2017
2 LMS plan v18
Executive Summary
“The birth of a child should be a wonderful, life changing time for a mother and her whole family. It is
a time of new beginnings, of fresh hopes and new dreams, of change and opportunity; it is a time
when the experiences we have can shape our lives and those of our babies and families forever. These
moments are so precious, and so important. It is the privilege of the NHS and healthcare professions
to care for women, babies and their families at these formative times”. (5 year Forward Review for
Maternity Services – Better Births. 2016.
To deliver this vision Baroness Cumberledge set out an ambitious new model of commissioning – The Local Maternity System (LMS). At the same time the Secretary of State asked for a 20% reduction in Stillbirths, neonatal death, Maternal Death and neonatal Brain Injury by 2020 and a 50% reduction in the same by 2030, this is based on 2010 data. Local Maternity Systems will also implement the recommendations from the Marmot Review (2010)
and the Annual Report of the Chief Medical Officer, Our Children Deserve Better: Prevention Pays
(2012) which states that the health and nutrition of expectant mothers is critical to the physical,
emotional and intellectual wellbeing of their unborn babies, both pre and post birth. Herefordshire &
Worcestershire providers will ensure that midwives and the broader workforce involved in supporting
women and their families play a crucial role in enabling every child to have the very best start in life
and in reducing health inequalities across the life course.
The LMS has been established on the Sustainability and Transformation Partnership (STP) local population footprint of Herefordshire and Worcestershire. The purpose of the LMS is to deliver this vision and provide place-based planning and leadership for transforming the way maternity care is delivered to women and new-borns. The plan will develop how the Local Maternity System in Herefordshire & Worcestershire delivers the following by the end of 2020/21:
Improving choice and personalisation of maternity services so that: o All pregnant women have a personalised care plan. o All women are able to make choices about their maternity care during
pregnancy, birth and post-natally. o Most women receive continuity of the person caring for them during
pregnancy, birth and post-natally. o More women are able to give birth in midwifery led settings (at home and in
midwifery units).
Improving the safety of maternity care so that by 2020/21 all services: o Have reduced rates of stillbirth, neonatal death, maternal death and neonatal
brain injury during birth by 20% by 2020 and 50% reduction by 2030. o Are investigating and learning from incidents and sharing this learning through
their Local Maternity System and with others. o Fully engaged in the development and implementation of the NHS
Improvement Maternity and Neonatal Health Safety Collaborative.
3 LMS plan v18
Vision for the Worcestershire & Herefordshire Local Maternity System
Our vision is that our citizens have access to high quality, safe and sustainable,
acute, Women and new-born/neonatal and mental health services localised
where possible and centralised where necessary.
Our Vision
The removal of traditional county boundaries with sharing of community and hospital based
resources across a wider area. This is not expected to result in a change to the provision of
obstetric services in Herefordshire.
A joint maternity care offer with common clinical pathways that guide women to the most
clinically appropriate place of birth.
Review maternity specifications to reflect the requirements of a local maternity system.
Our Values
We commit to:
Listening to women & families
Achieving personalised care
Learning together
To be better than the national average
Working together to sustain viability
Our LMS partner Organisations
Worcestershire Acute Hospitals NHS Trust
Wye Valley NHS Trust
Worcestershire Health & Care NHS Trust
West Midlands Ambulance Service
Public Health England
Worcestershire Clinical Commissioning Groups
Herefordshire Clinical Commissioning Group
NHS England
Health Education England
NHSE Specialised Commissioning
University of Worcester
Healthwatch Herefordshire
Healthwatch Worcestershire
Worcestershire County Council
Herefordshire Council
Maternity Voices Partnership
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Background to the Herefordshire & Worcestershire Local
Maternity System
Locality Data
Herefordshire and Worcestershire is one of the largest counties with one of the smallest populations.
It has the M5 running through the centre of Worcestershire and the M50 running from the M5 to
South Wales through Herefordshire. There is a good road infrastructure across the county but very
poor public transport services, e.g. there is no direct bus or train line from Redditch to Worcester. This
means the population of Redditch have to travel to Birmingham or Bromsgrove to access hospital
services at Worcester when using public transport. Many of the villages around Evesham, Malvern,
Ledbury, and Bromyard do not have a daily bus service. By way of example the distance between
Hereford County Hospital and Worcestershire Royal Hospital is more than 30 miles and typically takes
more than an hour to drive on single carriageway roads
The population of Herefordshire & Worcestershire is approximately 785,000. The population is 97% white with 2% Polish & Eastern European, 0.5 % Asian & Afro-Caribbean. The population is centred around two main cities, Worcester and Hereford, with many young people moving for work to Birmingham, Gloucester and Bristol. There is a good train network between Worcester and Hereford.
There is a large rural population which means that there are migrant and casual labourers as well as an extensive Gypsy, Romany traveller communities around Evesham and Hereford. There is also a high incidence of teenage pregnancy predominantly in Worcester City Centre.
Herefordshire
Council
Herefordshire CCG
Wye Valley NHS Trust
2gether NHS Foundation Trust
Taurus GP Federation
Worcestershire County Council
Redditch and Bromsgrove CCG
South Worcestershire CCG
Wyre Forest CCG
Worcestershire Acute Hospitals
NHS Trust
Worcestershire Health and Care
NHS Trust
4 Primary Care Collaborations
5 LMS plan v18
Public Health Data -
The following public health data, which determines and influences Fetal and Maternal Wellbeing, has
been derived from the Local Authorities. The following analysis, comparison and trends between
Worcestershire and Herefordshire have been used to establish the LMS priorities and objectives.
Below are the vital elements of data used to base the LMS plan upon. To view the full data sets, please
see appendix.
1. Smoking in Pregnancy
Definition: Percentage of women who smoke at time of delivery
1.1 Herefordshire and Worcestershire in context
2. Maternal Obesity
Definition: Percentage of women who are classified as Obese at booking appointment (where valid
height and weight recorded). This data is collected via the national Maternity Services Minimum
Dataset and reported monthly by Provider.
2.1Herefordshire and Worcestershire in context
The following graph shows the official reported percentage of women classified as obese by month
by Provider for the latest period (April 2016 – February 2017).
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Percentage of Women classified as Obese at Booking 2016/17
Worcestershire Acute looks to have almost consistently higher percentages than Wye Valley, however,
care should be taken when interpreting these official statistics, as included in the denominator is those
women with 'missing values'. This is a particular problem with Wye Valley who consistently reported
between 15% -20% unknown values compared with just 3% of Worcestershire Acute. If we exclude
the 'missing values' from the denominator the overall percentage of obese women for the 11 month
period is 23.5% in Wye Valley compared with 22% for Worcestershire Acute and 20% in England.
BMI Band
Wye Valley Worcestershire Acute
Number of women seen at booking % of total % with band
Number of women seen at booking % of total % with band
Underweight * suppressed because of small numbers 135 2.5% 2.6%
Normal 745 41.6% 50.7% 2525 47.2% 48.4%
Overweight 380 21.2% 25.9% 1410 26.3% 27.0%
Obese 345 19.3% 23.5% 1145 21.4% 22.0%
Missing Value 320 17.9% 140 2.6%
Total 1790 5355
Total (BMI band) 1470 5215
3. Premature Birth Rate Definition: Number of premature births (live or still) defined as gestational age less than 37 weeks per 1000 births (live and still)
0
5
10
15
20
25
30
Wye Valley
Worcestershire Acute
7 LMS plan v18
3.1 Herefordshire and Worcestershire in context
Worcestershire has a statistically significantly higher rate than England, however, Herefordshire consistently has an average rate.
4. Caesarean Section %
Definition: Total number of deliveries with OPCS Procedure codes R17 or R18 as a percentage of the total deliveries
4.1 Herefordshire and Worcestershire in context
Caesarean section % 2015/26 Percentage point - %
The official figures above indicate that both Herefordshire and Worcestershire are statistically significantly higher than the England average.
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5. Breastfeeding Definition: Percentage of women who initiate breastfeeding within 48 hours of delivery
5.1 Herefordshire and Worcestershire in context
Both Herefordshire and Worcestershire are statistically significantly worse than England for breastfeeding initiation.
6. Stillbirth Rate
6.1 Definition: Number of stillbirths (fetal deaths occurring after 24 weeks of gestation) per 1000 births (live and still)
Herefordshire and Worcestershire in context
Herefordshire had a higher stillbirth rate than England in the three year period 2013-2015 although this is not statistically significant. Worcestershire was average.
9 LMS plan v18
7 Perinatal Mortality Rate
Definition: Number of stillbirths and deaths of infants aged under 7 days per 1000 births (live and still)
7.1 Herefordshire and Worcestershire in context
Both Herefordshire and Worcestershire have higher PMRs than England, however, these are not statistically significant.
Perinatal Mortality (2013-15)
Area ValueLower
CI
Upper
CI
England 6.6 6.5 6.7
West Midlands region 8.2 7.8 8.6
Birmingham 10.6 9.8 11.6
Coventry 6.6 5.4 8.1
Dudley 6.7 5.4 8.4
Herefordshire 7.7 5.7 10.4
Sandwell 9.6 8.1 11.3
Shropshire 6.0 4.6 7.9
Solihull 8.1 6.2 10.5
Staffordshire 6.7 5.8 7.8
Stoke-on-Trent 8.9 7.3 10.9
Telford and Wrekin 8.0 6.1 10.6
Walsall 8.3 6.8 10.2
Warwickshire 6.0 4.9 7.2
Wolverhampton 8.5 6.9 10.4
Worcestershire 7.3 6.2 8.7
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8 Neonatal Mortality Rate
Definition: Deaths of infants aged <28 days per 1000 live births.
8.1 Herefordshire and Worcestershire in context
9 Maternal death There have been two maternal deaths in Worcestershire and none in Herefordshire in the past 5 years.
Neonatal Mortality (2013-15)
Area ValueLower
CI
Upper
CI
England 2.7 2.6 2.8
West Midlands region 4.2 3.9 4.5
Birmingham 5.6 5.0 6.3
Coventry 2.4 1.7 3.4
Dudley 3.5 2.5 4.7
Herefordshire 2.8 1.7 4.7
Sandwell 4.4 3.4 5.6
Shropshire 2.2 1.4 3.5
Solihull 4.1 2.9 6.0
Staffordshire 3.4 2.8 4.2
Stoke-on-Trent 5.8 4.5 7.4
Telford and Wrekin 4.8 3.3 6.8
Walsall 5.2 4.0 6.7
Warwickshire 3.4 2.6 4.3
Wolverhampton 4.0 2.9 5.4
Worcestershire 3.5 2.7 4.5
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Joint Strategic Needs Assessment
The Future of Worcestershire Acute Hospital Services is a commissioning strategic vision for services in
Worcestershire and has recently been agreed for implementation. In Herefordshire at the time of
writing there is no clinical strategic document published by the CCG. Wye Valley NHS Trust is currently
being managed by South Warwickshire NHS Foundation Trust through a management agreement set
up by NHS England.
The strategic intention for the LMS is to continue to have two obstetric based services, one in Wye
Valley Acute Hospital Trust and one in Worcestershire Acute Hospital Trust. The LMS will remove the
geographical boundaries to support women accessing the right care in the right unit.
The need for access to midwife led care has been debated widely this choice for women has been
accommodated in the Worcestershire Acute Hospital unit and midwife led care could be established in
Wye Valley by remodelling internal pathways.
There are currently a decreasing number of doctors in training in Obstetrics and Gynaecology and
Paediatrics, leading to maternity and neonatal units across the country developing new ways of
working to sustain local services for women and families.
There are inconsistencies across the two counties in how maternity and neonatal services are
commissioned and delivered, for example, there is no perinatal mental health Service and no
maternity specification in Herefordshire.
Associated Strategic Needs Assessments
There are no perinatal mental health services within Herefordshire and this need to be developed to
offer women access to services. This could be through the Worcestershire Health & Care Trust or
through 2gether NHS Foundation Trust.
Neonatal care has been reviewed by specialist commissioning and a strategic vision has been
published (2016) which outlines how the neonatal networks plan to maximise cot occupancy and keep
mothers and babies together, as close to home as possible, whilst being in a place which maximises
outcomes for both. Implications for this document for Herefordshire and Worcestershire are minimal
because Wye Valley NHS Trust offers transitional care and level 1 cots and Worcestershire Acute
Hospitals offers level 2, 1 and transitional care.
Better Birth sets out care as close to home as possible, being delivered through HUBS. The LMS has
identified geographical bases to offer this but believe the economies of scale and opportunity to link
other services for families would be a strategically stronger opportunity for the STP programs of care
being developed.
12 LMS plan v18
Service Provision
Worcestershire service provision
Currently at Worcestershire Acute Hospital Trust women are offered Obstetric Consultant Led care, as
alongside birthing unit and Home Confinement. The service offers level 2 Neonatal intensive care,
high dependency, special care, transitional care and outreach Care.
Community Midwifery services are geographically split over 4 areas, being based in Worcester City,
Kidderminster, Bromsgrove & Redditch and Evesham. The unit supports a population of 6000 women
and delivers approximately 5650 per annum. The difference in the population deliver in Gloucester,
Warwick and Birmingham.
Herefordshire service provision
In Wye Valley NHS Trust there is a Consultant Led and a Home Confinement service. Midwife led care
is offered however there is no defined separate midwife led delivery area. There are level 1 special
care unit cots. The unit supports approximately 2000 women across the county, delivering 1700
women per annum. The population gap delivers in Shropshire, Gloucester or Worcester. Wye Valley
support approximately 150 birthing women from across the Powys boarder per annum. These women
have a high home confinement rate as the distance to travel to the hospital can be over an hour.
Wales
13 LMS plan v18
Worcester Acute Hospital Trust
Wye Valley Acute Hospital Trust
Shared care with GP Shared care with GP
General obstetric/maternity services General obstetric/maternity services
Midwife Led Care Midwife Led Care
Consultant Fetal medicine
Cardiology ultrasound scanning
Amniocentesis
Joint care maternal cardiology clinics
Twin Services
Joint care Diabetes Pregnancy Service
Joint care Perinatal Mental Health Service
Consultant neonatal care levels 1 & 2 Neonatal level 1 care
Transitional Care
Outreach neonatal care
Antenatal screening Antenatal screening
General Maternity Ultrasound General Maternity Ultrasound
Home birthing Home birthing
Alongside midwife led unit
Bereavement services
Post-delivery counselling care
Breast feeding consultant care
Parent Education
14 LMS plan v18
Specialist service provision
Perinatal Mental Health: ‘The impact of mental health problems experienced by women in pregnancy and during the first year following the birth of their child can be devastating for both mother and baby, as well as their families. By 2020/21, NHS England should support at least 30,000 more women each year to access evidence-based specialist mental health care during the perinatal period. This should include access to psychological therapies and the right range of specialist community or inpatient care so that comprehensive, high-quality services are in place across England.’ “Key recent national strategies have also outlined perinatal mental health as a priority where improvements in access and outcomes for women and families are required. These include NHS England’s Five Year Forward View for Mental Health4 and the maternity review report Better Births, Improving Outcomes of Maternity Services in England5 Perinatal Mental Health in Worcestershire Current service provision: Worcestershire has a Community Perinatal Psychiatry Team that is a countywide service which is commissioned to provide a service to: Meet the needs of women with severe mental disorder in pregnancy and the post-natal period up to 12 months of the infants’ age, including those with bonding disorder. Screen for serious mental disorder during pregnancy and offer care to those considered of high risk. To provide a service for the family network. To ensure that safeguarding is a priority and paramount, the service ensures that older children and other dependants are supported appropriately; this is often done via other services such as early help, children and family social services and the health visitor. Develop joint working relationships to facilitate admissions to a mother and baby unit if necessary. The team provides an antenatal mental health screening clinic within the acute trust existing antenatal services. This safeguards an integrated care pathway to identify those at risk of a recurrence of serious mental disorder following delivery. The Community Perinatal Psychiatry Team will provide assessment, care and treatment for pregnant women and those with a baby up to 12 months of age. The team will work in conjunction with the Child Adolescent Mental Health Service for any female aged under 17 ½ years. Referrals to the team are accepted by all professionals and we encourage referrers to contact the team for specialist advice and support which includes prescribing in pregnancy and whilst breastfeeding. The team have extensive knowledge and skills to deliver a specialist perinatal care service. The team is an integrated service between Health and County Council and consists of qualified community psychiatric nurses, social worker, psychotherapist, Consultant Psychiatrist and a specialist staff grade Doctor. The delivery of care is holistic and collaborative across all services and professionals, promoting person centred care, maternal mental health and family support. This will include mother and infant bond, psycho- social and psycho- therapeutic interventions, treatment planning and extensive specialist assessments, medication and risk monitoring.
15 LMS plan v18
The model supports the Acute Trust midwifes who have a specialist interest in mental health, this promotes stronger working relationships which bridge the gap between maternity and mental health, incorporating the parity of esteem. This ensures that all women are receiving an equitable service provision countywide. A NHSE bid to enhance the current model to ensure that the team are fully NICE concordant has been submitted, this will allow the recruitment of a psychologist, OT and community nursery nursing support to cover the gaps against national guidance. The team are working towards national Royal College of Psychiatry accreditation and subsequently the achievement of a successful bid will enable achievement of accreditation. Perinatal mental health in Herefordshire Current service provision: Local statistics identify that just under 50% of women commence their pregnancies with varying levels of need with regard too emotional, depressive illness to chronic disorders that predisposes them during their pregnancy and post- delivery to increased illness and poorer outcomes for the babies. Currently Wye Valley NHS Trust do not have a robust system of support or help for vulnerable women. There are no commissioned counselling referral pathways and no mental health referral support mechanisms. A local bid for NHSE perinatal mental health development through the STP is being developed with "2Together ", the mental health provider in Gloucester. The Obstetrician and Midwives identify and monitor the mental health and emotional needs through careful assessment during planned and emergency contacts. Findings are recorded in the electronic patient record. There is no real referral pathway to Psychologist or Psychiatrist. Women with complex pre - existing factors often have a community psychiatric team support and treatment, however those with lower level vulnerability do not. When a woman becomes acutely ill a referral to the crisis team is made but can only happen if the woman is an inpatient. Where there are low level anxieties – support with CPN and GP/medication, personalised management plans are developed with woman for appropriate support. Should a women require a referral to a Consultant psychiatrist this is made by the Consultant Obstetrician or general practitioner. Specialist commissioning of Neonatal services; Specialist commissioning have completed a review of neonatal services nationally. An interim report has identified the opportunity to increase cot occupancy at WAHT and use the level 1 cots better at Wye Valley. This objective supports the Herefordshire and Worcestershire LMS plan to identify babies at risk and offer the most appropriate place of birth. This change in pathway designed to ensure capacity is maintained so the hospital offering the right level of care required can be accessed and retaining all level 2 and 1 neonatal care within the counties .This will mean the level 3 units need to also move women to a level 2 unit, if that’s the right level of care, to create capacity. Worcester have been working with the network to review unintended admissions to the NNU and action plans were developed to correct practice last year as part of a CQUIN . This led to practice change in the giving of hypo stop, the wearing of red and green hats for the babies in post-natal and increased training and awareness of cold babies care and treatment. This year the CQUIN is centred on neonatal out- reach development and the potential for home photo therapy being developed.
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More work and improved joint working is required to enable returning babies to the unit close to home to improve families’ experiences and maintain cot capacity across the network.
Activity (total births including location of birth, neonatal activity by level and location of unit)
Baseline activity data 2016/17
Workforce
We have a stable workforce in our LMS, turnover for trained midwifery staff is less than 10% as staff
tend to move to Herefordshire and Worcestershire to live and don’t move. The age profile of
midwives is one where the most experienced midwives are in the over 55 age bracket. This will need
to be carefully managed as midwives can retire at 55 years. Flexible retirement and part time flexible
working are options for both units to retain staff. Research from Aston University, Lancashire
University and work based studies looking at the generational differences and attitudes from the baby
boomers to generation z needs to be carefully integrated in to our plan to ensure we have a work
force who is able to offer what women and families want from maternity services.
Delivering continuity and 1 to 1 care as an ambition in Better Births may not be what our work force
can offer.
In Neonatology there continues to be difficulties in achieving qualified in speciality nurses. This is due
to difficulties in releasing staff to complete the qualified in speciality course but fundamentally it is
difficult to attract nurses to work in the speciality. That means we need to think differently and offer
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Local Maternity System Baseline Data, 2016/17
Herefordshire %
Worcestershire %
National target
17 LMS plan v18
more creative roots into through transitional care, secondments to the transport team, or level 1 2 or
level 3 units or outreach.
Medical staffing, consultant numbers are achieving full establishment. There are different models in
both units with consultant’s resident on call in Wye Valley NHS Trust and a traditional on call system
for Worcestershire Acute Hospital. Both units have paediatric consultant rotas which cover
Neonatology.
The main problem for both units is one where the doctors in training grades are not consistently filled
by Health Education England leading to difficulty in planning and delivering activity. The risk
associated with this is an over reliance on locum or temporary staff which is linked to an increase in
recorded serious incidents and Caesarean Section. Workforce numbers for the different disciplines are
proved in the appendix document.
System engagement, Interdependencies and alignment with the STP
All provider organisations, commissioning organisations and the Local Authorities have ratified the
terms of reference and reporting lines of accountability through their executive team, Board or
governing body. Support organisations have been involved in the development of the Herefordshire
and Worcestershire LMS. Patient groups and patient advocates have been actively involved and
approved the development of the LMS and the proposed ways of working.
The LMS actively works with the West Midlands Clinical Senate, Southern Midlands Maternity and
Neonatal network, the Midlands and East Maternity Alliance and Local West Midlands maternity and
new-born alliance. The LMS is actively participating in research, through CLAHRC WM [the west
midlands collaborations for leadership in applied health research and care] Place of Birth.
The LMS is linked to the STP through the communications and the information technology work
streams. In STP workforce discussions, joint roles for obstetricians and gynaecologists and paediatrics
and neonatology are discussed in relation to the maintenance of level 2 networked care and training
of generalist to continue to support rural units. In the STP elective care and primary care work streams
fertility care and management plans are scheduled to be discussed following the commissioned
service specification being published.
Financial Case for Change
The financial case for change has been driven by the need for the population to have local maternity
services which are sustainable. The service leaders recognise that both Herefordshire and
Worcestershire need the skills and capital infrastructure to work together to be viable. It is also
recognised that there are huge manpower shortages predicted for midwifery, nursing allied health
professionals and medical staff which would become easier to manage if there were joint
interdependencies and collaboration.
Maternity services are financially supported through a tariff which is paid in 3 care bandings, standard,
intermediate and intensive for antenatal care, with comorbidities and complications and without
comorbidities and complications for intrapartum, plus, standard, intermediate and intensive for
postnatal care. This payment structure was first implemented approximately 8 years ago and has
18 LMS plan v18
become more and more problematic for maternity services to deliver commissioned specifications.
The Secretary of State accepted the service arguments and has in 20016 increased the tariff by 8%
from 2017 to support his ambition to reduce still birth, neonatal death, neonatal brain injury and
maternal death.
The STP Strategic Board for Herefordshire and Worcestershire agreed that the maternity and neonatal
vision could only be met if any savings created through the plan be reinvested in to the emerging
manpower plan.
It is also recognised that the Better Births vision emphasis the need for choice and care close to home
through local HUBs. These hubs will need capital to support the purchase of ultrasound machines,
information technology connection and wiring to support electronic patient data from laboratories,
electronic prescribing, PACs and electronic patient records integrated with tertiary level 3 units and
primary care.
Currently Herefordshire maternity services have an end to end electronic patient record for maternity
and neonatal services, Badger net. Worcestershire has paper records and an intrapartum electronic
record, K2, Neonatal services in Worcester has Badger net. To deliver the vision and dismantle the
boundaries Worcester must adopt a paperless system which integrates with Herefordshire and other
associated databases which enable local care delivery. The cost of this will be circa £450k capital and £
7.00 per birth revenue.
Capital charges for room rental are being levied for the community midwives delivering shared care in
primary care settings as a result of recent changes in how the district valuator has assessed room
usage in GPs surgeries despite the midwives delivering care on behalf of GPs to their patients in an
agreed and commissioned model.
Options will need to be explored with the Local authorities and the community providers to see if the
hub model can be jointly accommodated with other specialities in the STP foot print to reduce costs.
A costing model will need to be completed to truly understand the increased pressure on tariff.
A full assessment of the ultrasound requirement and how this can be delivered in the hubs also needs
to be completed.
Cardiotocograph machines, Sonicaid monitors, carbon dioxide testing equipment and diabetic
monitoring equipment and testing will be required.
The cost of continuity of carer has to be modelled locally and nationally but the evidence in the Place
of Birth study shows that where the women receives continuity she will have less intervention, less
pain relief and a quicker recovery. This is hard to quantify in terms of cash releasing but it must be a
key strategic aim for women.
An understanding of what personalised budgets for women encompasses and how this is to be
administered is required
19 LMS plan v18
Gap Analysis
Publication Worcestershire Position Herefordshire Position GAP
Better births –personalised care
Care planning is led by the lead professional with women’s input
Care planning is led by lead professional with women’s input
Care needs to be planned by women and supported by professionals
Better birth -Perinatal mental health services is offered to all women in need
Service available for moderate and high risk women but self-help and low moral /previous history has no defined pathways
Women must be hospitalised before referral to a consultant psychiatrist is offered
The LMS must commission a full service for any women who needs help or support. Mental health is the largest cause of maternal death
Better births –birth choices offered
Women are disappointed when they deliver elsewhere or don’t get what they desire
Women would like a defined midwife led care pathway
We need to commission place of birth research to help the midwife offer consistent unbiased choice .women should not determine place of birth until there is enough information about likely comes for the pregnancy
Better birth –personal budgets
Women are unsure what this can be used for or how to access the money
Women and families are unsure on how to use this money
The LMS is waiting national guidance
Saving babies lives Smoking cessation for mother only not smoke free home Scanning skill deficit to meet demand Obesity strategy not impacting preconception as women continue to present obese
Smoking cessation should be commissioned for the whole family The obesity strategy needs to start impacting prenatally increased mentorship and ultrasound machines are required
The LMS must seek smoke free homes for families by changing smoking cessation access The LMS workforce and training plans must support increased ultrasound training. The capital plans must support increased purchase of ultrasound equipment. The obesity strategy needs to be part of every contact counts in primary and secondary care
Better births –breaking down boundaries
To breakdown boundaries the midwives and GPs need to be able to access information to deliver care seamlessly An end to end computerised patient record is required. A service specification is available
An end to end computerised record is available and boundaries are not an issue for existing referrals but women in Worcestershire or Herefordshire can interchange providers. No service specification is available
The LMS must secure an end to end computerised for Worcestershire An integrated commissioned service specification needs to be developed for the LMS
Better Births and saving lives and EMBRAC- learning together
Governance systems in place to identify variation and harm. Lessons learnt discussed, but themes continue to recur. Part of larger networking groups
Governance systems in place, recurrent themes continue .part of larger networking groups
Need to share and challenge more. Need to do more multidisciplinary learning which involves families. Rolling out SCOR to create uniformity of data capture and professional challenge across the sites.
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Better births – women and families involvement in care setting and commissioning
The MLSC chair resigned in 2016 and the group has crumbled –no meetings have been held in 2017
An active MSLC and women’s forum in in place
Maternity voices partnership needs to be established for the LMS
Better births –unwanted variation
A service specification is available with a dashboard and performance KPIs
No service specification is available ,dashboard and KPIs available
The LMS needs to exchange unit data and have a joint specification dashboard and KPIs. shared audit programs and clinical effectiveness needs to be established
Saving babies lives and better births –serial scanning, care close to home
Serial scanning to monitor growth is led from the hospital DAU
Serial scanning to monitor growth is led from the hospital DAU
Serial scan should be in the community HUBS but ultrasound machines will be required. there is no capital budget
Better birth –community hubs
Community hospital facilities to develop hubs are available
Community hospital sites are available to develop
Sites available to deliver the agenda but rent of rooms being requested. no non pay has been allocated to run the HUBS
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Governance
Governance structure for Local Maternity System
Worcestershire Acute Hospitals NHS Trust Wye Valley NHS Trust
Worcestershire Health & Care Trust NHS Worcestershire
West Midlands Ambulance Service NHS England
Wye Valley Clinical Commissioning Group Primary Care
NHSE Specialised Commissioning Herefordshire LA
Maternity Voices Partnership Public Health England
Health Education England Worcestershire LA
University of Worcester Healthwatch
National Maternity
Board
Midlands &
East
Maternity
Board
NHS
England
Trust Board
W&C Divisional
Performance
review
WAHT
Trust Divisional
Board
Local Maternity
System Board for
Hereford &
Worcestershire
West
Midlands
Maternity
Alliance
Herefordshire &
Worcestershire STP
Programme Board
22 LMS plan v18
Governance Every provider and commissioning organisation has adopted a personalised governance model based
on the above example. The outside line demonstrates the relationship with the alliance and the
maternity transformation board whilst the other arm represents the relationship with the STP.
Each organisation has personalised their organisational reporting/governance through the centre as
described. The LMS Board has been assured that each organisation has approved the governance
structure.
The board will be the accountable authority, seeking improvement trajectories on objectives which
deliver a 20 % reduction in still birth, neonatal death, maternal death and brain injury based on 2010
data and a 50% reduction by 2930.
The LMS Board will receive work group updates.
It will receive feedback from the clinical senate and maternity and new born network, HEE and PHE on
any National or local developments.
A discussion will be developed around learning from serious incidents. This will start though each
provider unit presented a closed SI to the Board to start a learning conversation. This must develop
with trust to a sharing of statistics for perinatal mortality, still birth, neonatal and maternal mortality.
Brain injury claims will be analysed and understood, a joint review of the past with any trends will be
identified and actions adopted to learn and avoid repetition of the past.
A dash board will be developed using the performance data available for both organisations. This is
likely to include booking before the 12th week, smoking at booking, feeding intention, measurement
of weight and actual BMI calculation, and any indicator of mental health, mode of delivery, patient
satisfaction and delivery outcome. Other quality indicators will be identified and scrutinised
Compliant responses will be completed in 20days. SI and comprehensive reviews will be completed in
45 days to allow the commissioner sign off and discussion. More importantly the LMS recognises this is
a rich source of information and learning to be able to improve the care for women and families.
The LMS alongside the National team will adopt the EMMBAC recommendations to have one way to
review still birth, neonatal death and perinatal mortality, this will take over a year to implement and
therefore Wye Valley and WAHT will adopt the Perinatal mortality SCOR package pending the
availability of the new National product being developed. The roll of the training for SCOR
(standardised computer outcomes review) is underway.
A summary of the case presentation will be shared with staff at perinatal and morbidity meetings.
Wye valley and Worcester prepare a dash board of outcome measures linked to the commissioner
specification and national outcomes. These will be monitored at the LMC board as well as form part of
each organisations governance framework.
When a suspected brain injury level 2 or3 occurs each organisation will notify their legal department
who will inform the NHS early resolution scheme within 14 days. Duty of candour will form part of the
23 LMS plan v18
parental discussion and a comprehensive or serious incident review will take place. This will involve
the family and any care aspects they wish to understand will be included in the terms of reference.
To ensure we learn together the consultants will review clinical cases from each organisation, offering
challenge and debate.
AUDIT
Audit will be a key area of work. Initially we will use the national audit material and formulate action
plans to develop working together. The EMMBRC report 14/15 will start this process
CLINICAL GUIDELINES
We believe that in the LMS clinical guidelines will be the key to transformational change. To this end
we know this will be the most difficult area of work as it will mean tackling culture.
An Organisational Development Strategy for the LMS will need to be developed to ensure cultural
change happens and is embedded.
We aim to start with ante natal screening as both organisations need each other to be sustainable.
Families will also benefit as it gives care closer to home and increases choice. Worcestershire Acute
hospital trust offers amniocentesis but only does 30 per year, to retain the service they must do a
minimum of 45. Wye Valley sends 15 to Birmingham women’s. This is a cost to wye valley as it is a
fetal medicine referral. A clinical pathway has been developed and a service level agreement
developed, it’s awaiting signature, this will save money for Wye Valley and support care and choice.
The next pathway will be cardiac scanning. This is currently a routine fetal monitoring service for
women at WAHT. At Wye valley the women travel to Birmingham women’s where they have the scan
and stay in the women’s for their care. This is only necessary if they require level 3 neonatal services.
The women can have a cardiac scan at WAHT, have a personalised care plan and deliver locally where
level 1 and 2 cots are available.
WAHT has developed a fetal medicine MDT. It is hoped at it matures that the consultants from Wye
Valley will join the clinical debate and from this more individualised care planning for pregnancies with
problems will be managed locally and again utilise the level 2 cot availability.
The LMS recognises the difficulty of running a small unit in a rural setting. The LMs has been invited to
join the National Rural maternity transformation group first meeting on the 4th October 17 and
accepted the invitation
24 LMS plan v18
Delivery Model - Local where possible. Centralised where necessary
Maternity Pathways in the Local Maternity System
Community Hub
Specialist Antenatal
Clinic
Shared care
Obstetric/Specialist
mother & baby care
Home birth/Midwife led unit
Midwife Led unit/obstetric
unit
Obstetric Unit with Level 2 or
3 Neonatal unit
Midwife led care
Po
stn
atal
car
e in
ho
spit
al, C
om
mu
nit
y h
ub
s o
r at
ho
me.
Han
d o
ver
to H
ealt
h V
isit
or
Pre
-co
nce
pti
on
car
e
Single point of access to
maternity services
Life style choices
Primary care Perinatal mental
health support
Early years support
Pre-conception care
Social care support
Pregnancy
9 Weeks
18 – 20
Weeks
28 – 30
Weeks
Up to 28
Days
25 LMS plan v18
The model is essentially based on the traditional values where childbirth is a normal event and
midwives supported by primary care, obstetricians and neonatologists working together to achieve
a healthy mother and baby.
Women and families are at the centre of the model and they require care as close to home as
possible but they will recognise the need to move to a centralised service to achieve optimal care.
The LMS covers one of the largest geographical areas in the country. This means the model has to be
flexible enough to manage the rural and the urban challenges which include transport deprivation,
poverty, seasonal employment, social isolation.
To this end the role of primary care and shared care is essential as is linking to practice nursing
district nursing the local authority support services in terms of health visiting safeguarding social
care and social work, education, childcare and schools
The Vision is to deliver services locally where possible and centralised where necessary. To achieve
this vision local HUBS will be developed in Kidderminster, Evesham, Bromsgrove, Redditch, Ledbury,
Bromyard, Leominster and Kingston with hub consultant obstetric and neonatal services based at
Wye Valley and Worcestershire Acute Hospital trusts.
A maternity Voices Partnership will be developed to work alongside the maternity system manager
to consistently support a cultural shift from professional s acting for women to a culture of women
being empowered to lead there care planning to achieve their choices.
We recognise from the data that booking before the 13th completed week is not consistently above
95% compliance. This is due to women confirming pregnancy and not being able to directly contact a
service but need to see primary care and be referred. We aim to set up a single point of access which
will stream line the process for women and offer a booking service in a local HUB. Wye Valley
Hospital Trust will lead this project. A home assessment visit can be completed later in the
pregnancy.
The hubs will deliver all antenatal booking and routine screening from a group of locality based
community midwives with a linked obstetric consultant in each HUB. Ultrasound scanning will be
offered from the hubs by either midwives trained to do this or from a radiologist or obstetrician.
Ultrasound will be for first trimester, second trimester and third trimester. Where specialist scanning
or consultant advice is required this may need to be offered in the tertiary centre in Birmingham
Women's and Children’s Health care Trust.
The hubs will offer a bespoke range of services including antenatal screening both routine and
specialist, exercise, dietary advice and support, mental health outreach, health visiting, antenatal
parent craft, infant feeding support, antenatal and post-natal drop in clinics, scheduled antenatal
and post-natal clinics and after birth counselling and VBAC service.
Specialist disease related clinics such as diabetes, twins or multiple pregnancy, cardiology, blood and
endocrine disorders will be based in the hospital centres of Wye valley and/ or Worcester.
Pregnancy care plans will be developed by the women and her family supported and informed by
the locally based community midwives, the linked or specialist Obstetrician.
26 LMS plan v18
To ensure women are offered the widest choices in care but receive a bespoke care plan and model
for them the place and range of birth choices will start to be discussed after the initial booking and
data capture. Place of birth choices will be risk assessed to avoid mixed communication and
disappointment though unfulfilled expectation for women and families. for example a women with
known cardiac disease who is likely to have an elective premature delivery in a centre with
cardiologists and neonatal intensive care should be delivered in the tertiary centre in Birmingham
and we would not offer home confinement.
Should antenatal support be requiring a hospital triage service will be available to contact 24/7 or
the women’s locality midwife team will offer an on call advisory support service?
Triage will offer midwifery advise, advice to call an ambulance through 999, travel to the hospital
where booked by car or stay at home and call through an agreed plan.
Antenatal inpatient beds are available for monitoring of high risk pregnancies and induction of
labour.
A joint agreement based on risk and the women's individual care needs and choices will be agreed at
30 weeks and constantly revised alongside the continual assessment and monitoring or the mother
and baby`s wellbeing.
The birth discussion will offer home confinement, midwife led care in a birth unit or in a midwife led
pathway, hospital based birth being midwife led and/or jointly managed with an obstetrician.
Midwife 1 to 1 care will be offered during labour and delivery. Hospital services will include elective
and emergency caesarean section. Pain relief will be dependent on place of birth. Delivery suite will
be staffed by consultant obstetricians 24/7 and supported by obstetric anaesthetists.
Post-natal care will be at home, in the hospital setting and through community drop in clinics in the
HUBS. Hearing screening will be at the bedside if in a hospital setting. Women who deliver at home
may need to return to a hospital for this service. An oxygen saturation test will also be carried out on
your baby to screen for cardiac disease.
Bereavement services will be offered to women who have pregnancy loss after 16weeks.
Wye Valley and Worcester acute hospital trust maternity and neo natal services work in a network
linked to Birmingham and Coventry, the network has hospital and neonatal services graded to
deliver the smallest sickest babies and women, the women and babies who need less support and
those where they are well and need minimal medical support.
Heart of England foundation trust, Birmingham Women's and Children’s NHS Foundation Trust,
University Hospital Coventry & Warwick are level 3 units who care for babies less than 27weeks,
Worcestershire Acute hospitals trust , Sandwell & West Birmingham NHS Trust are level 2 who
manage babies from 27 week and Wye Valley NHS Trust manage babies greater than 37 weeks, level
1.
Preconception advice and care will be commenced during the post-natal period to maximize the
opportunity to have a healthy second pregnancy in optimal health.
27 LMS plan v18
Implementation Plan
Leadership:
A LMS Board has been formed with the TOR and governance agreed and approved by all constituent
organisations.
Maternity Safety champions have been appointed on the Board of Wye Valley NHS Trust and
Worcester Acute Hospitals NHS Trust.
A non-executive Chair has been appointed to lead the LMS Board and an executive has been
appointed as the LMS SRO reporting as a board member to the STP Partnership Board.
A project consultant has been appointed for 2 days a week to develop the plan to meet the national
time table for approval and create the cross boundary and cross site clinical engagement to enable
the plan to be owned locally and be able to identify where centralisation is required to gain better
outcomes for women and babies.
Objectives
Improving choice and personalisation of maternity services so that: o All pregnant women have a personalised care plan. o All women are able to make choices about their maternity care during pregnancy,
birth and post-natally. o Most women receive continuity of the person caring for them during pregnancy,
birth and post-natally. o More women are able to give birth in midwifery led settings (at home and in
midwifery units).
Improving the safety of maternity care so that by 2020/21 all services: o Have reduced rates of stillbirth, neonatal death, maternal death and neonatal brain
injury during birth by 20% by 2020 and 50% reduction by 2030. o Are investigating and learning from incidents and sharing this learning through their
Local Maternity System and with others. o Fully engaged in the development and implementation of the NHS Improvement
Maternity and Neonatal Health Safety Collaborative.
Work streams:
Two work streams have been created to deliver the Local Maternity System. Clinical and Non-
Clinical. A stream lined approach in terms of number of work streams will support the development
and delivery of the plan:
Clinical Work stream:
This work stream will drive the development of clinical pathways, develop and monitor the quality
and safety metrics, support the learning and development and training of our workforce. The
pathways will address personalisation, choice and continuity. Public Health interventions to tackle
28 LMS plan v18
poor outcomes for mothers and babies will be identified with in the pathways. These include
smoking in pregnancy, obesity management, prematurity, breast feeding and low birth weight
Non clinical Work stream:
This work stream will develop the clinical specification and quality bench marking standards for
women, new-born and perinatal mental health .The financial tariff review, contracting and
commissioning will be modelled and implemented.
29 LMS plan v18
30 LMS plan v18
31 LMS plan v18
Clinical work stream including pathways Q and S and workforce
Actions Outcome and expected timeline
Safety Collaborative
Safety champions will be appointed to both Boards Training plan will be monitored 6/12 by HEE LW leadership will be strengthened Both units will participate in national learning and sharing Both organisations will participate in cohort 3 learning sets
The boards will have a raised awareness of maternity safety The training monies will be spent as planned and national returns will be completed on time National learning will be translated into local guidance Buddy support will facilitate team learning Still birth ,neonatal death and brain injury will be reduced
Saving babies lives
The 3 work streams in the care bundle will be established in each organisation and the targets will be monitored through local dashboards and the LMS
Still birth, perinatal mortality and brain injury will decrease. Staff will be confident in public health messaging Fetal monitoring in labour will be improved
Amino pathway A Review of numbers will be completed An SLA and clinical pathway will be developed and agreed
Women in H and W can access a Amniocentesis close to home
Cardiac scans Identify the numbers of Herefordshire women going to a tertiary unit. Develop a clinical pathway to Worcester. Develop a SLA and gain sign off
Herefordshire women will be able to access a local fetal medicine cardiac scan
SCOR system Both units gain training via webex Worcester job plans schedule time for review to allocated lead same at wye valley .panels set up
All deaths are reviewed in a standardised way with challenge from both consultant and midwifery panels. Learning will be translated into policy or guidance changes to reduce still birth and neonatal death
Breast feeding Initiation will be improved through family education, staff training and better recording Rates will be tracked at board
Breast feeding will improve and lead to reduced perinatal mortality.
Clinical pathways
Both units will develop clinical pathways to allow women care close to home but centralised where necessary
Women will receive optimal individualised care as close to home as possible
Smoking The public health strategy will Smoking will decrease and this will contribute
32 LMS plan v18
cessation include family stopping measures and smoke free homes. midwives will use carbon dioxide monitoring and all contacts to promote cessation Rates will be tracked at board
To the reduction of still birth and neonatal death Co2 testing will be for all women Surveillance of fetal growth will identify at risk pregnancies Fetal movements will be monitored
Monitoring of elective and emergency LSCS
Review of all emergency out of hours sections by LW lead /on call consultant No C/S without consultant discussion Elective Booking post 40weeks if less detailed case note rational Audit if statistical deviation after 2 months or 7 points
C/S toolkit principles will be used Monitoring of appropriate use of C/S in audit and divisional governance
Neonatal care Review of unintended admissions Review exported babies and reasons for not being able to accommodate in local network Review audit and guidelines with the network
Support SCOR for systematic review of neonatal deaths Monitor learning from unintended admissions
Develop outreach NNU care
Develop outreach team to pull babies out of transitional care and special care to create cot capacity
Babies are supported at home with their family. Less babies are exported. Babies from level 3 units are transferred to level 2 or outreach
Birth rate commissioned
Budget will be agreed to commission Birth-rate plus Review timetabled ,data collection period agreed
Acuity and workforce numbers determined January 2018 Base line of acuity and workforce agreed to be able to establish the benefits of the transformation plan for maternity and new-born.
Ultra sound Scanning requirements will be reviewed
Number of scans determined along- side workforce requirements for new care model i.e. HUB development and implications of saving babies lives. Training places will be commissioned, Budget identified Mentors identified An U/S equipment assessment is completed for the hospital and HUBS
A plan to support 1st, 2nd and 3rd trimester scanning is developed and the strategy is costed and agreed. Babies at risk will be identified and monitored to reduce the incidence of still birth and perinatal mortality The maternity units and HUBS will have ultrasound equipment to deliver care close to home.
Medical staffing Models are developed and a plan agreed which meets
H and W are seen as great places to work as a doctor in training and work post qualification.
33 LMS plan v18
RCOG guidance and provides safe cover for LW. Training standards are maintained
recruitment and retention is excellent and care is delivered safely
Midwifery development
Training numbers are constantly in focus to maintain full establishment. Midwifery roles are developed to give women holistic care
Women will receive optimal holistic care from an excellent well trained midwifery service
Midwifery professional advocates are established
The old supervisors of midwives will convert following training to become Midwifery Professional Advisors[ MPA] A model of restorative practice will be developed
Midwives will be able to access MPA to support them in care delivery or during times where there practice has not met standards
Modelling of 1 to 1 care for most women
Review national pioneer sites and outcomes Determine local model Consult with women and midwifery
Women will receive care from a known midwife most of the time
Development of perinatal mental health awareness and referral support
Review perinatal mental health audit of service 2017 Establish a development and learning action plan with the mental health provider Support the mental health provider with evidence for a national bid
The staff in the maternity and community know how to access support for women who require mental health support Women in crisis can access care There will be a reduction in maternal death
Neonatal clinical support
Wye valley staff are supported in skill updating by rotating through the network or by a staff rotation with WAHT
Babies get optimal care in level 1 and level 2 care by rotating through different organisations to maintain skill set. Medical staff are allocated to the NNU
Community and health visiting development
Workshop held in July 17 to review the influences of still birth and neonatal, maternal death.
Public health messaging ideas developed Hub bespoke modelling agreed Mental health pathways and support identified Breast feeding initiation and support plan agreed Professional clinical conversations and contacts
Non clinical Commissioning and Contracting
Joint maternity specification
A service specification for both counties will be agreed which sets out year on year clinical changes which need to happen to deliver the vision and ambition
Will receive choice ,with a personalised care plan, care close to home and a place of birth to give optimal care for mothers and baby .still birth ,neonatal death , maternal death and brain injury will be at targets
A perinatal A bid is submitted for Wye Better mental health will reduce maternal death
34 LMS plan v18
mental health service is commissioned for Wye valley and enhanced for WAHT
Valley and WAHT to be able to offer women support to stay well and treatment in a crisis
Specialist commissioners commission neonatal services for Wye valley and WAHT
A commissioned plan with activity and clinical quality standards agreed Service dashboard is monitored and outcomes discussed at the LMS board
At risk babies are identified and receive optimal care in a NNU which meets their needs Cots will be made available for babies to be repatriated as close to home as possible. Outreach capacity will be created through the team development Quality standards and outcomes will be reviewed as part of the contract monitoring
35 LMS plan v18
LMS Communication and Engagement Strategy
The LMS communication and engagement strategy is integrated with the STP engagement strategy
and part of all of the individual organisations who are working together for improved out comes for
mothers babies and families .
To ensure women are at the centre of decision making user representatives are established
members of the LMS Board and work streams.
Every organisation in the LMS is a board member and they have all agreed to work to a common
governance framework.
The commissioning organisations have traditionally supported the Maternity Service Liaison
Committee, a statutory body chaired and run by users and pressure groups relating to maternity
services with maternity clinical leaders supporting and hosting the group. This group held the service
leaders to account in terms of delivering women centred care. It was a traditional debating and
sharing forum. Many services have been transformed through such groups e.g. bereavement
facilities now include a double bed and a room which is sound proofed.
This group has been reformed to be known as the Maternity Voices Partnership. New terms of
reference, membership and objectives are being developed with the user LMS board and the
commissioners.
The neonatal support and pressure groups will be an integral part of Maternity Voices as they work
tirelessly to fund raise and raise awareness of neonatal care nationally. Baby Lifeline for example has
supported the introduction of manpower standards which are now part of every commissioning
specification. This important group will support the importance of being in the right place to get the
right care.
Establishing an identity was an initial objective and the lay membership and women’s forum from
Wye Valley NHS trust developed 5 logos which the LMS Board voted on and agreed.
To deliver the objectives in Better births the LMS needed to establish our first community HUB by
March 2017. This was identified and established in Kidderminster. This hub has evolved as the
women and the midwives have identified what could happen and what needed to happen in terms
of service development.
To develop future HUBS a HUB development strategy meeting was held in July 17. The invited
audience included users, community midwifery leaders from Wye Valley and Worcestershire Acute
hospitals and health visitors from both counties. This meeting allowed the community teams to hear
the public health evidence to make change. The potential HUB sites were identified and models
according to dependency and need started to emerge. Three questions were debated- the debate
summaries were:
36 LMS plan v18
How do we improve communication around public health messages?
How do we support perinatal mental health?
Improving communication between health visiting/public health nursing and midwifery
services
The community midwifery team managers and health visitors were tasked to take the outcomes
forward.
WAHT and the University of Worcester have employed a consultant midwife to support the
implementation of Better Births.
She has 3 key objectives
Work with women directly and through survey to understand what they understand and
what from “personalisation “.
Work with women to understand what women want to achieve from the services in
modelling” continuity “.
Formal public consultation meetings with groups of women will be established through local radio
advertising to debate and agree the suggested changes in the model of care.
The key debates will be
single point of access
place of birth decision delayed till 30 -34 weeks
37 LMS plan v18
Summary / Conclusion
By 2020
The traditional county boundaries will be removed with sharing of community and hospital
based resources across a wider area. This is not expected to result in a change to the provision
of obstetric services in Herefordshire.
A joint maternity care offer with common clinical pathways that guide women to the most
clinically appropriate place of birth.
A maternity specification that is jointly commissioned from Herefordshire and Worcestershire
CCGs, and delivered locally by the most appropriate provider will be evidenced.
A shared maternity service management structure and leadership will be in place.
Integrated specialist/clinical teams (such as Antenatal Screening team, Governance team etc.)
will be in place to increase skills and ensure adequate access for women.
Community hubs for maternity care will be established
There will be integrated neonatal pathways between Herefordshire and Worcestershire.
The initiation and sustainability of breastfeeding will be achieved in a coordinated way which
includes training midwives on skills to be used at 12 week appointments to begin early
discussions with parents on breast feeding and identifying peer support to increase pre-decision
on breast feeding.
All staff who come into contact with pregnant women will trigger quit attempts by delivering
brief advice on smoking, all maternity staff will be trained in MECC (Making Every Contact
Count).
The use of MECC and motivational interviewing skills of midwives will also support better
information sharing and highlight the importance of vaccination to protect the health of the
new-born.
A Shared approach for perinatal mental health offer for families will be commissioned.
A Shared end to end electronic maternity information system will be commissioned.
IT links between the hospitals services will be establishing through a national pan
In 2021 Herefordshire and Worcestershire LMS will have a commissioning maternity and neonatal
service delivering national specifications.
The population will have access to the widest choice of maternity and neonatal services: Local
where possible and centralised where necessary.
Perinatal mortality, stillbirth, maternal death and brain injury will be reduced by 20% and the
commissioning specification will be aimed at delivering a 50% reduction by 2030.
Women will access maternity services through hubs where the obstetrician and midwife will be able
to offer antenatal, postnatal and public health services. Women and families will view these centres
as a social hub where parenting, public health and preconception care will encourage self-support
and reduce social isolation.
38 LMS plan v18
Midwives will offer a comprehensive antenatal screening service with scanning for first, second and
third trimester. Women will choose their place of delivery most appropriate for them between 30 –
34 weeks and a detailed birth plan will be agreed with the midwife and/or obstetrician.
Women requiring perinatal mental health services will have access to a comprehensive
commissioned service regardless of where they live. Neonatal services will continue to be delivered
through a network solution with Worcester and Hereford offering levels 1 and 2 neonatal care.
Still birth ,neonatal deaths ,maternal deaths and brain injury will be monitored , lessons learnt will
be translated in to staff and parental guidance , policy changes and staff training,
A standardized method of reviewing deaths will; be implemented and the national statistics will be
starting to shift in a positive direction
By 2030
Pregnant women will be in optimal health when they conceive
Women will not be smoking, they will not be overweight and they will have attended
preconception counselling to establish screening requirements.
Women will empowered , they will have individualised care plans which the midwives and
High risk women will be delivered in a tertiary unit able to achieve optimal outcomes
Rates of still birth, neonatal death and maternal death will be 50 % less than the rate of
2010.
Although this is an ambitious plan, by all agencies working in collaboration with women and the
public, the aims are achievable.
