Dr Corinne Love Senior Medical Officer Maternity and Womens’ Health The Best Start The Future of Maternity and Neonatal Services in Scotland Dr Corinne Love Senior Medical Officer Maternity and Womens’ Health

Current Landscape NHS Scotland 5 million+ people 60,000 births 14 health boards 8 support boards NHS Education for Scotland Healthcare Improvement Scotland 35 maternity units (17 consultant led) Policy and Professional Landscape England - 53,012,456 Northern Ireland - 1,810,863 Scotland - 5,295,000 Wales - 3,063,456 (2011 Census Scot) 3

A Refreshed Framework for Maternity Care in Scotland   The Maternity Services Action Group The Scottish Government, Edinburgh 2011 Policy Landscape There are several pertinent and relevant policy documents in Scotland which I am going to refer to findings both align and challenge the direction of travel for Scottish maternity and neonatal services.

Am sure you will all be aware of Scotland’s CMO’s first report ‘Realistic Medicine’ which focussed on these 6 areas and the follow up report in 2017 ‘Realising Realistic Medicine’ These National reports provide the framework for professional change generally across Scotland, not just within maternity settings. One of the areas to focus on is around reducing unnecessary variation, which fits well with the NMPA aims and findings. One of the ways Scotland is enabling and assisting professional change is through the work of the SPSP

THE BEST START A Five-Year Forward Plan for Maternity and Neonatal Services

Maternal Mortality in the UK Professional Landscape Reporting on UK deaths for over 60 years Represents a gold standard internationally

Maternal Mortality 2003-13

2016 MBRRACE Report 241 women died in 2012-14 during pregnancy or up to 6 weeks after Death rate of 8.54 per 1oo,ooo maternities (lowest ever) 81 direct deaths 119 indirect deaths (psychiatric causes) 41 coincidental 323 late deaths (after 6 weeks. Includes direct and indirect) Total 564 Maternal suicides reclassified by WHO as a direct cause of maternal death. Rate unchanged since 2003 Maternal suicides are now the leading cause of direct maternal deaths occurring within a year after the end of pregnancy

Indirect Maternal Deaths 2011-13

Key Messages There continues to be a significant decrease in the maternal death rate in the UK No significant change in the rate of indirect death over the last 10 years Majority of women who died had pre existing medical or mental health problems or both Specialist perinatal mental health care matters Communication and Multidisciplinary working Continuity of care Perinatal mental health clinical networks should be established Red flags Support and education for families Greater awareness of this report amongst mental health staff

Death is the Tip of the Iceberg Morbidity 10-15% suffer anxiety or depression during pregnancy and first year after giving birth 5500-8000 women* per year in Scotland

THE BEST START A Five-Year Forward Plan for Maternity and Neonatal Services

Aim of the Review To examine choice, quality and safety of maternity and neonatal services in light of current evidence and best practice To consult widely with the workforce, NHS Boards and service users To make recommendations for a Scottish model of care that:- contributes to the Government’s aims of person-centred care, provides the right care for every women and baby every time gives all children the best start in life Remit To examine choice, quality and safety in light of current evidence and best practice; Choice Look at informed choice and consent, What is realistic and practical in offering women choice in maternity services? And for families in neonatal services? Can we provide choice in all care settings?   Safety How safe are our services? Do we have the right risk assessment protocols, do we have consistency of safe service provision, at all times and in all places? Do we have a consistent approach to review and learn lessons from incidents, and share this learning? Are our culture and behaviours compromising safety? Quality Are our risk assessment protocols, referral pathways and models of maternity and neonatal care as good as they can be? Have we got the right local, regional and national layers of care? Does data collection work to drive service improvement? Have we got the right balance of skills in the right places, are we using them effectively and is the model sustainable?

Vision All mothers and babies are offered a truly family-centred, compassionate approach to their care, recognising their own unique circumstances and preferences Fathers, partners and other family members encouraged to be part of maternal and newborn care Women experience real continuity of carer, across the whole maternity journey, with additional tailored support for vulnerable families Services are redesigned using the best available evidence, to ensure sustainability and maximise the opportunity to support normal birth processes Multi-professional team working is the norm within an open and honest team culture, with everyone’s contribution being equally valued Remit To examine choice, quality and safety in light of current evidence and best practice; Choice Look at informed choice and consent, What is realistic and practical in offering women choice in maternity services? And for families in neonatal services? Can we provide choice in all care settings?   Safety How safe are our services? Do we have the right risk assessment protocols, do we have consistency of safe service provision, at all times and in all places? Do we have a consistent approach to review and learn lessons from incidents, and share this learning? Are our culture and behaviours compromising safety? Quality Are our risk assessment protocols, referral pathways and models of maternity and neonatal care as good as they can be? Have we got the right local, regional and national layers of care? Does data collection work to drive service improvement? Have we got the right balance of skills in the right places, are we using them effectively and is the model sustainable?

Shaping the Recommendations Evidence and Data REVIEW RECOMMENDATIONS Sub Group Reports Feedback from Engagement

Perinatal mental health (4) Remote and rural challenges Chair: Jane Grant CE, NHS Forth Valley Launched 20th Jan 2017 Perinatal mental health highlighted as a key priority for maternal and infant health and wellbeing Recognised the opportunity and correlation between improved maternal health and lifelong health, wellbeing and attainment in children 76 Recommendations Vulnerable women (3) Perinatal mental health (4) Remote and rural challenges Health and social care integration – mental health is an ideal example of where this could and should work well. Principle of the report – aligned with Scottish Government priorities around health and social care integration. Recommendations around vulnerable women recognised the wide range of medical, social and psychological reasons which can lead to vulnerability. Perinatal mental health: was a consistent theme raised by staff, third sector organisations and users around Scotland when all Boards were visited. Particular areas highlighted were: Access to and range of services, need to improve the skills of staff in this area and need to increase awareness of the issue.

Person-centred maternity and neonatal care Key Recommendations: Continuity of carer from primary midwife and obstetrician care co-located for the provision of community and hospital-based services. Person-centred maternity and neonatal care Relationship-based, personalised care Aiming to keeping mums, babies & families together Safe & family centred neonatal care Multidisciplinary team care Women receive the level of care they need clear referral pathways

Safe, high quality and accessible care Development of community hubs Postnatal neonatal care Specialist maternity and neonatal care co-located Support for vulnerable women and improved perinatal mental health services Neonatal care Three to five neonatal intensive care units should be the immediate model for Scotland, moving to 3 within 5 years. Development of a national model for 7-day neonatal community services.

Perinatal Mental Health Recommendations Early and equitable access Clear referral pathways Adequate provision of staff training The Best Start aligns with the Mental Health Strategy Psychological support for parents of babies in the NNU Awareness and use of third sector support agencies

Implementation National Implementation Programme Board established – reps from across the service, professional bodies and service users Chaired by Jane Grant, Chief Executive of NHS Greater Glasgow and Clyde

National Implementation Structure

Sub Groups - Continuity of carer and local delivery of care Continuity of Carer model of care Operations of FMUs Community Hubs Support workers in the community Postnatal Neonatal Care Alignment with Obstetricians Caseload and core hospital based midwives

Sub Groups - Perinatal Services Neonatal Intensive Care Unit locations Risk Assessment Tool Pathways Cot locator system Cot availability protocol Neonatal transfer staffing model Medical care outwith maternity setting

Sub Groups - Workforce and Education Workforce Planning National education resources Protected training time Maintaining skills Examination of the newborn Remote and rural skills Non registered staff roles

Locally led recommendations NHS Boards will be empowered to drive forward many of the recommendations at local or regional level where possible and practical to do so 23 out of 76 recommendations suitable for delivery at a local level Local area implementation leads have been identified in all geographic NHS Boards

National linked projects Neonatal expenses Maternity network Perinatal mental health Refreshed information for parents Single MCN Electronic records Caesarean section study Adverse events

Early Adopter Boards NHS Forth Valley NHS Highland NHS Lanarkshire NHS Lothian NHS Greater Glasgow & Clyde (Clyde only) Announced Sept 2017

Organisational Changes Continuity of care and carer Increasing choice for place of birth Re – designing neonatal care Postnatal care Transitional care Community care Community hubs There are several significant organisational changes underway as part of the recommendations and improvement work planned. Continuity of care and carer I have already mentioned. However maternity and neonatal care are inextricably linked here and it will be impossible to move forwrad with one and not the other. Scotland had already recognised some of the limitations women have for choice of place of birth and this is another important area being addressed moving forward. Neonatal care redesign aims to keep mum and baby together by providing as much of that care as possible outwith neonatal units, whether that be in the post natal wards with a new model of transitional care or in the community with enhanced community neonatal care And of course having the smallest sickest babies cared for in fewer centres. The recommendation for the setting up of community hubs is aimed at both maternity and neonatal care So many of the organisational changes see us moving forward together and its impossible to do one without the other.

Professional Changes Revision of ‘risk’ pathways to much more individualised approach Criteria for Midwifery and Obstetric units – high risk fetal and maternal conditions Developing and supporting high performing multidisciplinary teams – work and train together There are also recommendations requiring professional changes but which would also benefit from maternity and neonates working closely together to achieve the best outcomes. Antenatal risk assessment was highlighted by women and staff as being too restrictive currently. There is a national risk assessment tool which is used but once assigned to a risk category is seems difficult to alter that during pregnancy as circumstances and situations change, so there is work currently underway to revise and individualise antenatal assessment better with an aim for labour and delivery outcomes to be the best possible. One of the other ways being looked at to achieve this is to review and provide national guidance on women who should be delivered in an obstetric unit, with a view to increasing the proportion and reducing the variation in women for whom delivery in a midwife led setting would be better. This is also aimed at ensuring the high risk fetal and maternal conditions are cared for in the correct place. Another of the professional recommendations is around multiprofessional team training. Obstericians, MW and anaesthetists do this already together, but is this an area where we could consider moving forward together with neonatology too. Routine examination of the newborn – the recommendation is for this to be performed by midwives, which is clearly going to require collaborative working to take this forward. And both maternity and neonatal transport considerations are going to require us all to work closely together to take this forward. Greater shared decision making for women and families Emphasis on care close to home

Supporting the Changes National maternity and neonatal dashboards Protected staff training time Single maternity care electronic system Scottish electronic women’s maternity record Single Maternity and Neonatal Clinical Network

Communication Twitter - @SGChildMaternal Blog - https://blogs.gov.scot/child-maternal-health Website - http://www.gov.scot/Topics/People/Young-People/child-maternal-health Newsletter – Issued 10 May – give us your email address! Email – thebeststart@gov.scot Local lead in each Board