2 The Trust s safety review concluded that there were two options for provision of midwifery-led care in the Berwick Maternity Unit.

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1 NHS Protect Joint Locality Executive Board 22 May 2013 Agenda Item: 8 Future arrangements for midwiferyled care in Berwick Sponsor: Dr Eileen Higgins Executive Summary 1 Northumbria Healthcare NHS Foundation Trust suspended part of the midwifery-led service on 1 August 2012 on safety grounds. The Trust has now completed its safety review and the required re-skilling of the midwives and is awaiting a decision from NHS Northumberland Clinical Commissioning Group (CCG) about the level of service which it intends to commission. 2 The Trust s safety review concluded that there were two options for provision of midwifery-led care in the Berwick Maternity Unit. Option 1 Resuming services as they were prior to 1 August 2012 i.e. providing antenatal, intrapartum and postnatal care in the unit on a 24/7 basis. Option 2 Providing a 24/7 on call midwifery-led service where women could deliver at home or in the unit returning home six hours after delivery with enhanced community midwifery support. 3 NHS North of Tyne led an extensive consultation exercise and the CCG has used the outcome of that exercise to prepare this report which will be considered by the Joint Locality Executive Board so that they can decide upon the options presented. The decision will then be scrutinised by the CCG s Governing Body which will provide assurance on the decision making process. 1

2 Purpose of report To bring together information that needs to be considered, including feedback from discussions that have taken place over several months with representatives of NHS Northumberland CCG member practices and with colleagues from Northumbria Healthcare NHS Foundation Trust, the public and other key stakeholders so that a decision can be made on future arrangements for midwifery-led care in Berwick. 1 Background Northumbria Healthcare NHS Foundation Trust, which manages hospital and community services in North Tyneside and hospital, community health and adult care services in Northumberland, suspended some maternity services (intrapartum and inpatient postnatal care) at Berwick Maternity Unit on 1 August This was as a result of safety concerns following two incidents. The suspension was against a background of a decreasing number of deliveries at Berwick (which had reduced from 40 to 13 over a five year period) in consequence of which midwives did not have sufficient opportunity to practise and maintain their skills. The Trust undertook a safety review of the service at Berwick which included: an analysis of national clinical guidelines and their impact on the model of care and the staffing requirements for a safe and sustainable service. Arrangements were also made for the Berwick midwives to undergo mandatory rotational training to update their skills and experience of different types of deliveries at Wansbeck General Hospital consultant-led maternity unit. The Trust published its safety review report on 7 November (attached as Appendix A). The report identified two options for future models of midwifery-led care in Berwick one resuming services as they were prior to 1 August 2012 and the other for a 24/7 on call midwifery-led service where women could deliver at home or in the unit, returning home six hours after delivery with enhanced community midwifery support. Both options would require midwives to undergo mandatory rotational training to practise and maintain their skills. The outcome of the safety review was considered by the NHS North of Tyne board on 27 November A formal process of public consultation was launched by NHS North of Tyne on 11 December 2012 and this ran over 14 weeks, until 19 March This was in line with statutory requirements for involvement and consultation i.e. sections 242 and 244 of the NHS Act (2006). 2

3 Following the temporary suspension of some services, and while the safety review was taking place, the then commissioners, NHS North of Tyne organised some independent research to provide an understanding of what is important to local women in terms of service provision when they become pregnant. Headlines from this research were shared publicly at a meeting in Berwick on 25 October Highlights from the consultation feedback were considered at the final board meeting of NHS North of Tyne on 26 March 2013, when it was agreed that all feedback should be compiled and handed over to the CCG in line with their new commissioning responsibilities. 2 Issues for the CCG to consider Whether they should commission midwifery-led maternity services in Berwick on the basis of: or Option 1 To resume services as they were before the temporary suspension of deliveries and inpatient postnatal services on 1 August This would include all antenatal care for low and high risk women, hospital and community deliveries for low risk women and 24/7 inpatient postnatal care and community midwifery services. This option would require the recruitment of additional midwives to allow for regular rotation and the unit to remain open 24/7. Option 2 The provision of a 24/7 on call midwifery-led service which would mean low risk women could give birth in Berwick, either in a birthing room or at home. Women would return home six hours after giving birth and there would be an enhanced community midwifery service to provide more support for women at home. All of the existing hospital and community antenatal care for low and high risk women would continue. This option would also require regular rotation of midwives. or a variant upon either option. 2.1 Assessment of the two options Since 1 August 2012 there have been discussions at the four CCG locality meetings (north, west, central and Blyth Valley) about Berwick maternity services, particularly at the north locality group, whose patients are most affected. 3

4 At their meetings in May 2013, each of the four locality meetings, were asked to specifically focus on: An assessment of the two options (as outlined by Northumbria Healthcare in its safety review report which included the pros and cons of each option) The CCG s legal requirements under s.14q of the Health and Social Care Act 2012 (which requires it to exercise its functions efficiently, effectively and economically) National requirements in respect of reconfiguration, which comprise four tests: o Support from GP commissioners; o Strengthened patient and public involvement (including feedback from the consultation and the extent to which patients, the public and stakeholders had been engaged); o Clarity about the evidence base (including national guidelines, clinical negligence scheme for trusts and evidence on free standing midwiferyled units) and o Patient choice as initially set out in Sir David Nicholson s letters dated 20 May 2010 and 29 July 2010 and subsequently endorsed by the Secretary of State (Gateway 14335). The locality groups were aware of the assessment by Northumbria Healthcare of the two options, as outlined in its safety review report, and considered the pros and cons for each which had been identified by the Trust. These were: Option 1 Pros: Maintains current service (i.e. as it was before 1 August) gains local community support will deliver a local service to a local community will act as a 24/7 back up for local community accessible for local pregnant women achieves national safety standards. Cons Bed occupancy will be likely to remain low (around 20%) and therefore midwives stationed at Berwick to deliver 24/7 postnatal inpatient care will not be fully occupied midwives will need to agree to mandatory rotation recruitment of additional midwives may be problematic due to an insufficient number appropriately qualified applicants, based on previous experience recruitment and employment of additional midwives will require significant 4

5 additional investment increasing midwives in Berwick may cause additional operational, supervisory and skills maintenance issues which may also impact on Wansbeck team (given the low birth numbers in Berwick and need for more Berwick staff to be rotated). Option 2 Pros Cons Maintains an on call safe and sustainable service in Berwick as staff will be rotated through maternity services at Wansbeck General Hospital to maintain skills more efficient use of NHS resources and time of Berwick midwives and healthcare staff supports the requirements of the community regarding a back-up service for local mothers 24/7 provides enhanced postnatal care at home for mothers maintains local antenatal services for high and low risk women supports Berwick mothers to have babies in Berwick achieves national safety standards. Long term inpatient postnatal care will cease, however, an enhanced community midwifery service will support mothers in their own home following delivery midwives will need to agree to mandatory rotation 2.2 Requirements under the Health and Social Care Act 2012 The locality groups were asked to consider their requirements under the Health and Social Care Act 2012 which stipulates that A clinical commissioning group must have a governing body. The main function of the governing body will be to ensure that CCGs have appropriate arrangements in place to ensure they exercise their functions effectively, efficiently and economically and in accordance with any generally accepted principles of good governance that are relevant to it. Their discussions to test each of these requirements took into consideration the following Exercising functions efficiently The number of women delivering in Berwick has reduced over the last five years due to: significant changes to national clinical and safety guidelines (which has meant fewer women are eligible to give birth in midwifery led units) 5

6 the declining birth rates in Berwick women exercising choices to deliver in consultant-led rather than midwiferyled units. During there were 40 deliveries in Berwick. By this figure had reduced to 13. At the time of the temporary suspension of some services, 12 deliveries had taken place at the unit in 2012/13, but had the service continued it was not expected that the number of deliveries in 2012/13 would have significantly exceeded those in 2011/2012, for the reasons outlined below, which are taken from the Trust s safety review report: 48% of women (which represents 133 women) were classed as high risk patients and therefore could not deliver in a midwifery-led unit 52% (which represents 145 women) were classed as low risk patients at the time of the initial assessment and therefore could choose to deliver in a midwifery-led unit. Of these low risk women: o 59% (85 women) chose to deliver in a consultant-led unit: 20% (29 women) chose Wansbeck General Hospital 39% (56 women) chose Borders General Hospital o 34% (49 women) chose to book their delivery at the Berwick midwiferyled unit o 7% (11 women) chose other venues for delivery, including Alnwick Infirmary, the Royal Victoria Infirmary and one home birth o When low risk patients were asked why they chose their particular place of delivery, 97% stated patient choice as the reason (i.e. personal preference) rather than the remaining options of pain relief, special care baby facilities, consultant presence or other Of the 49 women who initially chose to deliver at Berwick midwifery-led unit, 13 gave birth at the unit and 36 did not Of the 36 who did not give birth at Berwick: o Ten women commenced their labour in Berwick but had to be transferred to Wansbeck General Hospital during labour due to complications which required consultant-led care o Of the remaining 26 women who initially planned to deliver in Berwick: o Four changed their minds and wanted consultant-led care o Four women moved out of the Berwick area o Four women unfortunately miscarried o The remaining 14 women, developed complications either during pregnancy and/or birth which, based on the national guidelines, meant they needed to deliver in a consultant-led unit. 6

7 With such a small number of deliveries, even taking into account that some women returned to Berwick having given birth at a consultant-led unit for postnatal care, bed occupancy at Berwick is low. Northumbria Healthcare s safety review report showed that from 1 April 2011 to the 31 March 2012, out of 365 days: For 129 days, no patient occupied any beds in the unit For 126 days, only one of the six beds was occupied. This means that the unit was empty for a third of year and for another third of the year there was only one bed occupied. When the unit is open around the clock there must be midwives on duty (even when there are no inpatients). Therefore, prior to 1 August 2012 there were many occasions when midwives where at work and there were no patients in the unit to care for. Providing around the clock cover in the unit restricts the services that midwives could provide in the community Exercising functions effectively Against such a small number of deliveries it has been difficult for the Trust to ensure that midwives practise and maintain their skills. With so few deliveries they are not exposed to the broader range of experiences of deliveries in larger units which means they are not as well equipped to deal with unexpected complications that might arise during labour and delivery. A significant percentage of the midwifery resource is stationed in Berwick to ensure that around the clock cover is provided and as stated above, sometimes midwives have been on duty in the unit when there have been no patients there. The rotation of Berwick staff to Wansbeck, which has taken place since 1 August 2012, has been on a supernumerary basis to allow for the updating of skills and experiences. It was not possible to release any Wansbeck midwives to Berwick during this time as they were needed to deliver the consultant-led service in Wansbeck. This means that recruitment of additional staff to allow for on-going mandatory rotational training would be required to provide a 24/7 service in Berwick in the future. Northumbria Healthcare s safety review included comparison with arrangements in other parts of the country for free standing midwifery-led care. This showed that for the year in question, the unit at Berwick had the smallest number of births (13) of any free standing unit in England. The midwifery-led unit with the next lowest number of deliveries is in Penrith, which delivered 30 babies last year. However, this unit is not open or fully staffed 24 hours a day, seven days a week like Berwick and instead operates midwifery on call system for women giving birth. There are some midwifery-led units in Scotland which deal with a low number of births (between ten and 20 a year). However, these units are only opened on an as required basis. Community midwives take part in on call systems for intrapartum care, rather than providing a fully staffed unit 24 hours a day, seven days a week. These units open for delivery with women arriving to give birth and discharged home after six hours, with full community midwifery support. 7

8 2.2.3 Exercising functions economically As indicated above (2.2.2) the requirements for rotational training in a 24/7 service would mean additional recruitment and therefore additional costs. Declining birth rates, national guidance and women s choices mean it is unlikely that there will be a significant increase in deliveries at Berwick. The cost per birth in Berwick is already substantially greater than in other units and if Option 1 was selected this would increase further. 2.3 National requirements around reconfiguration The Secretary of State (Gateway 14335) identified four key areas in which reconfiguration processes need to improve as plans for significant service change are developed and consulted upon. These are: Support from GP commissioners will be essential Arrangements for public and patient engagement, including local authorities, should be strengthened There should be greater clarity about the evidence base underpinning proposals Proposals should take into account the need to develop and support patient choice. While these proposals were issued before CCGs became statutory bodies, the locality groups were aware that they remain in place as tests of reconfiguration proposals and therefore must be taken into consideration by the CCG. They were also aware that consideration must also be given to the recommendations in the report published in February 2013 by Robert Francis QC into the care provided at Mid-Staffordshire NHS Foundation Trust which has rightly led to an increased focus on safety and quality Support from GP commissioners This test was created while PCTs were the commissioners and CCGs were being created. Northumberland CCG is a member organisation made up of the 46 GP Practices within Northumberland which are organised into four geographical localities. At locality group meetings, members of the locality groups were reminded how important it is that the CCG member practices are aware of the issues and that their views are expressed to and represented by the locality directors at the Joint Locality Executive Board meeting. The Joint Locality Executive Board has a duty to bring together the views of all members across Northumberland and decide on the future arrangements for maternity care in Berwick. 8

9 2.3.2 Strengthened public and patient engagement The locality groups were asked to reflect on the consultation process including the extent to which local stakeholders and key local groups had been engaged and the feedback that had been received. (This is described in detail, along with feedback received in Appendix B.) Consultation process The groups were reminded that before consultation started, the then commissioners, NHS North of Tyne engaged with key local stakeholders and commissioned independent research to find out what is important to local women in terms of service provision when they become pregnant. During the14-week public consultation, starting on 11 December, there were concerted efforts to engage the public and involve the parish/town and county councils. The Mayor of Berwick chaired two public meetings held in Berwick to discuss the options and members of the parish/town and county council were present at public and other meetings. A county councillor was involved with the Save the Berwick Maternity Unit group and was present at the meetings held with that group during the consultation process. Meetings were attended at Berwick Town Council before and during the consultation process. A meeting was held for members of the Norham and Islandshire cluster of parish councils (which covers several councils) and a meeting was attended of Wooler Parish Council. The Northumberland County Council Care and Wellbeing Overview and Scrutiny Committee was involved in line with Section 244 of the NHS Act before and during the formal public consultation and at one of its meetings concluded (and minuted) that the consultation had been robust. Public involvement during the consultation process included: independent research (involving 240 women who took part in on-street activity and in-depth interviews) availability of a survey (315 completed copies submitted) which was independently evaluated attendance at 12 local meetings to target people of child bearing age letters to 200 pregnant women in Berwick and the surrounding area advising them of the consultation and how they could participate advertising and news coverage in the Berwick Advertiser and advertising campaigns on Borders Radio and Facebook Flyers distributed to more than 13,000 households in Berwick and the surrounding area with details of the consultation. Before and during the consultation there were on-going and constructive discussions with representatives from the Save the Berwick Maternity Unit group which ran a campaign on Facebook and which also organised two petitions resulting in more than 4,000 signatures. It should be noted that the activity surrounding the petitions started shortly after the decision by Northumbria Healthcare to temporarily suspend some maternity services at Berwick and therefore before the decision was taken to 9

10 consult on two options. It was clear in meetings, and in particular those with the main target audience, women of childbearing age, that there were high levels of awareness about the consultation and about the proposals. In addition, the Berwick Advertiser was helpful in terms of supporting efforts to ensure high levels of awareness of the consultation and in making copies of the consultation document available for local people to collect from its front office. Feedback received The locality groups were asked to consider the themes that emerged during the consultation, which were generally consistent across the independent research, the survey, discussions in meetings and in written or feedback. Inpatient postnatal care There were strong views expressed that six hours (as detailed under Option 2) was not long enough following delivery, for both first time mothers and also for women who have other children at home. It was clear from much of the feedback received that the care women have received in Berwick following the delivery of their baby has been very much valued. Some said that the midwives looked after the baby overnight to enable the new mothers to have some sleep. Others commented that having a midwife available down the corridor was preferable to having to telephone for advice from home. It was also clear that women wanted to be close to home. Availability of advice/support around the clock It is clear that some women have valued being able to call by the unit for advice throughout their pregnancy and following delivery. Feelings were expressed that there was no one to ask for advice if the unit was not open around the clock. Availability of on-call midwives (i.e. under Option 2) There were a lot of comments and questions about how the on-call arrangements would work, in particular where the midwives would be travelling in from and how they would manage in the winter when roads were bad. People asked for clarification about how women would contact the on-call midwives and asked if they would need to ring Wansbeck General Hospital first and if so, how would midwives be able to advise a woman about whether she was in labour over the telephone. It was clear during the consultation that women have felt able to call the unit or go to the Berwick unit 10

11 with any problems or questions they might have. Travelling/transport: Travelling was a constant theme. There were comments about the distance from Berwick to both Wansbeck and Borders, the difficulties experienced when travelling in bad weather and the lack of public transport and the inconvenience for family and friends when visiting someone in hospital so far away from home. There were many comments about the inconvenience for women who are not sure whether or not they are in labour and who make the journey to Wansbeck or Borders where they are told to go home, only to find that once home labour has started and within a couple of hours they are back on their way to hospital. There were questions about whether it would not be possible for a woman to go first to the Berwick unit for a check to avoid an unnecessary journey. Ambulance availability There were comments at a number of the meetings about ambulance availability and the perception of lengthy waits when ambulance transport was needed which people felt would increase the risk of babies being born enroute. It was clear that some believed that when a pregnant woman goes into labour, a 999 response is always necessary. Provision of most of antenatal and postnatal care locally Women already receive most of their antenatal and postnatal appointments locally which is much valued. Involvement of consultants/on-call obstetrician/gp with special interest At a few meetings there were questions about whether it would be possible to have an obstetrician on hand at Berwick or a GP with a special interest to enable more women to give birth there. Criteria/guidelines for low risk pregnancy Views were expressed by a number of people that the criteria to determine which women are eligible for delivery in a midwifery-led unit are applied too rigidly and that they are generally too strict. Safety It was clear in some of the discussions with women of childbearing age that they understood the importance of safety with some of them explaining why 11

12 they had delivered in a consultant-led unit i.e. that they had chosen to or that they needed to ensure that all available support was on hand should this be required. There were also strong references to this from clinicians who responded. Equity Some people commented on equity of provision on the one hand that women in Berwick should expect the same service as those in other parts of the county and on the other that women in Berwick received a level of postnatal care that was not available to women in many other areas. While there were positive comments about the value of the groups and organisations which provided support in Berwick and the surrounding area for mothers and their babies, there were questions about whether these were accessed by all who might need support. Financial implications A small number of people expressed strong views that the whole issue surrounding maternity care in Berwick was down to money. Broader issues about availability of healthcare services in Berwick Many people feel that they live such long distances from general hospitals that more care should be provided in Berwick Clarity about the evidence base National guidelines The locality groups were reminded that the safety review undertaken by Northumbria Healthcare included consideration of how intrapartum (labour and deliveries) and postnatal care can be safely delivered in the future at Berwick. As such the review took into consideration the recommendations for practice and safety provision as outlined in a range of national reports including guidance and reports from: the National Institute for Health and Clinical Excellence (NICE) Nursing and Midwifery Council Royal College of Obstetricians and Gynaecologists Royal College of Midwives Department of Health Clinical Negligence Scheme for Trusts National Child Birth Trust, National Institute for Health Research and 12

13 the NHS Commissioning Board (NHS England). Some of these reports included information on the changing national guidance on the eligibility of women to deliver in free standing midwifery-led units. They reflected on a number of areas where national guidance has changed significantly and affected the options available to women when deciding, with their clinician, where is the most appropriate and safest place to give birth. In general terms, such national changes mean it is more likely that more pregnancies will be classified as high risk and therefore not suitable for midwife-led delivery: Body mass index (BMI) of the expectant mother at the time of booking Deep vein thrombosis risk assessment Hypertension Diabetes assessment Complex and social factors. They noted that although there does not appear to be any nationally set minimum number of births that midwives are recommended to attend to maintain their skills, Northumbria Healthcare, following consultation with the Local Supervising Authority for Midwives, its head of midwifery and clinical director of obstetrics and gynaecology, concluded in its safety review report that the overall birth figures for Berwick are well below the number of deliveries necessary for the midwives to maintain a full range of midwifery skills. In its safety review report, the Trust also said that the Royal College of Midwives (2009) outlines a recommended birth to midwife ratio for workforce planning purposes, of one whole-time equivalent midwife to every 35 births for low risk midwifery-led births. In Berwick the equivalent birth to midwife ratio is 0.37 per whole-time equivalent midwife. Clinical Negligence Scheme for Trusts The locality groups noted that in its safety review report the Trust also considered the requirements of the Clinical Negligence Scheme for Trusts (CNST), administered by the NHS Litigation Authority (NHSLA), which handles all clinical negligence claims against NHS bodies. The CNST outlines a set of clear Clinical Risk Management Standards for Maternity Care which were newly updated in 2012 and originally introduced as a result of the significant proportion and cost of maternity related claims against NHS Trusts which are reported to the NHSLA. CNST reviews the standards. These standards are: 1) Organisation of care 2) Clinical care 3) High risk conditions 4) Communications 5) Postnatal and new-born care. 13

14 Within each standard there are ten criteria that reflect national recommendations for each area as detailed above. As a result of this, the Trust has local guidelines which are audited on an annual basis to ensure it maintains these very strict, safe standards of care. The Trust is also assessed on a three yearly basis by CNST. Since 2010, the Trust has obtained the highest possible CNST safety rating (level 3) in relation to maternity care and the five standards above, and this covers the Trust s four midwifery-led units and one consultant-led unit. This CNST level 3 safety rating forms the basis of the safety and quality standards the Trust expects to deliver across all maternity services. These CNST Maternity Standards provide the evidence base upon which risk is assessed and communicated to all women using maternity services provided by Northumbria Healthcare. This is to ensure that the Trust provides the required information to facilitate discussion with women around the most appropriate and safest setting in which to deliver their baby. The Trust said these stringent CNST safety standards were at risk of being compromised, had it not taken immediate action to suspend some services in Berwick on 1 August Evidence on free standing midwifery-led units The locality groups also considered evidence that free standing midwifery-led units are safe as outlined in the 2012 article by Health Improvement Scotland Update Evidence Note 18 Safety and risk associated with free standing midwife led maternity units and the additional advice on this note, Advice Statement 010/12 Nov 12 Safety and risk associated with free standing midwife-led maternity units. The key issues presented were as follows: For women at low risk of birth complications, the incidence of serious perinatal adverse events for the infant is low in all settings of maternity care. This means that very large studies are required to make comparisons between the safety of different settings. The Birthplace in England study, (n=64,538), found no significant difference in the risk of a composite outcome of serious adverse events for the baby (including stillbirth, early neonatal death and neonatal encephalopathy) between births planned in free standing midwifery units and births planned in obstetric units. The Birthplace in England study demonstrates a transfer rate from midwife led maternity units to obstetric units of 22%. This is broadly consistent with Scottish data of 20%, however, transfer times are known to be longer in Scotland (median 2 hours) compared to England (mean 0.5 hours). Births in the 23 freestanding midwifery units across Scotland account for about 3% of all Scottish births. The findings as to maternity services in 14

15 Scotland are influenced by geographical and transport factors as well as by service configuration parameters such as degree of cooperation between care settings and booking and transfer criteria. With robust criteria for risk assessment and effective transfer protocols, births planned in freestanding midwife-led maternity units are associated with the same level of safety for low risk mothers and infants when compared with births planned in consultant-led obstetric units. The Refreshed Framework for Maternity Care in Scotland (2011) recommends that the choice of where and how to give birth should be reached using a process of decision making where the clinician and the women are partners in ensuring the woman and baby are as safe as possible. The locality groups noted that the document quotes intrapartum transfer rates of 21.9% for England which is significantly different from the 43.4% transfer rate from Berwick on the last available figures. The document Safer childbirth: minimum standards for the organisation and delivery of care in labour published jointly in October 2007 by four medical royal colleges, the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives, the Royal College of Anaesthetists and the Royal College of Paediatrics and Child Health is also relevant. It states that in rural areas with a low number of births, usually less than 30 a year, the centre may open for a birth and close when the woman returns home a few hours later. The evidence suggests that free standing midwifery led units are safe, however, there are remaining concerns about the previous intrapartum transfer rate at Berwick. The on call midwife model is quoted by the RCOG and enquiries around other rural areas including Scotland and Cumbria suggest that this is the norm for units with low numbers of births. Cumbria operates a free standing midwifery-led unit in Penrith, delivering about 30 babies a year, which is staffed 8 hours a day, seven days a week with a rota of two on call midwives providing cover for the remaining hours. Other rural areas such as North Yorkshire are considering creating free standing midwifery-led units but have stipulated a minimum requirement of 300 births a year. All the other free standing midwifery-led units with fewer than 100 births a year in the England and Scotland operate a midwife on call system with many only opening as needed Patient Choice The locality groups noted that under both options low risk women will still be able to deliver their babies in Berwick (either in the hospital or at home) if they wish to do so or to deliver at a consultant-led unit such as at Wansbeck, Borders or the Royal Victoria Infirmary. For high risk women the situation remains the same in that they need to deliver in a consultant-led unit so that they have immediate access to medical and emergency facilities should these be needed. 15

16 Following comments received during the consultation, the CCG and Northumbria Healthcare have agreed that better information is needed for women to help inform their choice over place of delivery. 3 Feedback from locality meetings At the meetings held in May it was acknowledged by the locality groups that neither option offers an optimal solution. Members felt that the disadvantages listed in its safety review report by Northumbria Healthcare for Option 1 could be applied easily to Option 2. There were comments that for both options, given the small number of births involved, there could be ongoing quality and safety concerns and it was clear that there had been a great deal of consideration given to quality and safety by all locality groups. Also, some felt that the same argument about difficulty in recruiting midwives could be applied to either option. In reflecting on their legal requirements under the Health and Social Care Act, namely that they exercise their functions efficiently, effectively and economically, members considered the overall number of pregnancies in Berwick and the surrounding area, where deliveries were taking place, of which only 13 were at Berwick Maternity Unit during 2011/12. At the west meeting there were comments that this level of births was nowhere near enough. The low bed occupancy in the unit was discussed at all groups but they were mindful, particularly at the north locality meeting, that the inpatient postnatal service that has previously been provided at Berwick has been valued by local women. Although the focus has been very much on providing a safe service, with recognition that safety and quality are paramount, as part of their statutory requirements they reflected on the economics of a future service. In doing so they acknowledged that it already costs considerably more to deliver a baby in Berwick than at the Trust s other midwifery-led units. In terms of the national requirements in relation to reconfiguration, they reflected on the process for public consultation and on the comments which had been received from members of the public and other stakeholders. These included comments that a six hour postnatal stay was not long enough, the concerns about where women would go to for advice if the unit was closed (i.e. under Option 2) and about where the on-call midwives would travel from and what problems the midwives might face travelling from home to the unit in extreme weather conditions. They also reflected on comments about ambulance availability and the difficulties involved in travelling long distances to the consultant-led units. They recognised how much local women had valued the service they had received at Berwick and that they wanted to have as much of their maternity care as possible at Berwick. At the north locality meeting there was consideration of what could be done to 16

17 address some of the concerns that had been raised locally and there was a discussion about what the enhanced community midwifery service would actually include. During a discussion around cover arrangements for on-call midwives, there was a strong message from practice representatives that if Option 2 is agreed and if low risk women decide to deliver in the Berwick unit, then this should happen unless they need to be transferred to another hospital for clinical reasons i.e. there should not be a situation where there isn t a midwife available. At the north locality meeting, in particular, there had previously been two comprehensive updates on the process for public consultation and emerging themes, when it was felt that significant efforts were being made to engage all local stakeholders. Members considered the plethora of national guidance that now exists to help determine whether or not a woman is eligible to give birth in a free standing midwifery-led unit. They noted that the Berwick unit has the smallest number of deliveries of any free standing midwifery-led unit in England and the on-call models of care that appear to be providing a satisfactory service in Penrith, Cumbria and in rural areas in Scotland. In fact, all of the other free standing units with fewer than 100 births a year in England and Scotland operate a midwife on-call system with many only opening as needed. They were mindful that both options would enable low risk women to maintain their choice of delivering their babies at Berwick if they wished. At the north locality meeting there were some members who said they would prefer to see Option 1 introduced, most of whom said they had focused more on patient choice and that they had taken economics out of their deliberations. On the other hand, some who indicated a preference for Option 2 had considered bed usage at the Berwick maternity unit and overall costs as well as patient choice. At the central and Blyth Valley meetings, members were unanimous in their support for Option 2. Overall, the feeling was that while neither option provides the perfect model of care, or indeed addresses all of the concerns and comments made by local people, if midwifery-led care is to continue at Berwick, that with some amendments, Option 2 was the better way forward. It is a model that seems to be working well in other midwifery-led units across the country. However, at every locality meeting there were comments about the need to learn lessons from the Berwick safety review and consider them across Northumberland. Some felt that the provision of enhanced community midwifery care in Berwick would result in an inequitable situation in that this service is not available to other pregnant women and new mothers in other parts of Northumberland. At the Blyth Valley group there were comments that their local women do not receive enhanced postnatal community support. There were also feelings expressed that lengthy postnatal stays following delivery were not an appropriate model of care. 17

18 4 Discussion There have been extensive discussions around the future arrangements of midwifery-led care in Berwick since last summer when Northumbria Healthcare suspended deliveries and inpatient postnatal care following two incidents which raised serious concerns about safety. It must be stressed that in reaching a decision on the way forward, quality and safety are paramount. Over a number of years, the model of care that has developed in Berwick is one where women receive most of their antenatal care locally, deliver their babies at other units, mainly Wansbeck and Borders, where the full range of maternity care is available and then some have come back to the unit at Berwick for postnatal care, in some cases for several days. As such the unit has the smallest number of deliveries of any free standing midwifery-led unit in England. Women who have used the inpatient postnatal service have said that they valued the support they received for breastfeeding, general care of the baby and having a midwife at hand to offer advice and support. Even so, the unit was empty for a third of the year and for another third there was only one bed occupied. There is no doubt that people in Berwick and the surrounding area feel strongly that maternity services should be retained in the town. This has been a clear message throughout from the Save the Berwick Maternity Unit group and from other local groups and individuals. The strength of these views was recognised from the outset and as such there has been no focus on closing the unit but on trying to find a solution that is safe and sustainable and one that would result in women receiving as much of their maternity care locally as possible. However, there is no easy answer. As outlined in the previous section, this was recognised by the representatives from the CCG s member practices who reflected in locality meetings the outcome of their own local discussions. Safety and quality were identified as of central importance and they felt there were quality and safety issues for both options, given the low number of deliveries and the likelihood that there would be no significant increase, due to national guidelines around eligibility and women exercising choice about place of delivery. They also recognised that there could be similar staffing issues for either option i.e. around difficulties in recruiting midwives. Overall, taking all of the evidence before them into consideration, they felt that while neither option offers an optimal model of care, Option 2 was the better approach. While noting that the on call model of care appears to be working satisfactorily in 18

19 Penrith and parts of Scotland, they deliberated on the potential difficulties for on call midwives travelling into the unit, for example, in extreme weather conditions. The north locality group was also clear that if Option 2 was considered to be the way forward, then there would need to be assurances that the service would be there for women when they needed it. They were clear that if a low risk woman chooses to deliver at Berwick, she should only be transferred to another unit for clinical reasons and not because of staffing difficulties (although clearly recognising that for either option if staff are not available due, for example, to sudden sickness, transfer may be in the interests of the mother and baby). It was also noted that all other free standing midwifery-led units (outside Northumberland) in England and Wales with fewer than 100 births a year operate a midwife on call system, many opening only when needed. The public consultation was extensive and included independent research targeting women of child bearing age, a survey that was independently evaluated and 29 meetings (three of which were public and 12 were with people who had recent experience of maternity services). There were also 42 comments received (from 37 people and organisations). Overall, a mix of views was expressed. While the independent research (including the survey) showed more in favour of Option 1, there were still a significant number who favoured Option 2 or who were unsure. In the two Berwick public meetings which were attended by members of the Save the Berwick Maternity Unit group, town and county councillors, midwives and healthcare assistants, the MP and other local stakeholders from the local community, there were strong views expressed about Option 1. At both of the Berwick public meetings, references were made to the petition that had been organised by the Save the Berwick Maternity Unit group which had resulted in more than 4,000 signatures. In fact, there were two petitions, one online and the other paper copy, which were started shortly after the announcement that some maternity services were being suspended by the Trust. Both petitions were calling for the unit to be re-opened and were stressing the importance of women being able to deliver their babies in Berwick. Both were started before the Trust published its safety review which outlined the two options (both of which would result in women being able to deliver their babies in Berwick) and perhaps at a time when local people feared that the unit would close altogether. In meetings with mothers who had young children, most had not delivered their babies at Berwick, although they had used and valued the antenatal services there and some had returned there for inpatient care and again, this had been much valued. Their focus was generally less on expressing strong views on either option but more on what their own experiences had been. In many cases their experiences were fairly recent and there was a recognition that for safety reasons some women will always have to deliver at a unit where there is the full maternity team present in case of complications and also that while they would wish to have as much of their antenatal care as possible locally, some women will choose to deliver in a consultant-led unit. 19

20 Clinicians who responded to the consultation, including the NHS North of Tyne Maternity Partnership were more focused on safety and the Royal College of Midwives was clear in its support for Option 2. However, it is clear that no matter how the service is provided in the future, that it will need careful monitoring to ensure that the highest safety levels are met. The CCG will need to receive regular reports from the Trust during contract meetings. This will include considering data on usage of the service and on patient satisfaction and experience levels. 5 Equality impact assessment Before reaching a decision about the future model of midwifery-led care for Berwick, members of the Joint Locality Executive Board also need to consider an equality impact assessment of both options. This is attached as Appendix C. 6 Addressing issues raised There have been regular meetings between colleagues from the CCG and Northumbria Healthcare to discuss the Berwick maternity situation and to receive updates on the emerging themes from the consultation. The following table sets out the main themes that have emerged and possible solutions. Theme Issue Possible solution In patient postnatal care Six hours postnatal inpatient care is not enough and is too prescriptive. It is recognised that this reference was unpopular and possibly influenced the preferences expressed by people about the options. The decision to discharge should be based on clinical need, rather than on the number of hours post-delivery. Any reference to time restrictions should be removed from Option 2. The Trust has already given assurances publicly that if a woman delivered late in the evening she wouldn t be expected to leave the unit overnight and would be able to stay throughout the day if she wished. 20

21 Around the clock advice and support If unit is not open all the time, how will women get advice? There is 24 hour midwifery telephone advice available which any pregnant woman who needs advice would be encouraged to use. The call would be answered by a midwife at Wansbeck General Hospital maternity unit, who work very closely with the Berwick midwives. This is a central telephone, which is staffed around the clock. Enhanced postnatal community support What will this include? Taking into account comments that have been received during the public consultation, the Trust has said that the enhanced postnatal community midwifery service could include: Daily telephone contact by a trained healthcare assistant/midwife following discharge, to give any immediate advice and signpost to relevant services if required. Home visits by trained health care assistants to offer support with feeding, and infant care i.e. bathing, general baby wellbeing and such visits would be arranged according to identified individualised needs. Drop in postnatal care at the unit provided by qualified midwives and healthcare assistants to address any wellbeing concerns for mum or baby including full breast feeding support - if necessary, mums will be able to stay in the unit during opening times to receive feeding support. The Trust has also said that the enhanced community midwifery service would also enable greater links with local organisations such as Sure Start. 21

22 On-call midwife availability Travelling/distances involved How will women contact the on-call midwife? Concerns that expectant mothers will need to make more than one call before speaking to a local midwife. Concerns that in extreme weather conditions, midwives may not be able to get to the unit in time. General concerns about the distance women in Berwick and the surrounding area have to travel for maternity care. Concerns about travelling to Wansbeck or Borders, believing they are in labour, only to be turned away and asked to come back later, which for some has meant travelling back to hospital within hours. When the unit is closed (i.e. overnight when no patients are present), women would be advised to ring through to the 24 hour midwifery telephone advice number. There would be two midwives on call every evening who would be available for advice and support. The Trust would always have a good idea of which women were due to deliver at Berwick at any one time. Over a prolonged period of extreme weather (which would affect all services), it would make contingency arrangements to ensure that women were able to deliver safely, with the right support. Unfortunately, due to the geography and to their individual clinical circumstances, some women are always going to have to travel for their maternity care. Low risk full term women can call the Berwick midwifery-led unit for advice but for high risk women, delays in seeking advice from the consultant-led unit should be avoided. However, the Trust has already taken into account comments that have been received from women about avoidable travelling. It has established a dedicated triage area in the maternity unit at Wansbeck where a woman can stay, following triage, and be observed over a couple of hours. It is hoped that this will minimise the possibility of a woman going back home because she is not in labour and then having to return to the hospital almost immediately because labour has started. 22