THE QUALITY OF MATERNITY SERVICES IN LONDON: A SUMMARY OF THE HEALTHCARE COMMISSION SURVEYS KEY MESSAGES FOR LONDON:

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1 THE QUALITY OF MATERNITY SERVICES IN LONDON: A SUMMARY OF THE HEALTHCARE COMMISSION SURVEYS KEY MESSAGES FOR LONDON: London is different: the mobility and diversity of London s pregnant mothers together with recruitment and retention issues of staff make the provision of informed choices for mothers very challenging. The significant variation in quality of care between London s trusts means that good quality is achievable for some, and that the solutions should be shared across maternity networks. London leads the country on Down Syndrome screening although the take-up of best screening practice still varies between trusts. Outcomes and access to evidence -based interventions between ethnic groups will need to be monitored too to ensure the quality of care improves for all especially women at great risk of poor outcomes. SCOPE This paper provides a short summary of the key London findings of the two parts of the national maternity survey carried out by the Healthcare Commission 1 in Full details of the survey and its methods can be found at: It should be read in conjunction with the LHO briefing Born equal? that reports on inequalities in maternity outcomes. 2 INTRODUCTION Maternity services account for about births in England each year - with about births in London 3. But in recent years these services have become a cause for concern. The Healthcare Commission has investigated potentially serious issues affecting maternity services at three separate trusts, including Northwick Park Hospital in London 4, and found worrying similarities in the problems identified mainly relating to poor staffing practices and shortages of staff. The Commission s review of maternity services was set up in response to these concerns. The review was conducted in two parts, one was a survey of mothers (published November 2007)) and the other was a survey of trusts who deliver maternity care (published January 2008).

2 SECTION A: THE TRUST SURVEY The trust survey focused on whether trusts provide a high quality, value for money maternity service in order to set some benchmarks for service delivery. The assessment took into account guidance from NICE and the National Service Framework for maternity services 5. This will allow trusts to monitor performance and provide a baseline for a followup review by the Healthcare Commission. Performance was rated using four categories with no trust found to be delivering unsafe services: Least well performing (scoring 1): Fair performing (scoring 2): Better performing (scoring 3): Best performing (scoring 4-5): trusts in this category are not unsafe but show evidence of not delivering care in key areas and need to improve. trusts would benefit from improving care in one or more of the key areas. trusts are performing well in some key areas but demonstrate scope for improvement in others. the highest level of performance where trusts perform better than others in a range of key areas. 1. Overall performance for London s trusts delivering maternity services 27 trusts in London deliver maternity care, including the five Foundation hospitals and nine teaching hospitals. 1/27 was scored as better performing 1 teaching hospital: Guy's and St Thomas's NHS Foundation Trust 7/27 scored as fair performing 3 teaching hospitals: Kings College Hospital NHS Foundation Trust Royal Free Hampstead NHS Trust University College London Hospitals NHS Foundation Trust 4 non-teaching hospitals: North West London Hospitals NHS Trust Queen Elizabeth Hospital NHS Trust West Middlesex University Hospital NHS Trust Whipps Cross University Hospital NHS Trust 19/27 scored as least well performing 5 teaching hospitals: Barts and The London NHS Trust Chelsea and Westminster Hospital NHS Foundation Trust Hammersmith Hospitals NHS Trust St Georges Healthcare NHS Trust St Mary's NHS Trust 2

3 14 non-teaching hospitals: Barking, Havering and Redbridge Hospitals NHS Trust Barnet and Chase Farm Hospitals NHS Trust Bromley Hospitals NHS Trust Ealing Hospital NHS Trust Epsom and St Helier University Hospitals NHS Trust Hillingdon Hospital NHS Trust Homerton University Hospital NHS Foundation Trust Kingston Hospital NHS Trust Lewisham Hospital NHS Trust Mayday Healthcare NHS Trust Newham University Hospital NHS Trust North Middlesex University Hospital NHS Trust Queen Mary s Sidcup NHS Trust Whittington Hospital NHS Trust 2. Specific assessment The Healthcare Commission assessed trusts maternity services in three areas - clinical focus, women-centred care, and efficiency and capability using 25 indicators of performance that were designed to assess services that trusts would normally be expected to deliver (see appendix 1 for a list of indicators). Organisations with an average performance were scored as three. Those with a poorer performance scored one or two. Those with a better performance scored four or five. No London trust scored four or five. Figures for the average across the whole of England are given in brackets against the London average score. Clinical focus score This score reflects the views of clinicians and looks at the extent to which the trust is meeting the guidelines for best clinical practice, including availability of NICE recommended guidance on screening, appropriate caesarean and postnatal care 6. Average score for London: (3.037) Teaching hospitals average score: Highest: Royal Free Hampstead NHS Trust and University College London Hospitals: Lowest: Chelsea & Westminster: Non-teaching hospital average score: Lowest: Barking, Havering & Redbridge Hospitals Highest: Lewisham Hospital NHS Trust

4 Variation across London in scoring for clinical focus Score (1-5) Barking, Havering an... Barnet and Chase Fa.. Barts and The Londo... Bromley Hospitals NH... Chelsea and Westmin... Epsom and St Helier U... Ealing Hospital NHS Trust Guy's and St Thomas'... Hillingdon Hospital NH... Hammersmith Hospital... Kings College Hospita... Homerton University... Newham University... Kingston Hospital NH... Lewisham Hospital N.. Mayday Healthcare N.. North Middlesex Unive... NHS Trust North West London H... Royal Free Hampstea... Queen Elizabeth Hospit.. Queen Marys Sidcup... St Mary's NHS Trust St Georges Healthcar... University College Lo... West Middlesex Univer... Whittington Hospital... Whipps Cross Univers... Women-centred care score Many of these indicators are based on women s views of their maternity care. They cover access to antenatal care, choice in labour and the quality of support in caring for the baby after discharge. Average score for London: (3.031) Teaching hospitals average score: Highest: Guy's and St Thomas's NHS Foundation Trust and Hammersmith Hospitals NHS Trust Lowest: St Georges Healthcare NHS Trust Non-teaching hospitals average score: Highest: Queen Mary s Sidcup NHS Trust Lowest: Barking, Havering & Redbridge Hospitals Variation across London trusts for scoring in women-centred care Score (1-5) Barking, Havering an... Barnet and Chase Fa.. Barts and The Londo... Bromley Hospitals NH... Chelsea and Westmin... Guy's and St Thomas.. Epsom and St Helier U... Ealing Hospital NHS Trust Hammersmith Hospita.. Homerton University... Kings College Hospita... Kingston Hospital NHS... Hillingdon Hospital NH... Lewisham Hospital N.. Mayday Healthcare N.. Newham University... Queen Elizabeth Hospi... North Middlesex Unive... North West London H... NHS Trust Queen Marys Sidcup... St Georges Healthca.. Royal Free Hampstea... St Mary's NHS Trust University College Lo... West Middlesex Unive... Whipps Cross Universi.. Whittington Hospital N.. 4

5 Efficiency and capability score This score covers staffing levels, appropriate involvement of obstetricians and midwives in antenatal care, cost per delivery and the homeliness of the delivery room. Average score for London: (3.014) Teaching hospitals average score: Highest: Royal Free Hampstead NHS Trust Lowest: Barts & The London NHS Trust and Chelsea and Westminster Hospital Non-teaching hospitals average score: Highest: North West London Hospitals Lowest: Homerton University Hospital and Newham University Hospital NHS Trust Variation across London in scoring for efficiency & capability Score (1-5) Barnet and Chase Farm... Barking, Havering and R... Barts and The London N.. Bromley Hospitals NHS T... Chelsea and Westminste... Ealing Hospital NHS Trust Epsom and St Helier Uni... Guy's and St Thomas's... Hammersmith Hospitals... Hillingdon Hospital NHS T... Homerton University Hos... Kings College Hospital N.. Kingston Hospital NHS Trust Lewisham Hospital NHS... Mayday Healthcare NHS... Queen Elizabeth Hospita... Newham University Hospi... North Middlesex Universi.. North West London Hospi... NHS Trust St Georges Healthcare... Queen Marys Sidcup NH... Royal Free Hampstead N.. St Mary's NHS Trust University College Lond.. West Middlesex Universi.. Whipps Cross Universit... Whittington Hospital NHS... 5

6 SECTION B: SURVEY OF MOTHERS The survey was carried out on mothers who gave birth in January and February of 2007 in 151 trusts in England. 148 acute hospital trusts provided data, of which 27 were in London and two were PCTs that provide maternity services. Questionnaires were sent to almost women to ask them about their experiences of maternity care. Over women took part, a response rate of 59% of these women were in London. Main findings for London Many of the sub-tables for London hospital trusts show very similar findings to the averages for England, and in general maternity services were deemed good by mothers. However there are some important differences. 1. Greater proportion of underweight and pre-term babies in London In nine hospitals of the survey in England >10% of the babies born were underweight (<2500g). Five of these hospitals were in London, namely Barts and the London, Ealing, Mayday, Newham and Lewisham. Some of these (Ealing, Newham and Lewisham) also showed over 10% babies born being pre-term (<37 weeks gestation) which may explain some of the higher proportion of underweight babies. 2. Pregnancy care in London 2a) Which health professional to consult? More women in London (89%) than on average in England (78%) consult a GP first about pregnancy, rather than a midwife. Only 8% on average of London mothers consulted a midwife, compared with 19% across England. 2b) Where to be born? There appears to be less choice given to mothers in London about where to give birth to their baby than other parts of England. Only 73% across London, compared with 81% in England, stated they were given a choice about where to give birth. One trust, the Mayday Hospital, found that 57% of mothers said they were not given a choice at the start of their pregnancy. 2c) Home births. 55% of London mothers stated they were not given the choice to have their baby at home (as recommended by NICE), compared with 43% on average across England. However, in certain trusts in London, this proportion was even lower - 24% in Chelsea and Westminster Hospital, 26% in both Hammersmith and St Mary s Hospitals and 27% in Newham University Hospital. These were the least well performing hospitals for offering the home birth option in the country, but this could be because these PCTs manage the midwives who would be responsible for this, and there is a divide between hospital midwives and community midwives. 2d) Birth booking. The most common booking appointment time for a birth in London appeared to be later (12-18 weeks gestation) for more women (54%) than in the rest of England (38%). In most trusts in London over 60% of women booked later (12-18 or >19 weeks). It was not clear whether the late booking phenomenon was a result of variable access to information for mothers about how to book earlier, or a dilemma about wanting to have a home birth, and possibly not being able to have one, or for some other reason. 6

7 3. Antenatal care and check-ups 3a) Which health professional do women use in London? Whilst 98% of women in London said they saw a midwife for antenatal check-ups (99% across England), most women (74%) also saw a GP whilst only 47% across England saw a GP. 3b) Timely attention. 91% of women in England said they saw a health professional about their pregnancy as soon as they wanted and 90% of London mothers concurred with this. However, only 76% of women in London, against 90% of women in England, said they had the name and telephone number of a midwife they could contact during pregnancy, should any worries arise. 4. Pregnancy tests and scans 4a) Down s Syndrome. 34% of mothers in England did not want a screening test for Down s Syndrome (DS) whilst only 16% of mothers in London opted out of this test. The use of the Nuchal scan for DS was more prevalent in London, with 63% of mothers receiving this compared with only 37% in England as a whole. Only 30% in London were given a blood test alone for this, compared with 57% in England generally. However, this showed great variation from trust to trust in London. 4b) Consent for tests and ultrasound scans. In general, more London mothers than on average across England expressed the feeling that they did not have a choice about tests and scans. 20% felt they had no choice about a DS test (compared with the English average of 12%); 36% felt they had no choice about a dating ultrasound scan compared with the England average of 29%, and 33% said they had no choice about the 20 week pregnancy scan (27% for England). The majority of women in London (63%, the same as for England) opted for 2-3 scans in pregnancy. 5. Antenatal classes and general antenatal care. Despite the recommendation in the National Framework for Children, Young People and Maternity Services 5, 36% of women in London said they were not offered NHS antenatal classes. Responses ranged from 19% of all women at Bromley Hospitals saying they were not offered NHS classes, to 67% at Barking, Havering and Redbridge Hospitals. More London women had an overnight stay in hospital during pregnancy, before labour (21%) than on average in England (19%). Most antenatal classes were well attended (by 81% in London), and well appreciated. Most (84%) thought they were at a convenient time, and (94%) at a convenient place. Exceptions to this were in Barking Havering & Redbridge, Barnet & Chase Farm and Chelsea and Westminster Hospitals where >25% of mothers said classes were not at a convenient time. Only 58% of women in London (67% in England) thought they were involved enough always in decisions about their antenatal care. 5a) Partner s attendance. 92% of women in London (96% in England) stated that a partner or friend was allowed to attend antenatal classes. However, in three hospitals in London, over 23% of women stated this was not allowed: W. Middlesex with 30%; Epsom & St Helier with 28%, Kingston with 23%. 7

8 6. Care during labour and birth 6a) Cleanliness. In general, most women (95%) in London found the delivery rooms to be very clean (53%) or fairly clean (42%), but 18% found the toilets or bathrooms not very clean or not at all clean. There was considerable variation across hospitals in London but three hospitals scored badly for toilet/bathroom hygiene with 45% marking Barts & the London as unclean, 34% marking Chelsea and Westminster and 35% marking University College Hospital as unclean. 6b) Labour. Where labour was induced 49% of mothers in London felt they had no choice about this but this varied by hospital trust in London from 34%-64%, (43% nationwide felt this way). 89% of women in London, compared to 92% for England, said they definitely or to some extent received the pain relief they wanted. 7. Details of the birth The experience of London mothers is very much the same as in the rest of the country. 96% were born in hospital. A higher proportion (11% compared to 8% nationally) were transferred from one part of the hospital to another. 7a) Birth position. 59% of women in London gave birth either lying (31%) or lying with their legs supported in stirrups (28%). The most recently published NICE guidance recommends that for normal births women should be discouraged from having their baby in this position 5. At one hospital in London (Barts), 44% reported using stirrups, but only 14% at another (King s). Use of forceps or a vacuum cap are medical reasons that may require a women to give birth lying but only 12% of women had this type of birth in London. 8. Perceptions of staff care 8a) Being alone. 31% of women in London reported being left alone during labour or shortly after giving birth at a time that worried them, despite NICE guidelines recommending that women should not be left alone except for short periods. Looking at labour alone, 20% of women in London in one trust said they were left alone at a time that worried them, while 48% said this in another. In all of the London hospital trusts, 20% or more of women said they were left alone during labour at a time that worried them. 8b) How mothers were addressed. The majority of women said they were treated with kindness and understanding but beneath this there were variations. On average 77% of mothers in London (82% in England) said they were always spoken to in a way they could understand during labour and birth, but this varied from 63% in one trust to 88% in another in London. 72% of women (79% in England) said they were treated with respect and dignity, but this varied from 47% to 81% across different London hospitals. Similarly 69% of women in London (77% for England) said they were treated with kindness and understanding but this varied from only 43% (in Barts) to 83% in St Mary s. 9. Babies born at home. (no London data is available because numbers are too small) 8

9 10. Postnatal care in hospital 10a) Food. 23% of women in London said the food in hospital was poor. 73% said they had the right amount of food but 26% said they had had too little. At one trust in London only 15% of women said they had too little but 46% said this at another. There were 21 trusts in England where more than 30% of women said they did not get enough food, four of these were in London. b) Cleanliness. As in section 6 this was very variable. 11% of women in London said their hospital room or ward was not very clean or not at all clean while 26% said this of the toilets or bathrooms. At one trust (Barts) 63% of women said the toilets and bathrooms were not very clean or not at all clean, while at another trust (Whipps Cross) only 13% of women reported this. 11. Feeding the baby and 13. Care at home 34% of women in London (21% in England) said they would have liked to have seen a midwife more often after birth. 32% said their midwife did not discuss feeding their baby with them during pregnancy and 31% felt they did not receive practical help for feeding the baby but this varied from 18% to 41% by hospital within London. Most women (57%) saw a midwife 3-4 times after leaving hospital in London. However, 46% said their baby was aged 10 days or less on the occasion of the last visit by the midwife. Most mothers in London were given advice by a midwife or GP, in the six weeks after the birth of their baby on various issues - 62% for baby crying; 75% about the baby s sleeping position; 85% about feeding the baby; 66% about nappy rash; 87% regarding the baby s health and growth. 12. Babies needing special care. 88% of these babies were not cared for in a neonatal unit in London. 14. Demography London differs in the survey from the rest of England in that: a) 53% had had a previous pregnancy compared with 57% for all England. b) 68% are women aged 30 years or over, compared with 60% for all England. c) 77% speak English as their mother-tongue, compared with 92% for all respondents in England. d) only 66% in London were white whilst 87% of all respondents were white. e) 60% of London mothers were aged 19 or over when they left full-time education, whilst only 42% of all respondents were in this category. f) 12% of London mothers were from an Asian or Asian British background whilst only 7% of all respondents to the survey were from this ethnic group. Summary of maternal survey Overall 84% of women in London rated both their care in pregnancy, and during labour and birth as excellent, very good or good. 71% of mothers also gave this rating to their care after the birth, so in general maternity care in the NHS in London was seen to be positive. 9

10 REFERENCES 1. Review of maternity services London: Healthcare Commission, services.cfm#review 2. Born equal? A briefing on inequalities in infant mortality in London. London: London Health Observatory, Number and percentage of births London: London Health Observatory, Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April London: Healthcare Commission, National Service Framework for children, young people and maternity services: maternity services. London: Department of Health, ance/dh_ Gynaecology, pregnancy and childbirth compilation of guidelines. London: NICE, Acknowledgements We are grateful to Margaret Eames-Petersen, Head of Public Health Intelligence at the Acorns Public Health Research Unit, for her work in analysing the London data in the maternal survey. London Health Observatory 4 th Floor Southside, 105 Victoria St, London SW1E 6QT Tel: lhoenquiries@lho.nhs.uk February

11 Appendix 1: Indicators used in the trust survey Clinical focus score Womencentred care score Efficiency & capability score Indicator 1 Indicator 2 Indicator 3 Indicator 4 Indicator 5 Indicator 6 Indicator 7 Indicator 8 Indicator 9 Indicator 10 Indicator 11 Indicator 12 Indicator 13 Indicator 14 Indicator 15 Indicator 16 Indicator 17 Indicator 18 Indicator 19 Indicator 20 Indicator 21 Indicator 22 Indicator 23 Indicator 24 Indicator 25 Women not receiving NICE recommended number of antenatal appointments Availability of NICE recommended screening Appropriate use of caesarean sections Maternal morbidity Postnatal care of women and babies Progress on implementing mental health NICE guidance Extent that staff are trained in core maternity skills Safety culture Average time between first making contact and booking appointment Choice and continuity for antenatal care % Women offered an informed choice for screening tests % of women attending NHS antenatal classes who wanted to Extent of choice in labour Support for infant feeding Quality of support in caring for the baby after discharge Stakeholder involvement in service planning and evaluation Staffing levels Integration of support workers Average cost per delivery Delivery of hospital based antenatal care Data quality Appropriate involvement of obstetricians and midwives in antenatal care % women who considered their length of stay was about right Homeliness of delivery rooms Women s view of cleanliness of delivery and postnatal areas 11