better care, better outcomes - london clinical networks · 2015-06-18 · better care, better...

London Maternity Strategic Clinical Network

Date

Welcome from the London

Maternity SCN to

Better care, better outcomes

increasing satisfaction, improving quality and

using resources more effectively

Wednesday 10th June 2015

Introduction from the Co-Clinical Directors:

Professor Donald Peebles and Donna Ockenden

Welcome to the event

Housekeeping

Contents of the information pack provided

Evaluation forms

Format of the question and answer session scheduled for the end of the afternoon

Achievements of the London Maternity SCN

Development and recruitment

to Maternity Strategic Clinical

Leadership Group

Development and recruitment

to Maternity Commissioning Advisory Group

Set up of Models of care and Outcomes

working groups with subgroups

for identified work streams

Support to development of

five local maternity networks

across London

Work in progress and future priorities

Ongoing work

• User experience – use of film to promote improved care for women

during and after birth

• Maternal morbidity and mortality –development of London wide review

process for all maternal deaths

• Development of core maternity dataset to support outcomes of working

groups

• Development of maternity service specification for London

Planned future work areas

• Postnatal care including surgical infections, re-admission, use of safety

thermometer and rollout, enhanced recovery and decreased LOS

• Identification of high risk women

• Perinatal mental health

• Social and health inequalities

Session One – User experience



Date

‘In Their Shoes’

perspectives on

maternity care

Kath Evans, Head of Patient Experience – Maternity,

Newborn, Children and Young People, NHS England

10th June 2015

Introduction

• Improving service user experience in maternity care, a priority for NHS England

• Key policy drivers including the NHS Outcomes Framework, NICE guidelines and quality standards, national Audit Office report, the 6 C’s

• Critical to success is involving and engaging staff and service users

• The SCN as part of it’s user experience work have been working in collaboration with 5 hospitals in the London region to deliver five pilot user experience workshops using the ‘Whose Shoes’ tool

• In order to build on the outputs of the user experience workshops, a film has been developed as a training aid.

User experience film – ‘In Their Shoes’

• Aim / objective:

To explore the pregnancy journey and stand in the shoes of the user. The focus is the human voice as the user interacts with maternity services – the thoughts and feelings, concerns and joys.

• Purpose:

To promote understanding of the perspectives of others, challenge assumptions, harness empathy and compassion and improve professional practice.

• Target audience:

Health professionals working in maternity services

• Method of delivery:

Training workshops and user experience events / workshops

‘In Their Shoes’ – Perspectives on maternity care

https://youtu.be/UrsCeRHQ8XA

https://youtu.be/UrsCeRHQ8XA

Implementation

The film may be used in several ways:

Alongside mandatory or customer service training

As a motivational tool pre or post user experience workshops and as

a focus on improving outcomes

Discussion tool for team meetings / briefings

A training brief has also been developed in conjunction with the film

and it offers suggested ways in which the film might be used to

support training delivery in the following areas:

• Communication

• Quality Improvement

• Team Working

• Continuity of Care

Further information

• The film and training pack are available at the following link

• http://www.londonscn.nhs.uk/networks/maternity-childrens/maternity/

• If you would like to provide any feedback on the training pack or film, please email us on [email protected]

http://www.londonscn.nhs.uk/networks/maternity-childrens/maternity/






Date

Learning and actions

from pilot user

experience workshops

Florence Wilcock, SCN user experience lead, pilot

workshop leads and user representatives

10th June 2015

Introduction and context

• A priority for the London maternity SCN is improving women’s and

families experience of maternity care

• User subgroup planned as poor London performance in CQC maternity

survey 2013

• Snap shot survey March 2014 suggested basic communication & care sometimes lacking

• Looked for innovative way to explore issues

• Wanted a project to ‘light fires’ & get people thinking

• 5 pilot user experience workshops held across London & a ‘Train the

facilitators’ session using the ‘Whose Shoes’ concept

• Interactive workshops using bespoke maternity scenarios

Workshop aim

‘To use the workshop as an ‘ignition tool’ to build connections & relationships across the broad maternity community to enable true collaboration, co-design & ongoing conversations to improve maternity user experience.’

Principles of workshops

• Co – design / creativity

• Inclusivity

• Equality and respect

• Think differently

• Think beyond boundaries

• Local devolved leadership

• Essential to focus on action, work closely together and share results

• Next step to hear from users and the Trusts who have participated in the 5 pilot Whose Shoes workshops across London

Personal perspective on pilot workshops

• Leigh Kendall and Rosie Goode


Date

Pilot Workshop Kingston

Hospital NHS Foundation

Trust

Introduced by Florence Wilcock, Divisional

Director, Specialist Services Division,

Consultant Obstetrician

Kingston

TOP 4 achievements since ‘Whose shoes’

• MSLC - formed agenda for 15/16 around

workshop themes (utilising art work) and

creating a Mini ‘whose shoes’

• Development of local maternity notes with a

focus on creating a user friendly personalised

record

• 1 page profile development

• Development of website with a focus on

partners engagement

• Pledges developed into achievable actions

Kingston

• Social media - Important to utilise power to connect with

other providers of maternity services, individuals, charities

and business’

• Marketing - ‘whose shoes’ workshops to ensure

engagement of all levels of staff (chief exec to band 2s) to

raise the profile of maternity services within your trust.

• Encouraging wider participation – linking in with other

events e.g. NHS change day, Best beginning, Trust open day

etc.

• Publicising - the event to users and catering for their

practical needs (ensuring pram car park, changing facilities)

and ensuring they feel safe


Date

Pilot Workshop Lewisham

& Greenwich NHS Trust

Introduced by Helen Knower,

Head of Midwifery

• Whose Shoes?® workshop held in November 2014 (second pilot)

• Unit pledges

• To ban the words “Not allowed”

• Woman friendly handheld notes

Lewisham and Greenwich Experience

• South East London Maternity Network are

funding the roll out of the Whose Shoes

approach across the 3 Trusts

• Increase use of social media to keep it alive

• Involvement of all 6 Maternity Services Liaison

Committee chairs in helping to taking this

forward and assist with the monitoring of the

action plans

• Update newsletter distributed

•

Rolling Whose Shoes out across South East

London


Date

Pilot Workshop West

Middlesex University

Hospital

Introduced by Louise Page, Consultant

Obstetrician & Gynaecologist

The West Middlesex Experience

• Whose Shoes?® workshop held in December 2014

• Unit pledges

• Always Events

• Staff celebration board

• Pop up PALS

Speak Up!

• MSLC volunteers, MWs, Obstetricians, PALS

• Volunteers visiting different clinical areas

• AN Ward

• ANC

• PN Ward

• PN community clinics

• Questionnaires

• Mixture of tick box and free text

• Pilot underway May 2015

The West Middlesex Experience

• MW happy, kind, charming

• Appointments to fit in with school times

would be better

• “Feel like I have to push for answers”

• Pay and display parking – unpredictable

waiting times

• Put direction arrows on the floor rather

than on walls


Date

Pilot Workshop – Barking,

Havering & Redbridge

University Hospitals NHS

Trust

Introduced by Bernie Nipper, Supervisor of

Midwives

Queens Hospital (BHRUT)Workshop

Queens Hospital (BHRUT) Workshop

On the day

Whose Shoes? - Maternity Experience workshop - YouTube

• BHRUT found the whole experience an excellent way for staff to

work with the women who use the service and to share ideas.

• Most importantly it helped us to reflect on our current practices

and make pledges which have been acted upon within the

maternity unit to improve the experience of women and their

families.

• The women were very complimentary of our services and

encouraged us to share good news stories amongst the local

community.

https://www.youtube.com/watch?v=n1Xgv2h-CXQ







Queens Hospital (BHRUT) Action Plan

• Track impact & actions taken from user feedback e.g. walk the

patch/complaints/NHS Choices

• Take real notice of friends and family – to create positive

experiences (staff & women)

• More good stories share with Commissioners and with press locally

and nationally

• More investment in IT – to go paper light – for safety / demonstrate

improvements/safe guarding/ Audit.

• Share positive work stories of individual cases not just the negative

both locally & nationally.

• Share good news – more positivity – the importance of words and

body language.

• More user representation at the MSLC

• Debriefing service - offered to women and their families.


Date

Pilot Workshop – Whittington

Health NHS Trust

Introduced by Rosemary Hensman,

Consultant Midwife

& Marsha Jones, Lead Midwife

Whittington Hospital NHS Trust

• Discharge Planning Project

• MSLC

• ‘Being Our Best’- front of house

• Patient Experience workshop

• Celebration event for staff

Whittington Hospital NHS Trust


• Whose shoes workshops: Guernsey, SE

London

• #MatExp grass roots collaborative campaign

• Twitter & Face Book

• Matexp.org.uk launched 1st June

• Flaming June month of action

• Link to RCM Better Births

• Links to RCOG

• Link to National maternity review

Session Two – Continuity of care



Date

Better Care,

Better Outcomes

Continuity of Care - Understanding the

Challenges

Professor Jane Sandall King’s College, London

Case studies from the London Units

Continuity Of Care Toolkit

Project group:

• Jane Sandall - Professor of Social Science and Women's Health, King’s

College London

• Kate Brintworth – Local Supervising Authority Support Midwife

• Jenny Blundell – General Manager, Women's Services - Guy's and St

Thomas' NHS Foundation Trust

• Sarah Espenhahn - co-Chair of West Middlesex MSLC

• Caroline Moren – SCN Maternity Lead and Senior Project Manager

• Daryl Miller – SCN Maternity Project Manager

Overview

Aim: To increase the number of women accessing continuity of midwife care in London.

• Part of the London Maternity Strategic Clinical Network’s strategy to

identify areas of good practice for implementation across all

maternity units in the capital, ensuring equally good outcomes for all

pregnant women and their babies.

Background & Rationale

A woman who receives care from a known midwife is more likely to:

• Have a vaginal birth.

• Have fewer interventions during birth.

• Have a more positive experience of labour and birth.

• Successfully breastfeed her baby.

• Less likely to have a preterm birth

• Cost the health system less.

Current policy and guidelines

“every woman has a

named midwife who is

responsible for ensuring

she has personalised,

one-to-one care

throughout pregnancy,

childbirth and during the

postnatal period,

including additional

support for those who

have a maternal health

concern’ (p17) DH 2012

“Patients experience

continuity of care

delivered, whenever

possible, by the

same healthcare

professional or team

throughout a single

episode of care”

NICE Quality

statement 1.

Women’s Experience of continuity of care

(CQC 2013)

“After-care could have been better by seeing the same midwife. I was given

differing information from the four different midwives I was seen by - very

contradictory and confusing. This caused emotional upset to myself and difficulty

to the rest of my family. Continuity of care was non-existent.”

“I am really pleased with the continuity I received in my antenatal and postnatal

care - predominantly seeing the same midwife with the exception of her being on

annual leave or days off. I felt this contributed to a positive experience in the care

I received despite a difficult and traumatic labour and delivery.”

Knowing your midwife by location

To know and to be known to members of the team who will

potentially be looking after her

during pregnancy, labour and postnatally;

To be sure that their information is passed onto

each member of the team on

referral, handover and

transfer;

To see the same midwife/midwife team throughout

pregnancy, labour and

during the early postnatal period;

To have a midwife they know staying

with them throughout labour and

delivering their baby.

What do women want ?

NHS London (2010) What women and their families need and want from a

maternity service: overview of existing data

43

What do we mean ?

Midwifery continuity of carer (MCoC) models are where

midwifery care is provided by the same midwife or by a small group

of midwives for a woman.

The woman is able to get to know this midwife/ small group of

midwives throughout an entire pregnancy. This care begins in

early pregnancy, continues through pregnancy, labour and birth, to the

end of the postnatal period.

44

How do we provide it ?

Team midwifery care

• Antenatal, intrapartum and postnatal care is

provided by a small team of midwives (size

varies but usually six to eight) in

collaboration with doctors in the event of

identified risk factors. Intrapartum care can

be provided in a hospital, MLU or home.

• Midwifery Group Practice caseload care

• Antenatal, intrapartum and postnatal care is

provided by a known named midwife with

secondary backup midwife/midwives

providing out of hours cover and

assistance with collaboration with doctors

in the event of identified risk factors.

Women who received models of midwife-led continuity of care

were nearly eight times more likely to be attended at birth by a

known midwife, were :

What are the results ?

19% less likely to lose their baby

before 24 weeks,

23% less likely to experience pre-

term birth,

17% less likely to have regional

analgesia,

12% less likely to have instrumental

birth,

16% less likely to have an

episiotomy, and significantly more

likely to have a spontaneous vaginal birth.

Sandall J, et al Cochrane Database of Systematic Reviews 2013, Issue 8.

Impact on socially vulnerable women

Inclusion criteria

Domestic violence

Homelessness

Mental health issues

Substance and/or alcohol abuse

Asylum seekers or refugees

Learning difficulties

Travelling community

Safeguarding issues

Provision of continuity of care to women with social

and medical complications has the potential to

improve outcomes (NICE guidelines, 2010),

however there has been little formal evaluation of

current service models .

Boy & Salihu 2004, King-Hele et al 2009,

NICE 2010, CMACE 2011)

Women receiving caseload care were more significantly

more likely to experience;

• Spontaneous vaginal delivery (80% vs. 55%),

• Birth in the midwife led centre (26% vs.13%),

• Assessment by 10 weeks gestation (24% vs. 8%),

• Shorter postnatal stay (1 day vs. 3 days and know their midwife (90% vs. 8%).

• More women in the caseload group were referred to multidisciplinary support services; psychiatry (56% vs. 19%), domestic violence advocacy (42% vs.18%) and other services (56% vs. 31%).

They were significantly less

likely to experience;

• A caesarean section (11% vs. 33%),

• An epidural/spinal for pain relief (35% vs. 56%),

• Give birth on the labour ward (70% vs. 88%),

• fewer antenatal admissions and neonatal unit admissions (4% vs. 18%).

Outcomes


Date

Continuity of Care -

The Case Studies

Presented by representatives from the

participating Trusts

Continuity of Care - The Case teams at the trusts

Imperial Healthcare

Guy’s and St

Thomas’

Royal Free Hospitals

& Kings College Hospital NHS

Foundation Trust

Case Studies

Case Studies were produced to support the toolkit

The Panel

• Interviewer – Daryl Miller (Maternity SCN)

• Jenny Blundell - General Manager, Women's Services - Guy's and

St Thomas' NHS Foundation Trust

• Mitra Bakhtiari - Midwifery Matron/Supervisor of midwives/

Guy's and St Thomas' NHS Foundation Trust

• Jude Bayly – Named Midwife for Child Protection and Vulnerable

Families, The Royal Free Hospital

• Pauline Cooke – Consultant Midwife, The Imperial Hospital

• Sadie Holland – Midwife, Kings College Hospital NHS Foundation

Trust

• Vanessa James - Team Leader, Kings College Hospital NHS

Foundation Trust

Service User and Midwife

Robyn Jobson - Service User, Guy's and St Thomas'

NHS Foundation Trust

Lauren Chandler – Midwife Guy's and St Thomas' NHS

Foundation Trust

REFRESHMENT BREAK

REFRESHMENT BREAK


Session Three – Increase births in

midwifery-led settings



Date

Increasing the number of births at

home and in midwifery led units:

A best practice toolkit

MLU Subgroup

10th June 2015

MLU toolkit

Project group:

• Jessica Read, LSA Midwifery Officer, NHSE London

• Sarah Dunsdon, Senior Project Manager, SCN, NHSE London

• Pauline Cooke, Consultant Midwife, Imperial College Healthcare NHS

Trust

• Cathy Rogers, Consultant Midwife, Royal Free London NHS Foundation

Trust

• Gina Brockwell, Consultant Midwife / Supervisor of Midwives, Croydon

Health Services NHS Trust

• Rose Villar, Consultant Midwife, Royal Free London NHS Foundation

Trust

• Kirstie Coxon, Senior lecturer, King’s College London

• Logan Vanlessen, Consultant Midwife Public Health / Supervisor of

Midwives, Whittington

• Jane Sandall, Professor of Social Science and Women's Health, King’s

College London

Overview

• Aim: To increase the number of eligible women accessing

midwifery led settings in London (midwifery led units and

home births)

Reducing variation in London

Reducing the need for women to move between Trusts to

access services / facilities

• Population: Healthy women with uncomplicated pregnancies

entering labour at low risk of developing intrapartum

complications

Background and rationale

Core evidence base

Birthplace cohort study

NICE Intrapartum Care clinical guideline, 2014

Picture in London

Increase in birth centre services

Decline in home birth rate

Maternity services survey in London, 2014:

less than half of women felt they were offered a choice of giving birth in

an AMU or FMU

only a quarter felt that they were offered a choice of giving birth at home

Background and rationale

Figures for percentage of women utilising home birth and MLU settings over the past three years:

Year Rate in London

14/15 16%

13/14 15%

12/13: 13.5%

45% of women at the end of pregnancy are eligible

to access midwifery led settings

London wide definitions

• To be able to compare outcome data standardised definitions should be adopted by all units.

Definitions include:

• Alongside midwifery unit (AMU) –from Birthplace study

• Freestanding midwifery unit (FMU) –from Birthplace study

• Normal birth –from Maternity Care Working Party statement

Guidelines

• All women should be given evidence based information and advice about all available settings

• This includes information about outcomes, risks, benefits and consequences for the different settings

• Statistics should be provided for local birth settings including:

access to facilities (such as birth pools) and pain relief

access to midwives

and medical staff

the likelihood of

being transferred to an

obstetric unit – reasons why

and time it may take

Staffing considerations

• Safe staffing levels of midwives and support staff should be ring fenced and maintained, reviewed and audited annually

• Women should receive one to one care during labour

• One WTE consultant midwife is recommended for every 1:900 normal births, and the consultant midwife should provide leadership

• Each unit should have an

appropriate skill mix that supports

MLU activities

Recommendations for action

• Maternity services should accommodate an AMU and facilitate home birth

• Facilities should promote the wellbeing of women and their needs

• Facilities and equipment should support the promotion of normal birth

• Environment should

• promote privacy and

dignity.

• Sufficient pools should

be available

Guidelines

• Advise eligible nulliparous women that the rate of interventions is lower in a MLU and the outcome for the baby is no different compared with an obstetric unit

• Explain that if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby

• Ensure that there are robust protocols in place for transfer of care between settings

• Each unit should implement criteria / pathway from the NICE guideline for access to a midwifery led setting

• There must also be a clear pathway for women who are not eligible for AMU or FMU settings but wish to receive midwifery led care in those environments

Auditable standards

Each unit as a minimum should audit against the following standards:

• Percentage of women offered evidence based written information about planning place of birth

• Percentage of women offered the choice of planning birth at home or in a midwifery unit

• London Quality Standards for maternity services

• The number of women receiving intrapartum care and the number of births in each setting

• The number of primips utilising AMUs and FMUs

• The number of transfers and reasons

• The number and length of time that the AMU and FMU are closed and the home birth service is suspended

• Percentage of unexpected admissions to NICU

• Percentage of water births

Referral pathways

• Pathways should be defined for the following scenarios:

• Referrals directly from general practice to midwifery led units.

• For women who choose to self refer to midwives

Appendices

• Appendix 1 - Midwifery led pathway for eligible women accessing midwifery led settings.

Appendices

• Appendix 2 - Decision tree for place of birth - for midwives to use to help to provide women with information during birth place discussions.

The future

NHS 5 year forward view – reviewing future care models

Key considerations for midwifery led settings:

Role of freestanding units

Reducing health inequalities and improving outcomes and access for women who are low medical risk, high social risk

View from a service user

• Personal experience of accessing midwifery led settings in London

Toolkit implementation plan


Planned toolkit implemetation

London Maternity Strategic Clinical Network Proposed Implementation Plan – Maternity Toolkits

London Maternity

Networks x 5 – design

input

Maternity Strategic Clinical Network

Maternity Strategic

Clinical Leadership Group

Toolkit development and

sign off

Toolkit implementation

and audit plan sign off

London Maternity

Networks x 5 - design input

Des

ign

Ph

ase

Maternity Strategic Clinical Network

Maternity Strategic

Clinical Leadership Group

Imp

lem

en

tati

on

an

d A

ud

it

Ph

ase

Maternity Network Audit

of toolkits 5&6 Apr 2016

London Maternity

Networks x 5

Maternity Network Audit

of toolkits 1&2 Sept 2015

London Maternity

Networks x 5

Maternity network Audit

of toolkits 3&4 Jan 2016

London Maternity

Networks x 5

Collation of Data,

Benchmarking and

Shared Learning

Maternity Commissioning

Advisory Group

Question and answer panel session

Chairs: Donald Peebles and Donna Ockenden


Closing remarks

Donald Peebles and Donna Ockenden


Thank you for attending today

Please don’t forget to complete your evaluation

forms and have a safe trip home

Website and contact e-mail

All presentations and links can be found at the

Maternity SCN website: http://www.londonscn.nhs.uk/networks/maternity-

childrens/maternity/

• E-mail us on: [email protected]









mailto:[email protected]

better care, better outcomes - london clinical networks · 2015-06-18 · better care, better...

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