enhancing safety in women’s healthcare: does the nsf for children, young people and maternity...
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Enhancing safety in women’s healthcare: does the NSF for Children, Young
People and Maternity Services offer new opportunities?
Heather Mellows FRCOGConsultant Obstetrician and Gynaecologist Doncaster and Bassetlaw Hospitals NHS
Foundation Trust
ENTER Conference, Manchester
28 April 2005
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Enhancing Safety
Safe Maternity Services
WomenStaff
BabiesCommissioners
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Maternity Services – enhancing safety
Best possible outcomes for mother, baby and family
Best possible, high quality Maternity Services for all
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Number of CNST Claims by Specialty
0500
1,0001,5002,0002,5003,0003,5004,000
Specialty
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Cerebral Palsy
• Birth related brain damage accounted for 5% of cases and 60% of expenditure 02/03
• Between 3 and 20% of cerebral palsy may be related to birth asphyxia
• “most cerebral palsy is not due to birth asphyxia”
Dr Karen Nelson – quoted in Making Amends, DH June 2003
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Cerebral Palsy –cause not clear-cut
• Infection, Jaundice, Rh blood group incompatibility, birth asphyxia
• Risk factors:– Low birthweight– Premature birth– SGA– Multiple birth– Poverty/deprivation
Making Amends, DH, June 2003
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Claims - Obstetrics• cerebral palsy
• brachial plexus injury
(see NHSLA Journal Summer 2003)
• perineal injury
• failure of pre-natal diagnosis
• anaesthetic awareness
• retained swab
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An organisation with a memory –Report of an expert group on learning from
adverse events in the NHS: DH, 2000
• By 2005, reduce by 25% the number of instances of negligence in O & G which result in litigation
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What “Old Opportunities”?• CEMDBegan in 1951 and aims to assess main causes of,
and trends in, maternal deaths; to identify avoidable or substandard factors; to recommend improvements (including audit) to health commissioners and professionals, and to suggest directions for future research and audit locally and nationally.
A First Class Service – quality in the new NHS DH Sept 1998 page 20
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An organisation with a memory –Report of an expert group on learning from
adverse events in the NHS: DH, 2000
“The CEMD has helped to bring about dramatic improvements in the safety of some aspects of maternity care, but an audit of specific recommendations reveals that there are still areas in which key findings have not been universally acted upon.”
Page 68
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CEMD
“A recurring theme of CEMD reports has been the dangers of inadequate senior supervision and problems with delegation. A report in 1995 concluded that both were still factors in a number of maternal deaths.”
A First Class Service – quality in the new NHS DH Sept 1998 page 20
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Standards for service
“Towards Safer Childbirth – Minimum Standards for the Organisation of Labour Wards” RCOG and RCM: Feb 1999
• Organisation
• Staffing levels and roles
• Training , Accreditation and CME
• Facilities and equipment
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CNST Standards
• “During the working week, there should be 40 hours of dedicated specialist medical cover on labour ward, by a consultant or equivalent….”
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Where do we start?
• Do you know what an NSF is meant to do?
• Did you know that the “Children’s NSF” included Maternity Services?
• Has your Trust/PCT done anything yet towards implementation?
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What are National Service Frameworks (NSFs)?
• Government Policy• Designed to help people get fair access to high
quality care wherever they live• Set national standards and define service models• Driven by implementation plans and measures to
assess progress• Monitored by Healthcare Commission
A First Class Service, Quality in the NHS Sept 98
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The Children’s NSF Prompted by Kennedy and Laming
• Personalised service for children
• Earlier diagnosis and intervention
• Integration of health, social care and education
• To engineer a cultural change in the way children are dealt with
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NSF for Children,Young People and Maternity Services
Standard 11:
“Women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies”
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Changing Childbirth – 1993Indicators of success
• Hand-held notes• Named midwife• 30% midwifery led care• 75% know the midwife who delivers them• 30% deliver under care of a midwife• Ambulances have paramedics• All women have access to information about local
services
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Changing Childbirth
“There are factors beyond the scope of the maternity services, such as low incomes, poor housing and inadequate nutrition….restricting access to services and increasing risks to her and her baby”
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The National Service Framework for Children, Young People and
Maternity Services
A holistic approach
• Recognition that healthy mothers have healthy babies that grow into healthy children and have an impact on the future Health of the Nation
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The Children’s National Service Framework
is a 10 year strategy to improve the lives and health of children
The provision of the infrastructure and use of resources to enable best practice through use of evidence based clinical guidelines
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Maternity EWG members• Co-chairs
– Heather Mellows (RCOG) & Meryl Thomas (RCM)
• User reps– Mary Newburn (NCT)– Sue Eardley (MSLC and
Trust)– Lady Sarah Riddell
• Midwives– Jean Duerden (LSA)– Dame Lorna Muirhead
(RCM)– Lynne Leyshon (HoM)– Yana Richens (RCN –
inequalities)
• Obstetricians
– Prof. Bill Dunlop
– Prof. James Neilson
• GP – Dr David Jewell
• Anaesthetist – Griselda Cooper
• Paediatrician – Prof. Sunil Sinha
• Psychiatrist – Margaret Oates
• Public Health – Jean Chapple
• Researchers – Jane Sandall
– Jo Garcia
• PCT – Toni Horn
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Maternity EWG
Holistic approach to maternity services:
• Pre-birth
• Birth
• Post-birth
• Inequalities
• User involvement
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Why Mothers Die
Social disadvantage
Single mothers
Ethnic (other than white)
Black African
Poor communities
Risk of dying:
x 20
x 3
x 3
x 7
45% higher death rate
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Inclusive Maternity Services
• Multiple social problems
• Homeless• Travelling people• Asylum seekers• Refugees• In prison
• Disabilities• Teenage parents• Involvement of fathers• HIV/AIDS• Drug abuse• Alcohol abuse• Domestic violence
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Maternity Services – the context• NICE Clinical Guidelines
- Antenatal Care
- Caesarean Section
- (Intrapartum Care)
- (Post natal Care)
• National Screening Committee
recommendations
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Maternity Module - Standard: All women should have an
individualised AN care programme…
Rationale: Women presenting late or poor attenders generally have poorer health outcomes
Evidence: 25% of maternal deaths occurred in women who were poor AN attenders
Possible Interventions: Accessible and acceptable provision of care, prepregnancy information and education
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Maternity Standards
• Service provision – infrastructure, choice
• Clinical care provision – access, normality
• Information – women, families and carers
• Communication – women and all agencies
• Quality - care, carer and environment
• Training and education – carers and women
• Data collection, audit, research - planning
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Establishing Standards: service provision
NHS Maternity care providers and PCTs ensure that:
• the range of ...care services available locally constitutes real choice…
• local options for midwifery care will include MLUs in the community or on a hospital site
page 28
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Standards: clinical care provision
All NHS maternity care providers, PCTs and Local Authorities ensure that:
• Preconception services are available page 16
• Every woman .. has access to EPAU page 26
• Staffing levels .. on delivery suites comply with CNST standards page 28
• Consultant-led services have adequate facilities…including transfer to ITU page 30
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CEMD recommendations
• Further long-standing recommendations concern the availability of on-site blood banks and Intensive Care Units. In 1994, 21% of units in England still had no on-site ITU and 12% had no on-site blood bank.
An organisation with a memory, DH 2000
Page 69
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Standards: information
Maternity service providers should ensure that all pregnant women are offered clear information on:
• the full range of screening tests page 8
• what becoming a parent might be like page 17
• healthy life style page 17
• assistance with choice including risks and benefits page 19
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Standards: quality of care
• Evidence based care - NICE guidelinesAll maternity care providers and PCTs ensure
that (there is):• Learning from mistakes: critical incident
reporting• Participation in CEMACH• Research
pages 40-41
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Standards: training
• Multi-agency health promotion page 14
• Competence to assist in choice page 19
• Need for specialist services page 20
• Skills to support pain relief page 28
• On-site training for emergencies page 30
• Neonatal resuscitation page 36
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The Concepts of Care
• Managed Maternity and Neonatal care networks
• Individualised Care Pathways
“[a woman will] understand exactly how to access additional services should the need arise.”
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Managed Maternity and Neonatal Care Networks
“These are linked groups of health professionals and organisations from primary, secondary and tertiary care, and social services and other services, working together in a co-ordinated manner, to ensure an equitable provision of high quality, clinically effective care”
para 4.3
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woman
Voluntary care
Social services
Perinatalpsychiatry
Secondary care
Tertiary maternaland neonatal care
Midwifery care
Woman andfamily
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National Action for Implementation
• Developing managed networks
• Developing tools for use locally
• Untangling workforce issues
• Facilitating strategies for service redesign
• Prioritising National data collection plans
• Enabling on-going research to fill the gaps
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The Children’s NSF-the challenge
• No targets
• No (direct) funding
• In ten years for NHS Trusts and local authorities must bring in standards
• Progress monitoring by the Healthcare Commission
• And star ratings may be affected
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What can we do to enhance safety?
• What is missing from our service?
• What could we develop?
• What standards do we not meet?
• Which areas are most important for our women and families?
• How can we persuade the PCT to invest in maternity as a priority?
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Implementation – bite-sized chunks
Plan change
Implement and audit
Assess local needs
Assess local services
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NSF for Children,Young People and Maternity Services
Standard 11:
“Women have easy access to supportive, high quality maternity services, designed around their individual needs and those of their babies”
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Enhancing safety in women’s healthcare: does the NSF for Children, Young
People and Maternity Services offer new opportunities?
Yes, I think so, do you?