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West Yorkshire & Harrogate Health and Care Partnership

West Yorkshire & Harrogate Local Maternity System 2017 - 2021 PMO: October 2017

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Contents

Vision 3 Overarching outcomes for the LMS 3 The Current Picture across West Yorkshire and Harrogate 4 – 10

Maternity Offer 4

Better Births Annex A 4 - 6

Geography 7

Population 8

Deprivation 9

Births 10

Deliveries 10

What we know so far, women’s perspective 11 Health Needs Assessment 12 Health Needs Assessment – Highlights 12

Preconception 12

Antenatal 12

Birth 12

Postnatal 12

Neonatal 12

How will we achieve our vision and address the transformation? 13 - 14

Governance 13

Approach 13

Culture Change 14

Quality Improvement 14

National and Local programmes of work 14

Stakeholders and Partnership working 14

The Plan 15 Moving to implementation 15 Supporting Documents 16

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The LMS Vision

The vision of the West Yorkshire and Harrogate (WY&H) Local Maternity System (LMS) is based on the needs and collaboration of women and their partner and their families.

The WY&H LMS will develop and nurture a culture which puts women and babies at the centre of care, supports multi-professionalism, values learning and has the safety of women and their babies as a golden thread throughout.

It is as much about changing cultures and creating a lasting ethos of greater collaboration as it is about system design to achieve a critical mass beyond local population level to achieve the best outcomes for maternity including Preconceptual Care and prevention, Perinatal Mental Health and Postnatal Care.

WY&H LMS recognise that the maternity system cannot be considered in isolation and is inextricably linked to neonatal services, which are key in delivering optimal outcomes for babies.

Overarching outcomes for the LMS are:

WY&H LMS will ensure women and their partners and their families have the opportunity to participate at all levels in the development, implementation, evaluation and ongoing improvement of services to maximise quality and outcomes.

WY&H LMS will have in place financially sustainable maternity and neonatal services based on the identified needs of women and their partners and their families, clearly defined through a co-produced local offer resulting in reduced variation and improved outcomes.

WY&H LMS will provide safe maternity and neonatal care.

WY&H LMS and the Y&H Neonatal ODN will improve outcomes for all babies who are at risk of, or have developed complications, babies born too early, babies with congenital abnormalities and babies who experienced complications during birth.

WY&H LMS will ensure all women and their partners and their families are aware of the choices available to them and their preferences are heard across all elements of maternity and neonatal care.

WY&H LMS will ensure that the mental and emotional wellbeing needs of women and their families are seen as important as their physical wellbeing needs and are responded to with high quality and timely Perinatal Mental Health Services across WY&H LMS.

WY&H LMS will have a highly skilled and knowledgeable workforce encompassing all elements of the maternity and neonatal pathway, promoting a culture of learning and continuous improvement to maximise quality and outcomes.

Click on picture below to view the film

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The Current Picture across West Yorkshire & Harrogate

Maternity Offer

Airedale Bradford Calderdale & Huddersfield

Harrogate Mid

Yorkshire Leeds Total

Obstetric 1 1 1 1 1 1 6

MLU alongside 1 1 1 0 1 0 4

MLU 0 0 1 0 2 0 3

Better Births Annex A (2016) data collection

The table below highlights potential areas of good practice across the LMS, particularly in relation to Personalisation & Choice and Safer Maternity Care.

However, for the majority of elements, further development and improvement maybe required. Additional scoping will be undertaken in order to understand

areas for development and support the implementation of the WY&H LMS Plan.

Personalised care centred on the woman her baby and her family based around their needs and their decisions where they have genuine choice informed by unbiased information

Green Amber Red

Every woman should develop a personalised care plan, with their midwife and other health professionals, which sets out her decisions about her care, reflects her wider health needs and is kept up to date as her pregnancy progresses and after the birth.

3 2 1

Unbiased information should be available to all women to help them make their decisions and develop their care plan drawing on the latest evidence, and assessment of their individual needs, and what services are available locally. This should be through their digital maternity tool.

0 3 1

Women should be able to choose the provider of their antenatal, intrapartum and postnatal care and be in control of exercising those choices through their own NHS Personal Maternity Care Budget.

1 1 3

Women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit after full discussion of the benefits and risks associated with each option.

3 1 1

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Continuity of carer, to ensure safe care based on a relationship of mutual trust and respect in line with the woman’s decision Green Amber Red

Every woman should have a midwife, who is part of a small team of 4 to 6 midwives based in the community who know the women and family, and can provide continuity throughout the pregnancy, birth and postnatally.

1 4 1

Each team of midwives should have an identified obstetrician who can get to know and understand their service and can advise on issues as appropriate.

2 3 1

Community hubs should enable to access care in the community from their midwife and from a range of others services, particularly for antenatal and postnatal care.

0 4 1

The woman’s midwife should liaise closely with obstetric, neonatal and other services ensuring that they get the care they need and that it is joined up with the care they are receiving in the community.

4 2 0

Safer care, with professionals working together across boundaries to ensure rapid referral, and access to the right care in the right place; leadership for a safety culture within and across organisations; and investigation, honesty and learning when things go wrong.

Green Amber Red

Provider organisation boards should designate a board member as the board level lead for maternity services. The Board should routinely monitor information about quality, including safety and take necessary action to improve quality.

5 1 0

Boards should promote a culture of learning and continuous improvement to maximise quality and outcomes from their services, including multi- professional training. CQC should consider these issues during inspections.

3 3 0

There should be rapid referral protocols in place between professionals and across organisations to ensure that the woman and her baby can access more specialist care when they need it.

2 4 0

Teams should collect data on the quality and outcomes of their services routinely, to measure their own performance and to benchmark against others’ to improve the quality and outcomes of their services.

6 0 0

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Better postnatal and perinatal mental health care, to address the historic underfunding and provision in these two vital areas, which can have a significant impact on the life chances and wellbeing of the woman, baby and family.

Green Amber Red

There should be significant investment in perinatal mental health services in the community and in specialist care. 0 2 0

Postnatal care must be resourced appropriately. Women should have access to their midwife as they require after having had their baby.

3 1 1

Maternity services should ensure smooth transition between midwife and obstetric and neonatal care, and when appropriate to ongoing care in the community from their GP and health visitor.

2 3 0

Multi-professional working, breaking down barriers between midwives, obstetricians and other professionals to deliver safe and personalised care for women and their babies

Green Amber Red

Those who work together should train together. The Nursing and Midwifery Council and the Royal College of Obstetricians and Gynaecologists should review education to ensure that it promotes multi-professionalism and that there are shared elements where practical and sensible.

1 1 0

Multi-professional training should be a standard part of professionals’ continuous professional development, both in routine situations and in emergencies.

1 2 0

Multi-professional peer review of services should be available to support and spread learning. Providers should actively seek out this support to help them improve, and they must release their staff to be part of these reviews. CQC should consider the issue as part of inspections.

1 1 1

Working across boundaries to provide and commission maternity services to support personalisation, safety and choice, with access to specialist care whenever needed

Green Amber Red

Professionals, providers and commissioners should come together on a larger geographical area through Clinical Networks, coterminous for both maternity and neonatal services, to share information, best practice and learning, to provide support and to advise about the commissioning of specialist services which support local maternity systems.

2 0 0

Commissioners should take greater responsibility for improving outcomes, by commissioning against clear outcome measures, empowering providers to make service improvements and monitoring progress regularly.

1 1 1

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Geography

The LMS is one element of the West Yorkshire and Harrogate (WYH) Sustainability and Transformation Partnership (STP) and so the LMS population is a subset of the STP’s population. Where the data focuses on maternity services or maternity service users, the report refers to the LMS population. Where data refers to a wider population, the report refers to the STP. The map below shows the main organisations involved commissioning and providing care for the STP populations.

Figure 1: Map of WY&H STP

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Population

31,961 babies were born in the LMS in 2015. The population is very varied: Bradford City Clinical Commissioning Group (CCG) is the most deprived CCG in England, yet Harrogate and Rural District is amongst the least deprived. 86% of deliveries in Bradford City CCG were to mothers from a Black and Minority Ethnic (BME) background compared to 6.2% in Harrogate and Rural district. The fertility rate is highest in Bradford but Leeds and Kirklees are projected to see increases in births in the next 20 years.

Figure 2: Proportion of the CCG registered population who are female and aged 15-44

Source: NHS Digital, 2017

The above chart shows that for three CCGs in the STP area, a greater proportion of their population are female and aged 15-44 than the England average. Two CCGs are similar to the England value (Leeds South and East and North Kirklees); and the remaining six have a lower proportion of their population made up of women of reproductive age

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Deprivation

The map below shows levels of deprivation within the STP at lower super output area (LSOA)1. The most

deprived areas are mainly concentrated in city centre areas such as Leeds and Bradford, but there are also

pockets of deprivation in towns and in more rural areas.

Deprivation covers a broad range of issues and refers to unmet needs caused by a lack of resources of all

kinds, not just financial. The English Indices of Deprivation attempt to measure a broad concept of multiple

deprivation, made up of several distinct dimensions, or domains, of deprivation (DCLG 2015).

Figure 3: Indices of multiple deprivation map

Source data: IMD 2015,DCLG

1 LSOAs are geographical areas of 1,000-1,500 population defined for small area statistical reporting.

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Births

Table 1: Number of births by CCG of residence in 2015 (Source data: NHS Digital, 2017 and ONS births, 2015)

2016/17 CCG boundaries Number of births (2015)

England 665,260

West Yorkshire 31,961

NHS Bradford Districts CCG 5,032

NHS Leeds West CCG 4,016

NHS Wakefield CCG 4,003

NHS Leeds South and East CCG 3,714

NHS Greater Huddersfield CCG 2,811

NHS North Kirklees CCG 2,581

NHS Leeds North CCG 2,488

NHS Calderdale CCG 2,448

NHS Airedale, Wharfdale and Craven CCG 1,761

NHS Bradford City CCG 1,611

NHS Harrogate and Rural District CCG 1,496

Deliveries

Table 2: Deliveries by trust, 2014/15 to 2016/17 (Data source: Hospital Episode Statistics (HES) data *1617 is provisional data)

Trust 2014/15 2015/16 2016/17*

Airedale 2,152 2,274 2,094

Bradford 5,765 5,698 5,581

Calderdale and Huddersfield 5,467 5,401 5,350

Harrogate 1,838 1,872 1,896

Leeds 9,415 9,610 9,559

Mid Yorkshire 6,203 6,068 6,196

TOTAL 30,840 30,923 30,676

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What we know so far, women's perspective

WY&H LMS Communications and Engagement specialists have undertaken mapping exercise looking at previous engagement with women. The team have produced a comprehensive report to present the findings from all maternity engagement and consultation activity which has taken place during April 2013 to June 2017, across West Yorkshire and Harrogate Sustainability and Transformation Partnership (STP). The report captures intelligence collected from engagement and consultation activities and will support commissioners to:

Provide information on work which has already taken place or is underway to avoid duplication

Highlight any gaps in activity across West Yorkshire and Harrogate by each of the service areas

Understand some of the emerging views gathered from local people across West Yorkshire and Harrogate

Ensure that any future plans have a baseline of engagement intelligence to support the work

In addition, the report can be a working document which is added to as projects progress. The intelligence collected will ensure we meet our legal requirements and ensure we:

Consider the views of patients and the public as part of service redesign

Ensure the feedback is considered in the development of any future options to change the way a current service is provided or delivered

Highlight patient and public priorities and ensure these priorities are in line with current thinking and ensure commissioners can consider all public views

Women and their partners and families report that:

Women want to be offered the choice of where and how they give birth. To support them in this they need more information and support before pregnancy to ensure the right choices for

birth are made; this should include support for dads.

Lack of consistent midwifery cover meant that some women had to repeat their story a number of times. Women felt that relationships suffered in respect of developing a trusting, and

understanding relationship where a number of different midwives were involved in their care. In these situations women were less likely to seek support and advice from their midwife.

Staff need to be more helpful after birth including more support with baby bonding, not discharging parents too early, emotional

support and help with pain relief.

Engagement at all levels including co-production and with women their partners and their families has been

undertaken to develop the WY&H LMS Plan and will continue throughout the transformation.

An Equality Impact Assessment will also be carried out.

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Health Needs Assessment (please refer to the full HNA)

This HNA was prompted by the national maternity review, Better Births, and its implementation guidance (NHS England 2016, 2017). It presents and discusses the available data about the population who use maternity services in the WYH LMS, and makes recommendations for further consideration as part of the LMS review. The aim is to provide a resource to help commissioners and service providers have a good understanding of population need as they rethink and improve services.

The WY&H needs assessment takes a broad, high level look at health needs of maternity service users. The headline data explored will complement knowledge about service provision, access and experience to help prioritise action to implement the vision for the Local Maternity System.

The populations within the LMS are very different. The key message overall is that levels of socioeconomic deprivation are high, which leads to a high level of health need and poorer maternity outcomes. Much of the solution to improving maternity outcomes lies before and beyond the maternity system in improving people’s quality of life and reducing inequality.

Within the maternity system, however, there is a huge amount that can be done to recognise and understand the challenges that women their partners and families face and to support them and their babies to have the healthiest pregnancy and start to life possible.

There is a need to prioritise and focus efforts where they are most needed; and some more detailed analysis is required to underpin this process. Bradford stands out through much of the needs assessment as the geographical area of highest priority. However, the needs of a vulnerable person in other areas are not necessarily any less; and where the numbers are much smaller, the services and expertise may not be available. So there are opportunities for all trusts and CCGs to learn from each other and to support each other to share good practice and to reduce avoidable variation.

HNA Highlights (please refer to the full HNA)

Preconception and conception

Around 55% of pregnancies in the UK are planned. This chapter discusses infertility, teenage conception, abortion and miscarriage. Teenage conceptions have fallen dramatically, but some pockets of concern remain.

Antenatal

Experience data from the Care Quality Commission (CQC) shows lower scores for the care received at the start of pregnancy than overall during pregnancy. Screening and vaccination rates are OK, but could be improved. Pathway analysis shows considerable and unexpected variation between trusts, but data is incomplete. There are some gaps in knowledge, for example around antenatal parent education.

Birth

The CQC survey showed that women were less happy with care after birth than before, and local consultation data begins to unpick why. Data about birth settings is incomplete but suggests that for most women in the LMS there is not a choice of a midwife-led unit. Method of delivery is also difficult to analyse, and needs more detailed consideration. The levels of very low birthweight and stillbirth for families in Bradford is concerning.

Neonatal (please also refer to the Neonatal Dataset Pack)

Neonatal units (NNUs) and neonatal intensive care units (NICU) are an important element of the maternity

journey for a small number of families. There are interdependencies between location and capacity of

NICUs; patterns of transfers; and maternity services.

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How will we achieve our vision and address the

transformation?

Governance

Approach

Following the initial scoping of maternity services (building on Betters Births: Annex A and the WY&H Needs Assessment) WY&H LMS Development Group will identify the priorities and requires case for change.

Implementation will begin with testing a number of identified models/concepts of service transformation, these will include:

Continuity of Care

Safer Maternity Care

Personalisation and Choice

Timescales for additional scoping and implementation can be found in the WY&H LMS Plan.

Task and Finish Groups (T&FG) – Multiprofessional working groups with representation from all providers across the

footprint including commissioners, quality /safeguarding leads.

Members of the T&FG are identified champions for the WY&H LMS and report back to their organisations.

T&FG have met on a number of occasions to develop the plan and are now working towards implementation.

Maternity Voices Partnership (MVP’s) T&FG will transform into the WY&H LMS MVP Network bringing

together all local MVP’s across the footprint.

Through the work it has been identified that a 5th T&FG will be required focusing on Workforce Development.

STP System Leadership

Executive Group West Yorkshire

& Harrogate

North Region MTP Board

WY&H

LMS Board

Safer Maternity

Care Task & Finish Group

Maternity Voices

Partnership Task & Finish

Group

Choice & Personalisation

Task & Finish Group

LMS Development Task & Finish

Group

The current structure was

established to develop the WY&H

LMS Plan. This structure will be

reviewed to meet the needs of

implementation and

transformation moving forward.

General Structure – The WY&H

LMS is now a work programme

within the WY&H STP. The WY&H

LMS reports to the North Region

Maternity Transformation Board

for assurance.

LMS Board - Multidisciplinary

Board with representation from

across services including:

commissioning, public health, Y&H

Clinical Networks and STP

colleagues.

Project Management Office

A PMO was established to

support the LMS Board and

T&FG for the transformation,

the PMO has included:

Project Management Lead

Project Officer

Support from Y&H

Maternity Clinical

Network

STP communication and

engagement specialists

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Culture Change

It is recognised that the development of the WY&H LMS is a new way of working and the biggest influence on culture is leadership and people empowered to lead in all areas at all levels.

The WY&H LMS has embedded these principles from the start through co-production and engagement, providing staff the freedom and confidence to act in the interests of women their partners and their families.

The culture of the WY&H LMS will shape the behavior of those who work in it, enhancing the quality of care provided and overall performance, this approach will also ensure a healthy, resilient and sustainable workforce.

Quality Improvement

It is the responsibility of the WY&H LMS to ensure services commissioned within the system are providing high quality care for women their partners and families, adding value to local placed based services. In order to achieve this and improve outcomes for women their partners and families we will engage with and learn from programmes of work both nationally and locally.

National and Local Programmes of work

Interdependencies have been identified through the development of the WY&H LMS In particular:

PHE Prevention and Preconception workstream

Y&H Maternity Clinical Network

Neonatal Operational Delivery Network

Further work will be undertaken to identify the local place based services and interdependencies for implementation of the plan.

Stakeholders and Partnership Working

WY&H LMS PMO recognises the importance of understanding and analysing stakeholders, this is crucial to the success of the transformation and development of the LMS.

A systematic Stakeholder Analysis has been undertaken to identify stakeholder’s power, interest and influence. This can be found as part of both the communications and engagement strategy and the WY&H LMS Plan.

Communications

The PMO have produced a Communication and Engagement Strategy, this includes:

Inclusion on the WY&H STP website

Links to all organisation websites

Public Summary of the LMS Plan

A communications plan on a page for all T&FGs

A WY&H LMS road show pack and banner

Twitter feed & Kahootz online forum for T&FGs

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The Plan

This plan recognises the importance of learning from best practice and developing local provision to reduce

variation across the LMS whilst ensuring it achieves the best outcomes for the childbearing population of

WY&H by developing elements of service and provision that can only be achieved through a system

approach.

Monitoring and Evaluation is embedded in this plan, KPIs and performance indicators will developed as the

plan progresses. Workstreams will be continually monitored against the KPIs/performance indicators for

quality improvement and service development.

The WY&H LMS Plan will align to and work with the WY&H Sustainable Transformation Programme (STP)

with a particular focus on Governance, Workforce and Digitalisation.

The Plan is a live document and will be continually added to and updated, it will be the vehicle for

implementation using an agreed formal programme/project approach/method. Moving forward, as projects

develop day to day individual owners will be identified.

Moving on to Implementation

The West Yorkshire & Harrogate LMS Board, Task & Finish Groups supported by the Programme

Management Office will now identify what needs to be done to implement the LMS Plan and deliver the

outcomes for women, their partners and families, this will be achieved by:

Continuing to align to STP

Reviewing the Governance Structure and membership

Considering future staffing model for PMO

Identifying the model for Implementation

Identifying potential service quality improvement models to test.

Considering programme and project management tools to support implementation.

Identifying LMS Champions and Reference groups to support implementation

Delivering the Communications and Engagement Strategy and Plans

Identifying the potential financial case for change

Undertaking service scoping with all WY&H LMS Trusts by December 2017

Undertaking Equality Impact Assessment.

Facilitating a Stakeholder event January 2018

Learning from early adopters

Ensuring some early wins and celebrating success

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Supporting Documentation

Click on the documents and links below to open

West Yorkshire and Harrogate Health and Care Partnership: Maternity Services and Video

www.wyhpartnership.co.uk

West Yorkshire and Harrogate LMS Communications Strategy (8.11.17) WYH LMS

Communications Strategy Draft 8 Nov 2017.docx

West Yorkshire and Harrogate Health Needs Assessment October 2017 WYH LMS HNA final

02-10-17.pdf

West Yorkshire and Harrogate Engagement and Communications Mapping 2017 WY&H Maternity

Engagement and Consultation Mapping.pdf

Yorkshire and The Humber Neonatal ODN LMS Pack 2017 Neonatal LMS data Pack.xlsx

Yorkshire and The Humber Neonatal ODN Peer Review Report 2017 Neonatal Peer Review Report.pdf