APPENDIX 10
Memorandum by the Women's Health Directorate,
University College London Hospitals NHS Trust (MS 16)
SUMMARY
North Central London Strategic Health Authority
is currently reviewing maternity and children's services. UCLH
is contributing to this in addition to internal reviews and proposed
service redesign. Full details are appended.
These reviews reinforce the following as priorities
for maternity care:
— Safe delivery but mindful of maternal
choice.
— Continuity of care by midwives.
— Home deliveries when requested and
appropriate.
— High standard midwifery, and continuity
of midwifery care for women who also require obstetric management.
— Access to preferred method of pain
relief when necessary.
— Reduction in unnecessary caesarean
section rate.
— Prevention and management of birth
injuries.
— Avoiding practices which impede successful
breast-feeding.
— Keeping mothers and babies together
as much as possible.
— Integrated training of all professionals
caring for women, with emphasis on breastfeeding and neonatal
resuscitation.
— Increased recognition of and appropriate
interventions for victims of domestic violence and mental health
disorders, including drug and alcohol misuse.
— Recognising and appropriate management
of child protection issues.
— Access when necessary to medical
and allied professional expertise.
— Ability of women to move between
models of care, eg back to midwife-led after obstetric or medical
opinion.
— Provision of a day assessment unit,
staffed by midwives but with ready access to obstetric expertise
if required.
— Extended midwifery skills eg midwife
ultrasonographers.
— Provision of high quality specialist
services (eg neonatal intensive care) within a network, whilst
maintaining local delivery of all other services wherever possible.
— Interdisciplinary working across
traditional institutional and organisational boundaries.
— Enhanced staff recruitment, retention
and working lives.
— Involvement of all professionals
in service planning and redesign.
— Comprehensive antenatal counselling
and delivery, in an appropriate setting when complications are
envisaged.
— Accurate and comprehensive data collection
with integrated systems for maternity and neonatal outcomes.
— Sound academic and evidence base
for local and specialised services.
— Integral clinical governance.
— Working with users and partners to
develop the service, particularly through MSLC.
SUPPORTING INFORMATION
1. Background
UCLH health professionals and managers are participating
in the current Children's and Young People's Service Review, led
by North Central London Strategic Health Authority, which has
a number of working groups. The Maternity and Neonatal Services
Working Group included representatives of Trusts, CHCs, MSLC,
users, and race and health groups. At the same time, the London
Regional Specialist Commissioning Group has reviewed neonatal
services and is proposing managed clinical networks for neonatology.
It is envisaged that neonatal units in North Central London will
work together in a network. The Maternity and Neonatal Services
Working Group has taken a wider view, examining the provision
of maternity and neonatal services in response to views of users
and professionals.
UCLH has user members on all women's health
governance groups and receives and acts upon feedback form users
and partner organisations in many other ways—for example,
parent questionnaires, the work of a liaison midwife who debriefs
couples after delivery and when necessary investigates complaints,
involvement of users in service redesign, GP liaison committee,
maternity services liaison committee (MSLC). UCLH particularly
values the role of its local MSLC. In this way, we feel confident
that, in planning our service, we can learn from and respond to
the views of our users and partners, as well as the multidisciplinary
teams that provide maternity and neonatal care.
2. Midwifery
In response to views of women and midwives,
UCLH has successfully established three, including high-risk,
community group midwifery practices (with a fourth to be established
in April 2003), a model of midwife led care, and a midwife run
birthing centre which is separate to main delivery suite. The
birth centre philosophy of care, which embraces active childbirth
and waterbirth, offers low-risk women an alternative to our main
delivery suite, where epidural analgesia is available on request.
The birth centre midwives also support home birth.
Recruitment and retention of midwives in London
is a major problem for maternity services and one that has affected
our service in the past. UCLH has a robust recruitment strategy
that recognises that a natural turnover of staff, following promotion
or for other reasons, is inevitable. There is evidence that where
midwife-led care is developed, recruitment and retention improves,
this is the case for us at UCLH.
The group practices concentrate on midwife-led
care both in the community and within the birth centre. The aim
is to develop continuing streams of maternity care by known midwifery
carers, before, during and after birth. This is in line with
Changing Childbirth [1993] and as a response to the views of women
locally. Community midwife-led clinics have been developed as
part of the group practice strategy. This development has not
excluded GPs from maternity care; it has enabled midwives to see
more women and provide quality time for the women on one site.
This is instead of small individual clinics within GP surgeries.
The disposition of group practice clinics has been in response
to consultation with GPs and PCTs.
An additional group practice concentrates on
the needs of high-risk women, providing continuity of midwifery
carers within the hospital system.
3. Infant feeding
All professionals are committed to the support
of breast-feeding. Resources include a breast-feeding counsellor,
speech and language therapist support for babies with feeding
difficulties, antenatal breast-feeding workshops, and a postnatal
drop in forum.
4. Obstetric and high risk care
Those women who may require obstetric care are
seen in appropriate clinics, each attended by supporting professionals,
such as endocrinologists, physicians, diabetologists, psychiatrists
and counsellors. They continue, as far as possible, to have continuity
of midwifery care and may move between models of care, ultimately
having midwife led delivery.
UCLH receives referrals from all areas of London
and beyond for fetal medicine assessment, which affects the case-mix
of women who deliver here. Many women are referred because of
specialist tertiary services at UCLH and neighbouring Great Ormond
Street Hospital. These women and their partners receive detailed
antenatal counselling by appropriate professionals, including
fetal medicine specialists, neonatologists, surgeons, and cardiologists.
Women who have high risk or complicated pregnancies are managed
according to the recommendations in the reports of the Confidential
Enquiries into Maternal Deaths, and these standards are audited.
UCLH recognises the importance of good postnatal
support and follow-up care for women and babies. The unit has
recently reviewed the skill-mix of these ward with the midwives
and is shortly to introduce surgical nurses and nursery nurses
so that midwifery skills can be used appropriately.
Should it be necessary, women may be referred
to an on-site birth injuries clinic, run by a multi-speciality
team.
UCLH participated in the National Sentinel Caesarean
section study. In response to the results of the study and internal
review, measures have been put in place to minimise unnecessary
caesarean section and these are subject to ongoing audit. All
medical, and many complementary methods of pain relief, are available,
and the directorate is working with colleagues at the Royal London
Homeopathic Hospital (which is part of UCLH Trust) to develop
complementary therapies.
5. Neonatal care
Although UCLH has widespread recognition for
the standard of neonatal care provided in a level 3 unit which
meets BAPM (British Association of Perinatal Medicine) standards,
we aim to avoid admitting babies to the neonatal unit unless there
are clear clinical reasons. Written guidelines, developed and
accessed by neonatal nurses, midwives and paediatric staff, are
in place. Paediatricians are committed to the promotion and support
of breastfeeding and prevention of interventions which may disrupt
this. There is high level (consultant-led) paediatric support
for midwives caring for babies on the postnatal wards, and there
is a transitional care unit where some small and vulnerable babies
(who would otherwise be admitted to the neonatal unit) are cared
for alongside their mothers. This unit is staffed both by midwives
and neonatal nurses.
6. Staff training
UCLH considers that training of all health professionals
must be as integrated as possible. Medical staff, midwives, neonatal
nurses and health care assistants share the directorate educational
and training resources. There is a midwifery lecturer practitioner
who works with student midwives, adaptation midwives, newly qualified
midwives and medical students. There are two link lecturers for
student midwives who train here and at City University. There
is also a midwife responsible for NVQ training.
Key priorities for training are "skills
and drills" for obstetric and neonatal emergencies, breast-feeding
promotion (this brief is held by a designated health promotion
midwife), mental health and domestic violence, neonatal resuscitation,
and examination of the newborn.
7. Staffing
UCLH shares with many central London units issues
relating to staff recruitment and retention. It is developing
initiatives to counter this and is committed to the Improving
Working Lives programme. However, additional resource may be required
for central London Trusts to enable them to attract and retain
high quality staff in the numbers required to run a safe and comprehensive
service.
Medical rotas in the directorate are New Deal
compliant and this is partly achieved by recognising the skills
and extended roles of neonatal nurses and midwives. Posts for
consultant midwife and consultant neonatal nurse, advanced neonatal
nurse practitioners and gynaecology nurse practitioners are in
our establishment. Extended skills enhance service provision and
patient experience, for example, midwife ultrasonographers allow
continuity of care.
8. Response to confidential enquiries
The National Confidential Enquiries into Maternal
Deaths highlighted the risks of domestic violence and mental illness.
In response to this and internal reviews, cross-directorate working
groups have proposed arrangements to enhance detection and management
of these conditions. Multidisciplinary in-house training will
be developed within the next three months to aid detection and
provide care pathways. All staff will be expected to take part.
Women who misuse drugs are cared for by a dedicated group of professionals
with integrated antenatal counselling by neonatologists and planning
with relevant agencies, eg primary care services for drug users,
social services. Amongst these groups of women, child protection
issues may need to be addressed. The directorate has a designated
midwife and manager for child protection, and is well supported
by an on-site borough social service department. The directorate
has assured itself that the relevant recommendations made in the
Department of Health report on the Victoria Climbié Inquiry
are met.
9. New build for maternity unit
UCLH is fortunate to be planning a purpose-built
maternity unit, for completion in 2008. There has been wide consultation
with professionals, PCTS and users regarding these plans and the
service we will provide. There will be increased delivery suite,
obstetric ward and neonatal unit capacity. There will be a high-risk
observation area on delivery suite, a birthing centre separate
to main delivery suite, an integrated fetal medicine and day assessment
unit and a transitional care unit.
10. Data collection
UCLH recognises the need for the collection
of high quality and usable data. Although, in-house databases
have allowed monitoring of activity and outcomes of babies admitted
to the neonatal unit, until recently there has been no systematic
electronic data capture for maternity. The introduction of a computerised
CTG monitoring system (K2) has allowed collection of data for
all deliveries (even if CTG monitoring does not occur). This is
essential for the critical review of the quality of our service,
a process that currently requires manual data collection. Using
current data, we participate in the CHKS bench-marking process
for maternity care. When the electronic patient record is introduced,
there will be further opportunities for data collection and analysis,
and the linking of maternal and neonatal data. In turn this will
allow benchmarking within and between networks and beyond. We
consider critical review and bench-marking essential for the future
of maternity services, and this must involve aspects of the patient
experience, as well as clinical outcomes. It is essential that
data systems of each provider are able to interface for accurate
sharing and comparison of appropriate data.
February 2003
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