NHS Next Steps Review Initial Briefing Materials on Maternity and Newborn

1
NHS Next Steps Review Initial Briefing
Materials on Maternity and Newborn
CONFIDENTIAL
Draft
3 October 2007
2
Introduction to this regional briefing

• This briefing is intended to act as an
  introductory overview for the clinical group
• It reviews the current situation in this clinical
  area across the West Midlands, outlines selected
  parts of a case for change, and provides some
  examples
• This briefing is intended as the start of a wider
  process and as a helpful dialogue
• It aims to be fully consistent with the NHS West
  Midlands strategy document Investing for Health
  which also provides useful material in this
  clinical area

Purpose
Fit with national briefing materials

• The Department of Health (DH) has produced a
  separate introductory briefing that covers
• Key national facts and figures on this clinical
  area
• An overview of the evidence base on good practice
  in this area
• National or international case studies of
  successful work
• We have designed this regional briefing to avoid
  overlap with the DH materials, by focusing on
• Presenting the regional situation
• Starting to develop the case for change
• Putting forward some local examples of good
  practice or innovation

• This document points out some significant
  variations across the West Midlands and compares
  the West Midlands with other regions
• Understanding the root causes of regional
  variations can help identify best practices and
  improve outcomes across the health economy
• In a region such as the West Midlands, variations
  in practice or outcomes are typically not caused
  by resource availability
• Understanding what really drives this variation
  is likely to surface a number of improvement
  opportunities that can be taken forward by the
  clinical group

Interpreting regional variation
3
Introduction to this regional briefing (cont.)

• The document therefore contains the following
  parts
• Current situation across all clinical areas The
  challenges facing the West Midlands health
  services as a whole, across all clinical areas
• Current situation in this clinical area The
  starting point for this clinical area
  specifically, covering questions such as access,
  investment, inequalities and outcomes
• Case for change Selected issues with current
  common practice in the West Midlands
• Vision for the future Examples of successful
  work in the West Midlands to date, and some
  questions on the future path of services that
  your group may wish to consider.

Structure of this document
Further development

• NHS West Midlands intends this to be the start of
  a dialogue
• In particular, if you believe that some analyses
  in this document are misleading or incorrect,
  then we would welcome it if you would provide us
  with more appropriate, up-to-date or accurate
  information

4
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation in Maternity and Newborn
• Case for change
• Vision for the future

5
Executive summary Maternity and Newborn

• The West Midlands health system faces 7
  challenges outlined in Investing for Health
  widening inequalities, variability in quality and
  safety, services that are difficult to navigate,
  low public confidence, too little prevention, low
  return on investment, and cost pressures
• Within Maternity and Newborn we note that
• The West Midlands region sees around 66,000
  births per year, in over 20 units
• The region has the highest perinatal death rate
  in England, driven particularly by early neonatal
  mortality
• Perinatal mortality shows large variations across
  the region, closely correlated with deprivation
• Significant variation in delivery practices
  (e.g., caesarean rates) are seen across the West
  Midlands
• The region faces a challenge in retaining
  sufficient midwives, with many current midwives
  approaching retirement

Current situation
Case for change

• We identify two aspects of the case for change in
  the West Midlands
• Antenatal care of high-risk groups performance
  against the most important care and risk factors
• Care at delivery safety, efficiency and scale

Vision for the future

• Examples of good practice and innovation exist in
  the region, such as the parent education and
  caesarean rate work at the Royal Wolverhampton
  Hospital, and Worcestershire Acute Hospitals
  VBAC clinic
• There are therefore several questions about the
  future direction for the clinical group to
  consider, including
• What are the key issues for you?
• What best practices/innovations have you seen?
  Are there barriers to implementing them?
• What is your vision for the future?

6
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation in Maternity and Newborn
• Case for change
• Vision for the future

7
The West Midlands health system faces 7 challenges
Challenge
1
Outcomesand quality
Widening inequalities
Despite improvements in overall health status,
inequalities in health have widened
2
There remains an unjustifiable variability in the
quality and safety of services and individual care
Variability in quality and safety
3
Patientfocus
We do not always help patients to navigate the
system
Difficult to navigate
4
Low public confidence
The public, our customers have little
confidence that their local NHS will get better
5
Too little prevention
We are not achieving enough in prevention
Investmentfocus
6
We spend substantial amounts of resources on
clinical activities where there is little return
on investment in terms of improved health, or
where there are more cost-effective alternatives
Low return on investment
7
Cost
The rate of cost pressures arising from doing
more of the same outstrips any conceivable rate
of increased funding
Cost pressures and opportunity costs
Source Investing for Health
8
Inequalities in health are significant
471
1
Deprivation index
Standardised years of life lost per 10,000
population
200305 pooled
2004 ward-based figures
Warwickshire
Worcestershire
Shropshire
South Staffs
Herfordshire
Solihull
North Staffs
Telford Wrekin
Dudley
West Mids average
Coventry
Walsall
Wolverhampton
Stoke on Trent
Sandwell
S Birminghanm
Heart of Birmingham
Birmingham E N
England average
Standardised YLL rate is the number of years
of life lost divided by the age-standardised
resident population aged under 75 years. The
age-standardised rate is the rate of events that
would occur in a standard population if that
population were to experience the age-specific
rates of the subject population Source National
Centre for Health Outcomes Development
9
and have widened in recent years
1
Gap between highest and lowest life expectancy,
years
84
Female highest
82
3.8 years
80
Female lowest
3.3 years
78
Male highest
76
4.9 years
74
4 years
Male lowest
72
19911993
9294
9395
9496
9597
9698
9799
982000
9901
200002
0103
0204
20032005
Source National Centre for Health Outcomes
Development
10
There remains an unjustifiable variability in the
quality and safety of services and individual care
90
2
STROKE EXAMPLE
Equal to or above national average
Below national average
2006 audit
Patients treated in a stroke unit,
Emergency brain scan within 24 hours of stroke,
Screening for swallowing disorders within 24
hrs of admission,
Trust (Site)
Burton Hospitals
Dudley Group of Hospitals
George Eliot
Good Hope Hospitals
Heart of England
Hereford Hospitals
Mid Staffordshire General Hospitals
Royal Wolverhampton Hospitals
Sandwell and W Birmingham (City Hospital)
Sandwell and W Birmingham (Sandwell District
Hospital)
Shrewsbury Telford Hospital
University Hospital Birmingham
South Warwickshire General Hospitals
N/A
100
South Worcestershire PCT
University Hospital North Staffordshire North
Staffords
UH Coventry and Warwickshire (St Cross Rugby)
UH Coventry and Warwickshire (Walsgrave Hospital)
Walsall Hospitals
Worcestershire Acute Hospitals (Alexandra H,
Redditch)
Worcestershire Acute Hospitals (Worcester Royal
Hospital)
62
66
42
National average
International evidence indicates maximum of 3
hours is preferred
England, Wales and Northern Ireland Source T
he National Sentinel Audit of Stroke 2006,
February 2007
11
We do not always help patients to navigate the
system
129
3
are serious in the West Midlands and result in
high emergency admissions rates
Issues with providing joined-up care for asthma
Standardised emergency hospital admissions for
asthma, 2004. Average admission rate 100

• In England
• 1 in 4 people with asthma are not offered or do
  not have a routine asthma review
• More than three-quarters of all adults and
  children with asthma (82 and 75 respectively)
  do not have written personal asthma action plans
• 12 of people who had experienced an asthma
  attack requiring emergency care do not know what
  to do during an asthma attack, and 16 do not
  know what to do after an attack
• People who do not have a written personal asthma
  action plan are four times more likely to have an
  asthma attack requiring hospital treatment than
  those with a plan

East
South East
South West
London
East Midlands
North East
West Midlands
Yorkshire andHumberside
North West
Source The Asthma Divide, Asthma UK, 2007
12
The public, our customers have little
confidence that their local NHS will get better
32
4
Thinking about the health services in your area,
do you expect them to . . .?
dont know
. . . get much better
. . . get much worse
11
2
. . . get better
29
. . . get worse
. . . stay about the same
Source Ipsos MORI Survey for NHS West Midlands
August and September 2006 3,555 responents
13
We are not achieving enough in prevention
18
5
Smoking cessation success rate
Women smoking during pregnancy
06/07, of people who set a quit date who
successfully stopped smoking
2005/06, of births
Telford And Wrekin
Shropshire County
Birmingham E N
South Birmingham
South Staffordshire
Heart Of Birmingham
Worcestershire
Solihull Care
Coventry
West Mid Avg
Dudley
Herefordshire
North Staffordshire
Warwickshire
Walsall
Stoke On Trent
Wolverhampton City
Sandwell
National average
53
15.9
Source The Information Centre for Health and
Social Care, Healthcare Commission Annual Health
Check
14
We continue to spend substantial amounts of
resources on clinical activities where there is
little return on investment in terms of improved
health, or where there are more cost-effective
alternatives
121
6
Improvement opportunity from bringing
standardised surgery rate for 5 procedures down
to that of lowest quartile
Relative level of surgery
HRG cost, annualised, 000
Actual vs. expected rate
105
Warwicks
109
S Staffs
91
Worcs
118
S Bhm
109
Sandwell
83
Bhm E N
81
Coventry
89
Solihull
69
H of Bhm
Total opportunity for five procedures in 13 PCTs
9.5m
64
Wolverhampton
79
Shropshire
68
Dudley
75
Telford Wrekin
Four PCTs excluded owing data quality or lack
of data supplied Myringotomy, hysterectomy,
lower back surgery, tonsillectomy, and dilation
and curettage. Selected because evidence-based
thresholds for when the surgery is likely to be
effective are sometimes ignored Given the
PCTs population base. 100 expected, under 100
lower than expected, over 100 higher than
expected. Figures are across all five procedures,
and so a PCT with under 100 overall can
nonetheless have savings potential as it is over
100 in one or more procedures. Source NHS
Better Care, Better Value Indicators
15
The rate of cost pressures arising from doing
more of the same outstrips any conceivable rate
of increased funding
9
7
PCT allocations, W Midlands
Annual growth rate, nominal

• Cost of inpatient activity in the region has
  grown at around 10 annually in recent years
• This has been manageable given the significant
  funding increases seen since the release of the
  NHS Plan
• In the future the funding settlement is likely to
  be tighter and so similar rates of activity
  increase will not be sustainable

5
Cost of inpatient activity, W Midlands
Annual growth rate, nominal
10
10
99/0005/06
05/0611/12
Assumes 2.5 real increase above GDP
deflator Assumes continuation of historical
rate of activity growth of 6 p.a. and 4 p.a.
tariff inflation Source DH HES
16
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation in Maternity and Newborn
• Case for change
• Vision for the future

17
This section sets the context for maternity and
newborn in the West Midlands

• West Midlands region sees around 66,000 births
  per year, in over 20 units

• The region has the highest perinatal death rate
  in England, driven particularly by early neonatal
  mortality

• Perinatal mortality shows large variations across
  the region, closely correlated with deprivation

• Significant variation in delivery practices
  (e.g., caesarean rates) are seen across the West
  Midlands

• The region faces a challenge in retaining
  sufficient midwives, with many current midwives
  approaching retirement

18
The number of births in the West Midlands is
increasing
66.3
Births in the West Midlands, 2001-2005, thousands
Compound annual growth rate 2
2001
2002
2003
2004
2005
Source VSOB, ONS
19
Maternity episodes are concentrated on BBCHA area
. . .

• Maternity episodes by hospital trust site, 2004/05

Source NHS West Midlands analysis
20
. . . although North Staffs and Coventry are also
major delivery units
21
Maternity episodes by hospital trust site, 2005/06
Birmingham Womens Health Care
North Staffs Maternity Hospital
University Hospital (Coventry)
Heartlands Hospital
Russells Hall Hospital
Royal Shrewsbury Hospital (Maternity)
Manor Hospital, Walsall
Worcestershire Royal Hospital
New Cross Hospital
Queens Hospital, Burton Upon Trent
City Hospital
Good Hope Hospital
Warwick Hospital
George Eliot Hospital
Sandwell General Hospital
Solihull Hospital
Staffordshire General Hospital
Alexandra Hospital
Hereford County Hospital
Princess Royal Hospital (Maternity)
Robert Jones Agnes Hunt Hospital
Ludlow Hospital (maternity)
Bridgenorth Hospital
Source Womens and Childrens Services in the
West Midlands SHA, Durrow, September 2007
21
West Midlands has the highest neonatal mortality
rate in England, and the third highest stillbirth
rate
3.1
Perinatal mortality per 1000 live births by
maternal region of residence, 2005
Stillbirth rate
Neonatal mortality rate
London
Yorkshire and Humber
West Midlands
North East
North West
South Central
East Midlands
South East Coast
East of England
South West
England average 5.5
England average 3.5
Source CEMACH PDN 2005,2006
22
This is driven in particular by early neonatal
deaths
0.4
Early and late neonatal mortality rates per 1000
live births by maternal region of residence, 2005
Late neonatal mortality rate
Early neonatal mortality rate
West Midlands
Yorkshire and Humber
North West
East Midlands
London
South West
North East
South Central
South East Coast
East of England
Source CEMACH PDN 2005,2006, ONS 2005, NI GRO
2005
23
The gap to the national average does not appear
to be closing
BBCHA EXAMPLE
Perinatal death rate per 1000 live births,
1997-2005
BBCHA
England Wales
Source West Midlands Perinatal Institute
24
Stillbirths are disproportionately higher in some
ethnic groups
1.8
Ethnic origin distribution in West Midlands,
1998-2004, of total
Other
2.5
3.0
3.0
1.8
African
2.0
1.5
2.1
3.6
Bangladeshi
4.3
Afro-Carribbean
Pakistani
6.0
4.3
Indian
85.9
68.5
63.5
European
Of early neonatal deaths associated with
congenital abnormalities
Of women aged 1544
Of early neonatal deaths
Source West Midlands Perinatal Institute
25
The same is true of early neonatal deaths
26.7
Ethnic origin distribution in West Midlands,
1998-2004, of total
Other
3.0
African
2.1
1.4
1.7
1.7
0.9
3.6
2.4
Bangladeshi
4.3
Afro-Carribbean
Pakistani
5.4
6.2
Indian
85.9
65.7
56.7
European
Of early neonatal deaths associated with
congenital abnormalities
Of women aged 1544
Of early neonatal deaths
Source West Midlands Perinatal Institute
26
Most common underlying condition for stillbirths
is fetal growth restriction. Congenital
abnormalities also important, especially amongst
most deprived
1.2
BBCHA EXAMPLE
Underlying condition for stillbirths in BBCHA,
1998-2005, of total
Four least deprived quintiles
Most deprived quintile
39.8
Fetal growth restriction
43.2
20.6
Congenital abnormalities
17.0
10.5
Placenta
Intrapartum asphyxia
Umbilical cord
Mother
Infection
19.8
Misc / unclassified
21.0
RECODE classification Source West Midlands
Perinatal Institute
27
Severe pulmonary immaturity is most frequent
cause of infant deaths. Again, congenital
abnormalities are an especially important cause
amongst most deprived
2.6
BBCHA EXAMPLE
Underlying condition for infant deaths in BBCHA,
1998-2004, of total
Four least deprived quintiles
Most deprived quintile
29.5
31.4
Severe pulmonary immaturity
26.6
30.8
Congenital abnormalities
13.4
12.7
Infection
Cot death
Hyaline membrane disease
Intrapartum asphyxia
Intracranial haemorrhage
12.7
Misc and unclassified
10.1
Fetal/Neonatal classification Source West
Midlands Perinatal Institute
28
Significant differences in mortality rates by
PCT, closely correlated with deprivation
25.4
BBCHA EXAMPLE
Deprivation and mortality in BBCHA, 1997-2005
Perinatal mortality rate per 1000 live births,
1997-2005
Infant mortality rate per 1000 live births,
1997-2004
Index of multiple deprivation, 2004
53.5
Heart of Bhm.
14.5
10.7
42.4
Birmingham E N
12.2
8.8
40.3
S Birmingham
12.1
5.6
37.8
Sandwell
11.0
7.5
36.6
Wolverhampton
10.2
8.1
34.3
Walsall
9.1
7.3
25.4
Dudley
8.7
5.2
20.2
Solihull
8.8
4.4
Calculated by super output area, weighted by
number of births Source West Midlands Perinatal
Institute
29
Very wide variation seen within individual PCTs,
also somewhat correlated with deprivation
6.0
BBCHA EXAMPLE
Deprivation and mortality by ward in Birmingham
East and North, 1997-2005
Index of multiple deprivation, 2004
Perinatal mortality rate per 1000 live births,
1997-2005
Infant mortality rate per 1000 live births,
1997-2004
62.2
Washwood Heath
17.0
12.8
53.0
Kingstanding
51.5
Shard End
12.7
50.3
Bordesley Green
15.6
10.1
44.7
Tyburn
12.0
10.4
44.5
Stechford Ydly. N.
10.5
42.3
South Yardley
14.5
41.9
Hodge Hill
11.3
41.2
Stockland Green
13.8
11.1
40.6
Erdington
39.6
Acocks Green
13.1
33.5
Sheldon
12.0
29.0
Oscott
21.4
Sutton Trinity
13.8
Sutton Vesey
13.1
Sutton New Hall
10.6
Sutton Four Oaks
Calculated by super output area, weighted by
number of births Source West Midlands Perinatal
Institute
30
Significant differences in availability of SCBU
cots
12
Availability of SCBU cots in the West Midlands,
September 2007
Number of cots
No of deliveries per SCBU cot
Total
Deliveries per SCBU cot
Level 1
Level 3
Level 2
318
Manor Hospital, Walsall
12
295
Staffordshire General Hospital
267
North Staffs Maternity Hospital
10
20
253
11
Queens Hospital, Burton Upon Trent
14
233
Alexandra Hospital
232
13
Russells Hall Hospital
18
11
Warwick Hospital
11
228
12
Worcestershire Royal Hospital
18
208
Good Hope Hospital
10
16
207
10
George Eliot Hospital
12
207
16
University Hospital (Coventry)
27
191
20
Heartlands Hospital
27
181
16
Royal Shrewsbury Hospital (Maternity)
22
180
10
Sandwell General Hospital
14
175
12
City Hospital
21
162
32
Birmingham Womens Health Care
44
154
10
New Cross Hospital
24
150
Hereford County Hospital
12
149
Source Womens and Childrens Services in the
West Midlands SHA, Durrow, September 2007
31
Breastfeeding rates are lower in the West
Midlands than the national average
17
Incidence of breastfeeding, 2005, of mothers
Initially
At 6 months
London
39
South West
33
South Central
28
South East Coast
34
East of England
28
East Midlands
26
Yorkshire and Humber
21
West Midlands
24
North West
17
North East
17
England average 78
England average 26
Source Infant feeding survey 2005, Information
Centre
32
West Midlands caesarean rate is 23, in line with
the national average
0
Method of delivery in West Midlands, NHS hospital
deliveries, 2005-06, of total
Emergency
Elective
23
Forceps
Breech or breech extraction
Other
Spontaneous
Caesarean
Ventouse
England average
65
23
7
4
1
0
Source NHS Maternity Statistics, England
2005-06, Information Centre
33
Little consistency in delivery methods across the
region
62
Method of delivery, 2005-06, of all deliveries
Spontaneous
Instrumental
Caesarean
100
Ludlow Hospital
100
SATH (Maternity)
100
Princess Royal Hospital (Maternity)
99
Victoria Hospital Lichfield
75
Royal Shrewsbury (Maternity)
11
14
71
Mid-Staffs General
12
17
70
Heart of England
23
69
City Hospital Birmingham
23
69
George Eliot
25
68
Hereford Hospitals
25
65
Birmingham Womens
12
23
65
Good Hope
11
24
64
Dudley GoH
28
64
Sandwell and West Birmingham
30
64
UHCW
10
27
63
South Warwicks
13
24
62
Burton Hospitals
13
25
Source NHS Maternity Statistics, England
2005-06, Information Centre
34
West Midlands is close to the national average
for episiotomy rates
11.0
Deliveries with episiotomy, 2005-06, of all
deliveries
South East
North West
East
Yorkshire and Humber
West Midlands
North East
London
South West
East Midlands
England average 14
Source NHS Maternity Statistics, England
2005-06, Information Centre
35
There is however wide variation in episiotomy
rates by trust
0
Spontaneous deliveries with episiotomy, 2005-06,
of all spontaneous deliveries
George Eliot
UHCW
Good Hope
Mid-Staffs General
Burton Hospitals
South Warwicks
Royal Shrewsbury (Maternity)
City Hospital Birmingham
Hereford Hospitals
Heart of England
SATH (Maternity)
Birmingham Womens
Sandwell and West Birmingham
Dudley GoH
Ludlow Hospital
Princess Royal Hospital (Maternity)
Victoria Hospital Lichfield
Source NHS Maternity Statistics, England
2005-06, Information Centre
36
Majority of deliveries take place on same day or
day after admission
2
Days from start of episode to delivery in West
Midlands, NHS hospital deliveries, 2005-06,
Same day
1
2
3
4
5
England average
61
30
6
2
1
1
Note Figures may not sum to 100 owing to
rounding Source NHS Maternity Statistics,
England 2005-06, Information Centre
37
Mothers typically leave hospital within two days
of delivery, though there is a small proportion
of long stays of five or more days
6
Days from delivery to end of episode in West
Midlands, NHS hospital deliveries, 2005-06,
4
1
Same day
2
3
5
England average
16
35
21
15
6
7
Note Figures may not sum to 100 owing to
rounding Source NHS Maternity Statistics,
England 2005-06, Information Centre
38
Deliveries on consultant wards are 69 of the
total, considerably higher than the national
average
2
Place of delivery, NHS hospital deliveries,
2005-06,
Consultant / midwife / GP ward
Consultant ward
GP ward
Midwife ward / other
England average
50
42
2
7
Note Figures may not sum to 100 owing to
rounding Source NHS Maternity Statistics,
England 2005-06, Information Centre
39
No increase in West Midlands midwife numbers
since 2001 and a 1.5 reduction during 2006
No. of midwives FTE
England
West Midlands
2001
02
03
04
05
2006
Source Maternity Matters Choice, Access and
Continuity of Care in a Safe Service, Caroline
Donovan, Deputy Head of Workforce Development,
West Midlands Workforce Deanery
40
Significant numbers of midwives are likely to
retire over the next five years
30
Midwives by age group 2006 (FTE)
Under 25
2529
3034
3539
4044
4549
5054
5559
6064
65
Note Excludes midwives where age not
available Source Maternity Matters Choice,
Access and Continuity of Care in a Safe Service,
Caroline Donovan, Deputy Head of Workforce
Development, West Midlands Workforce Deanery
41
West Midlands has fewer births per midwife than
the English average
Births per midwife by SHA, 2005
East Midlands
South East Coast
London
East of England
Yorkshire and Humber
West Midlands
North East
North West
South West
South Central
National average 35
Source Dr Foster Birth Guide 2006
42
Variations in births per midwife are large across
the region
29
Births per midwife by site, 2006-07
Russells Hall Hospital
Heartlands Hospital
Warwick Hospital
Worcestershire Royal Hospital
Solihull Hospital
University Hospital (Coventry)
Queens Hospital, Burton Upon Trent
Hereford County Hospital
George Eliot Hospital
Birmingham Womens Health Care
North Staffs Maternity Hospital
New Cross Hospital
Staffordshire General Hospital
Good Hope Hospital
Alexandra Hospital
Sandwell General Hospital
City Hospital
-28
Manor Hospital, Walsall
Source Womens and Childrens Services in the
West Midlands SHA, Durrow, September 2007
43
Considerable differences in cost per birth,
driven by use of N12s, outpatient attendances,
and community midwifery contracts
2,200
Cost per birth by component, 2006-07 activity at
2007/08 prices,
Community midwifery
Inpatient activity(exc. N12)
Outpatientactivity
N12
3,351
Sandwell W Bhm
2,971
Dudley Grp
2,878
Heart of England inc. Good Hope
2,692
UH Coventry Warwicks.
2,652
Birmingham Womens
2,636
Royal Wolverhampton
2,542
Walsall
2,458
Worcester Acute
2,291
Hereford
0
2,243
Sth Warwick General
2,200
Shrewsbury Telford
148
Antenatal Admissions not Related to Delivery
Event Community midwifery costs not
detailed Source West Midlands Commissioning
Business Support Agency
44
The West Midlands has average access to
infertility treatment
4
2003/04,
Of total U.K. couples with difficulty conceiving
Of total U.K. IVF treatment
London
South East
North West
West Midlands
Yorkshire Humber
East of England
Scotland
East Midlands
South West
North East
Wales
Northern Ireland
Source HFEA
45
Success rates of fertility treatment are mostly
below national average
28.1

• Fertility treatment success rates, 2003/04

Live births per cycle started,
Cycles started
334
Birmingham Womens
186
BMI Priory
102
Burton
Centre for Reproductive Medicine, Coventry
257
354
Midland Fertility Centre
105
Shropshire and Mid Wales
54
St. Judes
West Midlands
England
Source HFEA
46
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation in Maternity and Newborn
• Case for change
• Vision for the future

47
This section presents two key aspects of the case
for change

• Antenatal care of high-risk groups performance
  against the most important care and risk factors

• Care at delivery safety, efficiency and scale

48
Quality of antenatal care in Birmingham and the
Black Country was tested against the most
important care and risk factors
Background
Performance indicators selected

• Reducing Perinatal Mortality project began in
  2004, led by Birmingham and the Black Country SHA
  and the then 12 PCTs
• Primary aim to reduce perinatal mortality by
  providing an equitable and evidence-based mother-
  and baby-oriented maternity service, by
• Identifying the areas of highest mortality
• Redesigning services through Local Implementation
  Groups
• Conducting maternal experience survey
• Establishing ongoing data collection from all
  agencies, including five selected performance
  indicators
• Confidential panel inquiries of the largest
  component of perinatal mortality (stillbirths
  with evidence of intrauterine growth restriction)

Carer continuity

• 75 of visits to midwifery with named midwife

Early booking

• 80 booking in first trimester

• 60 of growth-restricted babies detected
  antenatally

Detection of fetal growth restriction

• Reduced to prevalence of 15 by 2010, or 1
  reduction per year (national target)

Smoking in pregnancy
Breast feeding

• Increase in initiation rates by 2 per year
  (national target)

Following pages present some interim results
Source Birmingham and the Black Country
Reducing Perinatal Mortality Project Interim
Report, January 2007
49
Early booking rate is lower than target but
wide variation between units suggests target
should be achievable
43
BBCHA EXAMPLE

• Early booking (lt12 weeks) rate, October 2006,

By ethnicity. Target 80
By unit. Target 80
Afro Caribbean
Asian
European
By age. Target 80
Average
Lowest
Highest
lt20
2035
35
Source Birmingham and the Black Country
Reducing Perinatal Mortality Project Interim
Report, January 2007
50
Some units are already providing continuity of
carer but the average is far below the target
37
BBCHA EXAMPLE

• Continuity of carer in over 75 of interactions,
  October 2006,

By ethnicity. Target 75
By unit. Target 75
Afro Caribbean
Asian
European
By age. Target 75
Lowest
Average
Highest
lt20
2035
35
Source Birmingham and the Black Country
Reducing Perinatal Mortality Project Interim
Report, January 2007
51
Detection of growth restriction falls short
across the board
19
BBCHA EXAMPLE
Antenatal detection of growth restriction,
October 2006,
By ethnicity. Target 80
By unit. Target 80
Afro Caribbean
Asian
European
By age. Target 80
Lowest
Average
Highest
lt20
2035
35
Source Birmingham and the Black Country
Reducing Perinatal Mortality Project Interim
Report, January 2007
52
One in seven mothers smoke at delivery and
amongst young mothers this rises to one in three
8
BBCHA EXAMPLE

• Rate of smoking at delivery, October 2006,

By ethnicity. Target 15
By unit. Target 15
Afro Caribbean
Asian
European
By age. Target 15
Lowest
Average
Highest
35
lt20
2035
Source Birmingham and the Black Country
Reducing Perinatal Mortality Project Interim
Report, January 2007
53
Breastfeeding initiation varies significantly
with ethnicitybut the average is well below the
England average
70
BBCHA EXAMPLE

• Rate of breastfeeding initiation, October 2006,

By ethnicity. Target 78
By unit. Target 78
Afro Caribbean
Asian
European
By age. Target 78
Lower
Average
Higher
lt20
2035
35
Source Birmingham and the Black Country
Reducing Perinatal Mortality Project Interim
Report, January 2007
54
This section presents two key aspects of the case
for change

• Antenatal care of high-risk groups performance
  against the most important care and risk factors

• Care at delivery safety, efficiency and scale

55
NHS West Midlands Investing for Health
developed a set of principles for paediatrics
and maternity services
FOR DISCUSSION

• All parents/guardians should have 24-hour access
  to comprehensive services to assess their unwell
  child
• Primary care services close to home are usually
  the most appropriate services for children who
  are less unwell
• Quality of specialist services for critically ill
  and injured children is often more important than
  proximity

1
Assessment of theunwell child
2
Primary care basedservices

• Services offered by GPs and community nursing and
  midwifery teams are a crucial part of the care of
  children and maternity patients
• Pregnant women who wish to deliver their babies
  in community units or at home should be supported
  safely

3
Rota compliance

• In order that specialist care is delivered by
  clinicians who are well-trained, well supervised
  and not overtired, they will work in centres
  where there are enough specialists working
  together to ensure safe rotas which meet the
  legal requirements

4

• Safety of critically ill patients is improved by
  immediate transport to the units that have the
  full facilities to cope
• Well trained ambulance personnel working in well
  equipped emergency transport services are an
  essential component

Clinical safety andclinical effectiveness
5
Availability of skill mix and education/training
for a multi-professional workforce

• Effective services for children, young people,
  babies and mothers depend on many different
  well-trained health professionals
• Training and employment of specialist nurses,
  midwives and allied health professionals in
  sustainable services is important - as well as
  specialist doctors

6
Choice of service models

• In emergency the overwhelming majority of
  patients place safety as the top priority, and
  for this reason we are encouraging the
  development of a network of specialist centres
  with the best facilities
• Choice of place of birth, the method of delivery,
  and the method of pain relief in childbirth is
  important for pregnant women, and needs to be
  based on best available evidence

Source Investing for Health, NHS West Midlands
56
A recent audit of West Midlands maternity unit
performance used staffing and size as key
indicators of safety and viability
Approach
Factors used

• Review designed to test the long-term safety and
  economic viability of womens and childrens
  services, based on ability to staff with
  consultants and middle grade doctors and overall
  size
• Not intended to suggest that dependence on
  midwives and RSCNs is not vital
• Risk scores developed as follows
• Score 1 sufficiently large to function safely
  with adequate staffing and cover
• Score 2 significant gaps in staffing and cover,
  and/or of a size unable to guarantee safety and
  viability
• Score 3 glaring gaps in staffing and cover,
  and/or too small to sustain a safe service
• For multi-site trusts, score of site with highest
  score is used

Risk rating awarded
(Lowest risk) 1
(Highest risk) 3
2

• Number of births

3,000
2,0003,000
lt2,000

• Obstetric consultants

6
56
lt5

• Middle grade obstetric cover

7
6
lt6

• Paediatric consultants

6
56
lt5

• Middle grade paediatric cover

7
6
lt7
Source Womens and Childrens Services in the
West Midlands SHA, Durrow, September 2007
57
Of the 15 trusts covered, 8 were shown to be at
medium or high risk for obstetrics cover or
overall scale
2
Draft outcome of review of West Midlands trusts,
number of trusts per category
Number of births
Obstetric consultants
Middle grade obstetrics cover
Score
(Lowest risk) 1
11
13
2
(Highest risk) 3
In progress not scored
Note Review is currently being finalised and so
trust names are not given here Source Womens
and Childrens Services in the West Midlands SHA,
Durrow, September 2007
58
The review identified serious issues at some
trusts
2
Examples of issues identified, obstetrics
Trust 1

• The division of maternity and childrens
  services between the. . . hospitals creates
  potential difficulties of cover and
  sustainability although together the services are
  easily large enough to assure viability

Trust 2

• Only 4 consultants currently provide the
  maternity service

Trust 3

• The number of births has been scored as a 2
  because of the very low number of births at some
  of the midwifery units. This requires further
  checking of the skills maintenance and clinical
  safety of the units

Note Review is currently being finalised and so
trust names are not given here Source Womens
and Childrens Services in the West Midlands SHA,
Durrow, September 2007
59
Contents

• Executive summary
• Current situation
• Challenges facing the West Midlands health system
• Current situation in Maternity and Newborn
• Case for change
• Vision for the future

60
This section looks ahead to the future for the
West Midlands

• Examples of good practice and innovation exist
  for both antenatal care

• and improving quality and outcomes in care at
  delivery

• There are therefore several questions about the
  future direction for the clinical group to
  consider

61
Example (1) Changes to the parent education
service, Royal Wolverhampton Hospitals
Overview
Achievements

• Aimed to develop a modern approach to parent
  education by
• Providing midwives with equipment needed
• Standardising classes so that women receive
  consistent information wherever classes held
• Standard developed for three classes to be held,
  facilitated by the midwife
• Active birth (labour), including practical
  demonstration of pelvis, and positions using the
  birthing ball
• When things do not go to plan and pain control,
  including a game facilitated by the midwife but
  led by women or couples
• First few days with a baby, including a quiz
  dealing with common problems dealt with by
  community midwife in first visits

• Very popular service with highly positive
  feedback from couples
• Women likely to labour at home longer
• Women describe positive birth experiences and
  feel more confident postnatally
• Partners feel they were able to offer confident
  support in labour as they have a better awareness
  of the birth process
• May have contributed to a reduction in the rates
  of epidural and caesarean section

Source NHS West Midlands case studies database
62
Example (2) Reducing caesarean section rates,
Royal Wolverhampton Hospitals
24.0
Overview

• Developed in 2004 a midwife-led steering group to
  identify a model of good practice with the focus
  on normality (low risk birth pathway)
• Activities included
• Active birth workshops
• Avoidance of unnecessary intervention for
  low-risk women
• Risk assessments (at every contact with the
  woman, backed by updated documentation)
• Introduction of alternative methods of pain
  management (including water birth facility)
• Room décor
• Standardised information to enable informed
  choice for women requested vaginal birth after
  caesarean
• Fetal blood sampling
• Visible consultant and senior midwifery presence
  on delivery suite

Achievements
Caesarean rate development, of births
2007YTD
2004
2005
2006
Source NHS West Midlands case studies database
63
Example (3) Worcestershire Acute Hospitals VBAC
clinic
Overview

• An audit into the elective caesarean rate showed
  that 55 were due to having had a previous
  caesarean, and 40 were due to the womans choice
• Information given to these women was extremely
  poor, with 97 not given sufficient information
  to make an informed choice of their options for
  mode of birth
• Vaginal Birth After Caesarean (VBAC) clinic was
  initiated in October 2005 at the Alexandra
  Hospital, Redditch
• Run by consultant midwife
• Appointments given to all women who previously
  have had caesarean
• Risks of VBAC and caesarean equally discussed,
  with information also given in written form

Achievements

• Prior to VBAC clinic commencing
• 22 of women wanted VBAC
• 100 of them had a caesarean
• From December 2005 to December 2006 after
  establishment of clinic
• 66 of women elected to have a VBAC
• 66 of these had a vaginal birth (and 34 an
  emergency caesarean)

Source NHS West Midlands case studies database
64
Questions for the clinical group to consider

• What are the key issues for you?
• What best practices/innovations have you seen?
  Are there barriers to implementing them?
• What is your vision for the future?