The
argument for re-opening comprehensive maternity services at King
George Hospital.
Better
Births
The
National Maternity Review ‘Better
Births’ (Feb 2016)i
set out the FYFV for maternity services in England. It aimed to make
maternity care safer, in line with the Health Secretary’s ambition
to halve the number of stillbirths, neonatal deaths and serious brain
injuries occurring during birth, but also to ensure care that was
kinder, more personalised, and “wrapped care around each woman”.
Better
Births’
recommendations included:
- Genuine choice, with the ‘choice journey” beginning with services recognising women’s needs;
- Choice discussions with midwife about options for care beginning at booking;
- Organising services around women and their families (through, for example community hubs with a range of relevant services);
- Continuity of carer, close to home where possible;
- Choice of place of birth offered to all with unbiased information;
- Transfer to post-natal care that is seamless and well supported;
- Co-designing of services with local women.
New
structures
In
response to the Review, NHSE established a national Maternity
Transformation Programme to be implemented by
- a National Maternity Transformation Board (NMTB)
- a London Maternity Transformation Board (LMTB), reporting to the NMTB, and
- Local Maternity Systems (LMSs), bringing together commissioners, providers and service users and reporting, in London, to the LMTB.
North
East London
NE
London is covered by the East London Local Maternity System (ELLMS),
reporting to the LMTB but also to the East London Health and Care
Partnership (ELHCP) - or STP.
ELLMS
has now developed a plan for the next 5 years to look at how their
system will deliver NHSE’s ‘Better Birth’ recommendations. This
plan involves significant ‘transformation’ from providers of
maternity services.
Neither
ELHCP nor ELLMS is a statutory body: they are not accountable for the
delivery of maternity services. Instead accountability for
commissioning remains with CCGs, and accountability for service
provision remains with Trust Boards.
NHSE
has produced a set of Key
Lines of Enquiries
for all LMSs to bear in mind while developing plans ahead of an
assurance submission to NHSE in October 2017.
Better
Care and Wellbeing in East London
The
East London Health and Care Partnership’s document Better
Care and Wellbeing in East London
states that
With
a shared goal to help people live healthy and independent lives, the
Partnership’s mission is to protect vital services and provide
better treatment and care built around the needs of local people,
safely and conveniently, closer to home.
(http://eastlondonhcp.nhs.uk/wp-content/uploads/2017/06/Better-Care-and-Wellbeing-in-East-London.pdf)
Plans
of East London Local Maternity System (ELLMS)
Plans
by the ELHCP and ELLMS for transforming the maternity services of
East London were set out in a report to the Inner North East London
Joint Health Overview and Scrutiny Committee in November 2017. This
report confirmed that the aims of this transformation include:
- To ensure more women have a personalised care plan
- To expand choice, including choice in “the three places of birth” (hospital, midwifery led centre and home)
- To ensure that women receive continuity of the person caring for them during pregnancy, birth and post-natally.
- To ensure that more women will be enabled to give birth in midwifery led settings.
Current
maternity services in East London
i)
Provision
Maternity
services are currently provided by the Royal London, Whipps Cross,
Newham, BHRUT (Queens), and Homerton hospitals. Each has an obstetric
labour ward and an alongside midwifery led unit. (King George’s
provides clinics and antenatal care only.) In addition, the
Barkentine Centre is a midwife-led birthing centre provided by
BartsHealth NHS Trust.
A
pilot is currently underway in Waltham Forest with a midwifery-led
provider, Neighbourhood
Midwives, in which
low-risk women are offered continuity of care from the same midwife
throughout pregnancy, labour and the post natal period.
(Neighbourhood Midwives does not provide a birthing centre: birth
takes place either at home or in one of the hospitals or midwife-led
units described above.)ii
ii)
Challenges
According
to the ELHCP and the ELLMS, challenges facing maternity services in
East London include:
- A projected increase by 4.41% (about 1500 births) within the next 5 years, with greater pressure anticipated in the BHR footprint. iii
- High turnover of midwifery staff and workforce gaps in acute providers means challenges with clinical capacity or transformation.
- Variations exist in patient ratio to GP with Redbridge and Waltham Forest falling in the lowest 20%
- The age of women giving birth is higher than national average (NEL 32.16 years compared to national average of 30.4 years).
- 19.9% (2712) of women are presenting with multiple co-morbidities (which may rise as high as 23% by 2018)
- A more than 2% rise in the last 2 years in the number of women reported as unable to speak or understand English (from 6.9% to 9.3%).
- An expected increase in the prevalence of diabetes by 1.5% (1051 women) per year.
- A further 1% (254 women) of women are expected to develop gestational diabetes during pregnancy.
- Mental health conditions are rising by 1% (254 women) per year.
- Achieving continuity of carer is highly dependent on funding
Argument
This
assessment of the challenges facing providers of maternity services
in East London corresponds with BartsHealth’s assessment, set out
in Transforming
Services Together.
This states that maternity services are struggling with rising birth
rates and a population whose health complexity is increasing, while
staffing levels are below recognised standards.
Pressure
on services in East London is indicated by the fact that between
April to June 2017, the obstetric unit at Newham was closed on three
occasions, and the obstetric unit at Whipps Cross was closed once
during the same period.
We
support the intention to increase midwifery-led units for
straightforward pregnancies as evidence suggests that these units, if
well-resourced, can provide more continuity of care, fewer
unnecessary interventions and better experience of care. However, to
ensure the safety of maternity care, these units must be backed up by
fully reliable emergency contingency provision.
At
the moment, with the loss of obstetric or midwifery-led provision at
King George’s Hospital (other than clinics and antenatal care),
there is a significant gap - a substantial area of East London that
is not covered by local maternity services or emergency provision.
Currently, women going into labour in the (Redbridge/Ilford??) area
who are not having a home birth have to travel to Queen’s, Newham
or Whipps Cross. Any community hub or midwife-led unit set up in
(Redbridge/Ilford) would have no local facilities for emergency
contingencies.
Moreover,
Better
Births
promotes choice for women in terms of place of birth as well as
recognition of their needs. Yet lack of provision in the
(Redbridge/Ilford) area ignores local womens’ needs and denies them
any real choice. Local services have not been co-designed with local
women. Without
urgently meeting current and future demand for local maternity
services, there is a risk that women will experience unsafe, poor
quality services that do not meet their needs or choices.
We
therefore urge ….. to re-open comprehensive maternity services at
King George’s.
APPENDIX
Total
births in NEL Jan-June 2017
Provider
|
Jan
|
Feb
|
Mar
|
April
|
May
|
June
|
RLH
|
436
|
358
|
430
|
420
|
434
|
414
|
WX
|
428
|
334
|
371
|
388
|
443
|
387
|
Newham
|
537
|
479
|
507
|
524
|
533
|
517
|
BHRUT
|
666
|
611
|
679
|
657
|
701
|
718
|
Homerton
|
496
|
406
|
469
|
419
|
502
|
521
|
Neighbourhood
midwives
|
4
|
7
|
8
|
7
|
7
|
8
|
Out
of Obstetric Unit Births
- Data suggests that low risk women are safer giving birth in midwife led settings and have a better experience of care
- In 2016-17 approx 18% of births in NEL were in midwifery led settings with wide variation across providers from 13-25%
- There is capacity to increase these figures even in the face of rising acuity
BHRUT
|
HUH
|
NEWHAM
|
RLH
|
WX
|
|
Out of
Obstetric Unit birth rate 2016/17
|
18.34%
|
17.45%
|
25.3%
|
13.1%
|
15.6%
|
Aspirations
for Out of Obstetric Unit Births 2021
|
22%
|
25%
|
40%
|
30%
|
35%
|
NEL
Obstetric Unit births
April
|
May
|
June
|
|
RLH
|
79.5%
|
84.3%
|
80.7%
|
WX
|
84.5%
|
84.2%
|
86.8%
|
Newham
|
75.8%
|
74.3%
|
76.8%
|
BHRUT
|
79.9%
|
82.0%
|
79.1%
|
Homerton
|
80.7%
|
80.3%
|
81.8%
|
Neighbourhood
midwives
|
29%
|
29%
|
38%
|
NEL
Homebirths
April
|
May
|
June
|
|
RLH
|
0.95%
|
1.15%
|
1.45%
|
WX
|
0.52%
|
0.45%
|
0.78%
|
Newham
|
0.38%
|
0.75%
|
0.97%
|
BHRUT
|
0.20%
|
0.70%
|
1.80%
|
Homerton
|
1.60%
|
2.60%
|
1.80%
|
Neighbourhood
midwives
|
43%
|
71%
|
63%
|
ii
Neighbourhood Midwives is a
private, employee-owned company, selling itself on the basis that
the NHS is overstretched and often cannot provide continuity of
care. Its website provides a link to its NHS funded services pate,
where it says it is working with the NHS to offer women in Newham
the chance to take part in a pilot of midwifery continuity of care.
(Privately provided care cost - depending on the package - between
£592 - £742 per
month. The
Programme Director of Neighbourhood Midwives was on the Review team
for Better Births, along with Sam Everington among others).
Neighbourhood Midwives is piloting ways of cross-boundary working
and developing a new model of transitional care, including care in
the community that would currently be hospital based.
iii
Transforming Services
Together (http://www.transformingservices.org.uk), the BartsHealth
NHS Trust’s initiative to improve the local health and social care
economy in Newham, Tower Hamlets and Waltham Forest states that
maternity services in these areas are struggling to a population
with increasingly complex health needs, staffing levels below
recognised standards, and an estate that does not meet the needs of
users. Over the next ten years, it is predicted that there will be
an extra 5,000 births per
year across
north-east London, in particular in Tower Hamlets and Newham.
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