Agenda item

1.1.         The Committee considered a report on the quality and performance of maternity services for East Sussex residents, including feedback from local women obtained from a survey undertaken by Eastbourne Borough Council.

1.2.        Councillor Robert Smart, Eastbourne Borough Council; Peter Finnis, Assistant Director – Corporate Governance, Eastbourne Borough Council; Amanda Philpott, Chief Officer, EHS/HR CCG; Jessica Britton, Chief Operating Officer, EHS/HR CCG; Vikki Carruth, Director of Nursing, ESHT; and Sarah Blanchard-Stow, Head of Midwifery, ESHT were present for this item.

1.1.        In addition to the written report submitted to HOSC by Eastbourne Borough Council, Cllr Robert Smart made the following additional points:

·         The Eastbourne Borough Council survey is the most extensive of its kind and was sent to all mothers who gave birth in East Sussex during 2016, based on Office of National Statistics (ONS) data. The response rate was 35%.

·         The survey provides evidence that 93% of mothers in the EHS CCG area who responded to the survey would wish to give birth at EDGH if there were a full obstetric service available.

·         There should be an independent review to consider whether the ONS figures for stillbirths in Eastbourne are in any way correlated to the single siting of obstetrics services at Conquest Hospital, Hastings, and the related travel times.

·         The extensive Netherlands study (of over 700,000 mothers) simply concludes that a travel time of over 20 minutes increases risk.

·         The National Maternity and Perinatal Audit published in 2017 shows that maternity services are not performing as well as is set out in the CCGs’ report.

·         Any complete review of maternity services should look into its share of ESHT's reported clinical negligence liabilities of £80 million, with £13m being paid out. Nationally, maternity accounts for 50% of payouts, according to NHS Resolution, so this would amount to approximately £6.5m maternity payments.

1.2.        A number of questions from HOSC were answered by witnesses.

Transfers during labour

1.3.        Councillor Robert Smart said that a figure of 90 patients transferred during labour referred to the number of respondents to the survey who had been transferred to the Obstetric Unit at Conquest Hospital during labour. He said that 55 came from the EHS CCG area, 15 from the HR CCG area and 20 from the HWLH CCG area.

1.4.        Peter Finnis observed that the survey findings indicated more Eastbourne mothers experienced transfer than the rest of the county put together and suggested that this was an inequality of service that is an ongoing concern to the Eastbourne community.

1.5.        Sarah Blanchard-Stow said that the Midwife Led Unit (MLU) at Eastbourne District General Hospital (EDGH) is staffed solely by midwives. Normal, low risk labour can take place at the MLU, but if at any point there is a deviation from normality or the woman requests more pain relief then a transfer will take place. A lack of other MLUs in the local area makes comparisons of transfer rates difficult, but the figures are compared to those published by the Birthplace Study.

1.6.        Ms Blanchard-Stow explained that there were 63 transfers from the MLU in 2017 on safety grounds. She said the outcomes for all patients who were transferred were followed up and none had an emergency caesarean section within an hour of arriving at the Conquest Hospital. This indicates that the decision was the correct one to have taken and none of those patients were put at risk by either using the MLU in the first place, or being transferred when it became necessary.

1.7.        Jessica Britton said that there will always be a certain level of transfers from an MLU to an obstetric unit, as the decision to transfer is based on clinical need and national guidelines on when people should be transferred.

Definition of ‘near miss’

1.8.        Councillor Robert Smart said that he had no information available on the 150 near misses mentioned in the Eastbourne Borough Council presentation but suggested that such information was difficult to obtain from ESHT. Peter Finnis added that Eastbourne Borough Council did not have enough information on near misses, serious incidents, or transfer times, which is why the report concluded that more work was needed to understand those issues.

1.9.        Vikki Carruth said that the 150 near miss figure was not one that ESHT recognised. She said that such a figure would, however, indicate a good reporting culture and ESHT encourages all staff to report all near misses including those that are relatively minor.

Born Before Arrival (BBA)

1.10.      Councillor Smart said he had not had time to review the additional Born Before Arrival (BBA) figures submitted by the CCGs after the publication of the agenda that indicated a higher BBA rate in Hastings.

1.11.      Sarah Blanchard-Stow explained that BBAs refer to a birth before a midwife is in attendance and do not necessarily refer to hospital births as the mother may have intended to give birth at home, for example, the 20 BBAs between January 2016 and December 2017 in Eastbourne included 6 planned home births.

1.12.      Ms Blanchard-Stow said that it is not always possible to reach a woman with a precipitate labour in time, however, each BBA case is reviewed to ensure that the correct pre-natal advice was given to the mother beforehand. The review records whether the BBA was avoidable or unavoidable, with any lessons learned taken on board where it was avoidable. Ms Blanchard-Stow confirmed that there were no adverse outcomes from any BBA in the previous year, and a midwife or ambulance crew attended each incident.

Stillbirths

1.13.      Councillor Smart referred to the ONS statistics for 2016 stillbirths which reported eight for Eastbourne, which he suggested is close to double the national rate. He recognised that stillbirths were not necessarily reported as serious incidents but suggested that the public may consider it an oddity that there were reportedly eight stillbirths in Eastbourne in 2016 and only one had been deemed a serious incident. He added that part of the problem is that hospital trusts report their own serious incident figures and that the Secretary of State has suggested an independent review of stillbirths would be necessary in the future. He also raised concerns about the different still birth figures supplied by the CCGs compared to those provided by the ONS which are quoted in the Eastbourne Borough Council report.

1.14.      Jessica Britton explained that the discrepancy in the stillbirth figures provided by Eastbourne Borough Council and the CCGs is due to how the NHS and ONS are required to report their data in different ways.

1.15.      Sarah Blanchard-Stow confirmed that of the eight stillbirths being quoted for Eastbourne during 2016 these were classified as anomalies, reduced foetal movements, or abruptions. One of the anomalies went through a vigorous serious incident process during which the midwife was referred to the Nursing and Midwifery Council.

1.16.      Ms Blanchard-Stow explained that reduced foetal movements and abruptions cannot be prepared for but ESHT has done considerable work to raise awareness amongst pregnant women to monitor foetal movement; and the Trust is looking for links between communities with high rates of cocaine use and incidents of abruptions, due to the increased likelihood of cocaine use causing an abruption.

1.17.      Ms Blanchard-Stow reiterated that ESHT’s maternity service has not been an outlier in any national indicators, including stillbirths, for the past three years. Furthermore, the small numbers mean statistically it is difficult to compare year-on-year rates of stillbirths. However, ESHT has a stillbirth rate of 3.45 per 1,000 compared to the national average of 3.46 for comparably sized units and 3.96 for larger units.

1.18.      Sarah Blanchard-Stow said two bereavement midwives and a consultant are employed to investigate all stillbirths and monitor local stillbirth rates against national trends.

1.19.      Ms Blanchard-Stow explained that the maternity services operate an after care service that involves the bereavement midwives visiting bereaved parents. The after care service has close ties with East Sussex SANDS charity and was shortlisted for an award by the Royal College of Midwives.

Performance of maternity services since the reconfiguration

1.20.      Councillor Smart said that it was possible that the maternity services appeared to be improving due to how statistics had been presented in the CCGs’ report to the Committee.

1.21.      Amanda Philpott said she had no doubt about the integrity of all people who are involved in providing and monitoring maternity services. She also welcomed HOSC and Liz Walke, Chair of Save the DGH campaign, consistently holding the CCGs to account.

1.22.      Amanda Philpott clarified that the CCGs report data to the national maternity databases in a different way to how it is reported locally, and there is a difference between actual numbers of incidents and rates of incidents per 1,000.

1.23.      Jessica Britton said that during the ‘Better Beginnings’ reconfiguration of maternity services in 2014 the CCGs critically reviewed the evidence base to determine the safest service that could be provided based on a number of indicators. She said that these indicators are still used for reporting the quality and safety of the service, and the data is provided in good faith and accurately to the best of the knowledge of those who compile it.

1.24.      Jessica Britton said that the CCG can provide some assurance that the safety and quality figures provided demonstrate that the reconfiguration has made sustained improvements, for example, quality indicators around staffing levels of midwifes and consultants, and the number of locums being used have all improved.

1.25.      Ms Britton said that there will always be areas where further improvement could be made, and indicators such as those around serious incident numbers and BBAs in Hastings are kept under review.

1.26.      Vikki Carruth said that all decisions that ESHT takes are first and foremost about ensuring the safety of mothers and babies. She acknowledged that these decisions might not be what local mothers want and that they may well want services that are closer to homes but the priority is to provide the best possible service that is safe. If a service cannot be staffed safely, ESHT will not want to provide that service.

Satisfaction rating

1.27.      Councillor Smart said that the Eastbourne Borough Council’s report had been relatively objective in reporting the survey respondent’s satisfaction levels. He quoted the Secretary of State’s November 2017 statement saying “there are high levels of satisfaction from parents, however, there is still too much avoidable harm and death” and argued that the report potentially reflected this concern by showing a 6% dissatisfaction rate amongst mothers alongside comments from survey responses that appeared more negative than the overall satisfaction levels would suggest.

Sustainability of MLU

1.28.      Sarah Blanchard-Stow said that since the reconfiguration staff at the MLU are much happier and there is a better retention rate. A recent staff survey has shown an increase in satisfaction levels amongst staff over the past year, including feeling that management are listening to their concerns and taking action to address them.

1.29.      Ms Blanchard-Stow explained that the MLU has some of the best staffing levels of midwives in the south coast at a ratio of one midwife to every 26 births – compared to 1:35 on average. 

1.30.      Ms Blanchard-Stow said that work is underway to improve the quality of the service provided by the MLU and increase awareness that the MLU is a safe place to give birth. This includes:

·         Reviewing staffing levels to determine whether they are sufficient to provide continuity of care for mothers.

·         Developing an Integrated Community Model of care involving community midwives and midwives within the MLU working together as a team.

·         Providing reflexology at the MLU.

1.31.      Ms Blanchard-Stow argued that there has been a slight increase in the number of births in recent years, but a lot of mothers who are low risk and could birth happily at the MLU are choosing to go to the Conquest Hospital instead due to local perceptions about safety and availability of a service at Eastbourne DGH.

Purpose of the Eastbourne Borough Council report

1.32.      Peter Finnis said that the report was not intended to be scientific but was instead Eastbourne Borough Council, as a community leader, deciding to ask the recipients of the maternity service what they thought about the service in order to understand how the service change brought in four years ago has impacted mothers in Eastbourne.

1.33.      Mr Finnis added that the survey questions had to be approved by the ONS and so were not deliberately slanted in a way to get a particular answer.

Netherlands study

1.34.      Councillor Smart said that he would seek advice but disagreed that the Netherlands study of transfer times he had quoted from was not academically accepted.

1.35.      Peter Finnis said that the Netherlands study looked at the impact on outcomes from a 20 minute travel time, whereas the travel time for patients from Eastbourne was 40 minutes.

Involvement of NHS with Eastbourne Borough Council’s scrutiny committee

1.36.      Councillor Smart said that he had expected more involvement from NHS organisations. He said that EHS CCG was invited to two Eastbourne Borough Council scrutiny committees and declined to attend.

1.37.      Amanda Philpott responded that she heard about the survey via Facebook and the first invitation to a scrutiny committee for the CCGs came via a hand written note attached to the paperwork for the meeting. Ms Philpott said that it was felt more appropriate to attend the HOSC meeting to ensure continuity, due to the Committee previously having considered the Better Beginnings reconfiguration.

Independent review of maternity services

1.38.      Councillor Smart said he believed that there was enough evidence for an independent review of maternity services provided by ESHT to be commissioned in order to bring the issue to a conclusion.

1.39.      Vikki Carruth questioned the value of a further independent review given the range of independent reviews that ESHT is subject to, for example, recent Care Quality Commission (CQC) inspections, and upcoming reviews of serious incidents by the Healthcare Safety Investigation Branch.

1.40.      Amanda Philpott added that it is already the case that it is not a self-assessment that determines the quality and safety of services provided by ESHT but a range of independent inspections and reviews by independent organisations.

1.41.      Ms Philpott said that there is a case for independent review when a Trust is an outlier in national indicators of quality and safety, which is what drove the reconfiguration in 2014. However, most of the indicators are now at the better end of the range and so it would be unusual to call for an independent review in those circumstances. Commissioners, she said, would also consider that in a time of great pressure on services and resources the prospect of an independent review would unsettle the existing workforce and make it more challenging to attract additional staff.

1.42.      Sarah Blanchard-Stow raised concerns that the maternity service has been reviewed so frequently that staff are beginning to question whether they are doing a good job. Furthermore, the Eastbourne Borough Council and CQC surveys both indicated a high level of satisfaction from women in relation to the MLU. The only element they are not as happy with is the post-natal service, but ESHT considers this a priority area for improvement and has commissioned a workforce review to address this.

1.43.      The Committee Resolved to:

1) note the report;

2) request future briefings on progress with preventative pre-natal measures to reduce stillbirths and actions taken to improve post-natal services