Excellence in Maternity, Obstetrics and Gynaecology
Final Report
______________________________________________________________________
Purpose: to consider how we can improve the quality of services
To deliver: improved outcomes through collaboration across boundaries
______________________________________________________________________________
1.
Introduction
This workshop is part of a programme of work to develop detailed actions to progress the
strategic direction of County Durham and Darlington NHS Foundation Trust (CDDFT) based on
broad, systematic engagement. In this way we aim to develop a shared vision with partners and
understand together the service improvements required to deliver that shared vision, based on a
clear understanding of connections and inter-dependencies across the system of care.
This is a fundamental part of the delivery of the four “touchstones” for CDDFT:




Best outcomes,
Best efficiency,
Best experience and
Best workforce
The workshop focussed on a number of real patient stories and health system responses;
aiming to improve outcomes through collaboration across boundaries. The methodology
followed throughout the workshop kept the woman and her family at the centre of discussions
by focussing on the real stories of Emma, Jennifer, Lisa and Jane and their journey through the
health system; and we intend to keep real women at the centre of all our future
discussions.
A broad range of agencies were invited to the session, along with a number of families; with the
following agencies represented for all or part of the workshop (a full list of attendees is detailed
in appendix 1):











County Durham and Darlington NHS FT
Darlington Borough Council
Durham County Council
Durham Dales, Easington and Sedgefield Clinical Commissioning Group
North Durham Clinical Commissioning Group
Darlington Clinical Commissioning Group
Hambleton, Richmond and Whitby Clinical Commissioning Group
NHS County Durham and Darlington
North East Local Supervising Authority
Royal College of Nurses
Maternity Services Liaison Committee
This workshop is the continuation of existing work in a number of areas, with the aim being to
bring together a number of workstreams into a consolidated programme. We intend to develop
a full programme of engagement with all partners, specifically women and families (using
existing mechanisms wherever possible) to ensure that we keep women and families at the
centre of all our work on improving the systems of care to deliver improved outcomes.
2.
Current State of Service User Experiences: Patient Stories
The workgroups considered Emma’s story (detailed in appendix 2) and made the following
observations:











Very common story – upsetting for the patient and clinicians involved
Access to the Early Pregnancy Assessment Service should be all day, all week
Delays at every step of the process – would a 24/7 ward based helpline have helped
manage the situation?
Surgical delays (nil by mouth) for 24 hours is not appropriate (increases risk)
Access to scans can be poor – too many routine scans reducing availability of
emergency scans
Emotional support is as important as the process – coping with miscarriage needs to be
recognised as part of the service
Need to consider the promotion of bereavement services – does the name scare women
and families? Service needs to be accessible through multiple routes (phone, text, on
line etc)
Communication is a clear issue throughout the story, leading to heightened anxiety at an
already stressful time
Do the internal systems match the needs of patients using them?
Was a surgical procedure the most appropriate (clinically and emotionally) option?
Was the right balance struck between clinical emergency and emotional stress?
The workgroups considered Jennifer’s story (detailed in appendix 2) and made the following
observations:















An example of how a midwifery led unit (MLU) can work to promote normal birth
Co-located units may increase numbers choosing midwifery-led care
All second births and beyond (subject to risk analysis) should default to MLU
Awareness of the outcomes delivered in MLUs of GPs needs to be higher to promote as
the preferred option – although the relationship between the mother and midwife is more
important in shaping decisions on care choices
Exercising choice (ie of MLU) is dependent on confidence and receiving the right
information at the right time in the right form
With current systems, processes and capacity Jennifer’s experience cannot be
guaranteed every time (on a busier day Jennifer’s story might not have been like this)
Could the booking appointments be provided in GP surgeries?
GPs feel disconnected from the care of pregnant women
Consistency of breastfeeding support, and availability of advice is an issue; there is the
potential to roll out the pilot of the daily follow up calls
Potential to involve other “supporters” (Mum, Grandma, peer volunteers) in continuing
breastfeeding and parenting
Care is not just about the birth – it is about the whole package; ante and post natal.
There are currently pressures on high risk units because of the number of low risk
patients using them
Quality of the facilities is an important part of choice
Where do the partners feature in this story – are they a relevant part of the care?
Could Jennifer become a champion for the service?

Even in a positive story relationships and communication are critical – handover to the
health visitor and with the GP for on-going care and communication to Jennifer to reduce
the potential for the use of multiple contact points to access care
The workgroups considered Lisa’s story (detailed in appendix 2) and made the following
observations:





Whilst the care given seems considered issues like breastfeeding and the importance of
skin to skin contact on birth are missing
Lisa’s care seemed to be very medicalised and less holistic than perhaps it could have
been
An earlier anaesthetic assessment should have been undertaken to make anaesthetists
aware of issues and risks prior to delivery
Unclear how health prevention messages and support had been communicated (for
example smoking cessation, diet etc)
Discharge letters to GPs need to be improved for complicated deliveries to improve
onward care
The workgroups considered Jane’s story (detailed in appendix 2) and made the following
observations:






3.
Importance of clear communication of the potential reason behind the outpatient
appointment – Jane did not feel part of the process
All waits combined led to a 56 day wait for Jane from first referral to the histology results
Should urgency take precedence over geography under choose and book in the case of
possible cancer diagnosis?
“2 week rule” is NHS jargon – are patients aware of the significance of this?
Internal processes need to be slicker
Seems an old fashioned pathway – one stop rapid access clinics for scans and
hysteroscopy
Agreed Priorities (for afternoon session)
Following a presentation from Bob Aitken (Consultant Obstetrician and Clinical Director for
Obstetrics & Gynaecology) outlining the national and local picture in more detail (see appendix
3); participants were asked to agree priority themes to improve the patients’ journeys.
The priority areas were discussed and framed as:
1.
2.
3.
4.
5.
4.
Internal Scheduling of interventions and processes
Gynae Services – what’s the future shape?
Working more seamlessly with GPs
How should we consider choice?
Holistic approach to the care of women
Marketplace
A critical aim of the workshop was to encourage and facilitate dialogue across services,
professions and sectors. A number of “marketplace” stalls, manned by senior nurses, were
available for delegates to find out more about current services and challenges (some of which
have been tackled). These conversations fed into the “emerging future” discussions.
The stalls covered:








5.
Standards
Shape of gynaecology services
Community Midwifery
Pregnancy assessment
High risk ante natal care
Complex care labour ward
Post natal care
Antenatal and Newborn Screening Programmes
Our Patient’s Voice
A session exploring patient experience ran concurrently with the marketplace, and Lynsey Wills
spoke to delegates about her experiences of care at CDDFT.
The key issues (full details in appendix 4) to emerge from that experience were:
 Emotional upset of having to deal with a three hour wait when there is a concern of
bleeding (though understanding there are emergencies)
 Lack of scanning equipment - no machines available on a Sunday
 Many emotions to be aware of: layout of the room in hospitals is insensitive (for people
experiencing difficulties having to see other healthy pregnant women, and vice versa)
 On the whole the service was excellent: lovely staff, excellent support with breast
feeding, hospital phone line going through the pregnancy, having someone to talk to
 Consistency of staff is important
 The benefit of taking husband appointments to take in all the information - it is difficult to
absorb everything
 Practical observations: bigger beds for mothers of twins (had to use bedside table as a
prop to extend the width of the bed)
 Breast feeding workshops were great, but would have liked more than one meeting in
preparation. Postnatal midwife support is important – able to call for advice on breast
feeding
 Mapping of support groups available would be helpful - not assuming that we all know
what is available
 Rooms with two or three beds, to be able to support each other and appreciate some
peer support. Relationships can continue once discharged, alleviating any feelings of
isolation.
 Information packs - leaflet for grandparents was really useful and helped in involving
grandparents more.
 Using plain English - be careful of terminology and medic speak. This can cause a
barrier with relationships
6.
The Emerging Future
Delegates self-selected which priority areas they wanted to discuss and considered what the
critical actions were to achieve the outcomes expressed.
 Internal Scheduling of interventions and processes (facilitated by Paul Cummings & Kelly
Bentham)
 Map access points and what happens at them
 Test for:
o Timeliness
o Right input first time, every time
o Clear communication on what’s happening and outcomes
The key area was agreed as access to ultrasound scans 7 days a week, with specific issues
being:
 Should routine services for both early and late pregnancy be available on a Saturday
and Sunday?
 How can wait times for services be reduced and communication to patients waiting
increased
 Availability of ultrasound to support obstetrics at the weekend at Darlington Memorial
Hospital (DMH)
 Need more midwives trained to scan
 Consider a scan capacity review (balance between urgent access and routine volumes)
and more appropriate use of ultrasound slots
 Have moved more scan work into DMH but not enhanced the scanning capacity

Better facilities are required to deliver the service

What a medical priority is and a patient priority is may not be the same thing
Pledges:
 24 hour Pregnancy Assessment Unit with relocation to better facilities and 7 day a
week Early Pregnancy Assessment Clinic
 7 day week Early Pregnancy Assessment Units across Durham & Darlington
Note that the issues around improving the service to gynae emergencies (access to theatres)
and access to elective lists are also being explored following discussions of Emma’s story
 Gynae Services – what’s the future shape? (facilitated by Edmund Lovell)
 To ensure easy access
 Closer to home
The future shape of Gynae services was also one of the market stall areas, so this discussion
was also informed by the conversations in that section of the day. The key issues determined
during the discussion were:
 Shift to “office” gynaecology will offer a better service, but has implications for:
o Skill mix – specialist nurses and consultants










o Facilities – need adequate outpatient-type space; will also free theatre space
Greatest pressure on the service at present is the volumes referred through the 2 week
cancer rule
Key to sustainability is to invest in non-medical staff (ie nurse colposcopies,
hysteroscopies, ultrasound etc)
Need to develop trust-wide gynae networks similar to oncology (eg urogynaecology;
subfertility; for rare diseases)
Potential to identify and develop clinicians with necessary skills to provide specialist
gynae services to build the service
Consider how we develop seamless integration between GP and specialist GP gynae to
reduce hand offs in the patient journey and increase the availability of services in the
community
Need more interventional radiologists
Potential to utilise remaining theatre space more effectively:
o Service to run 52 weeks of the year
o Use service utilisation as a measure, not individual utilisation
Consultant job planning needs to be more sophisticated and visionary to match the
needs of the service (eg more obstetrics on the labour ward)
Need to identify specialist gynae surgical skills (eg advanced laparoscopic surgery) so
patients have equitable services from consultants able to deliver the entire package of
care
Gynae service needs to establish a collective direction, led by nurse practioners
delivered by a core team of dedicated staff
Pledges:
 Commence service at Chester le Street in January 2013
 Align consultant job plans to the needs of the service
 Invest in non-medical staff
 Working more seamlessly with GPs (facilitated by Ian Briggs)
 Enabling GPs to keep women in their line of sight throughout their involvement with us
 Discharge and referrals in appropriate detail and agreed standard format
 Communication between clinicians to be the norm – “how we do business”
The key issues discussed to enable closer working across sectors were:
 Communication between clinicians is hampered by fractured record keeping and
systems
 Approach to contracting can hamper relationship building
 Development of pathways of care to enable the patient's care to progress from primary
to secondary care smoothly, with the best use of resources (no duplication) and
sufficient time for both the patient and the clinicians involved in her care (eg developing
a pathway for post-menopausal bleeding that reduces the number of women attending
overcrowded two week rule clinics).
 Communication at interfaces can be very poor affecting the quality of care provided (ie
referral letters, discharge letters)
Pledges:
 Align meetings (across sectors) to improve the development of shared agenda’s
and work out issues in partnership

Sort out the information systems across sectors to facilitate information sharing
 How should we consider choice? (facilitated by Di Murphy & Chris Williams)
 How can we increase the use of midwifery led units?
 How do we facilitate choice?
The issue of choice in maternity was discussed, with the critical issues being:
 Choice is leading women away from stand-alone midwifery led units (MLU) and into
obstetrician led care
 Should patients be able to choose an obstetrician when their risk status does not
indicate one is required?
 Co-location of MLUs could potentially allay fears of transfer to obstetrician led care
 Co-location creates environmental issues between the medical environment of
obstetrician led care and the more homely environment desired for MLUs
 Access to Pregnancy Assessment Clinic is critical to managing appropriate access to the
labour wards
 Additional activity from the Friarage at Northallerton need to be factored into planning
assumptions
Pledge: Develop a model for co-location of midwifery-led units
 Holistic approach to the care of women (facilitated by Lee Mack and Emma Shipley)
 Confidence building for better care and better services
 Embedding of emotional support systems in everyday practice
 Looking after partner, family, carer needs better
 Core information (what/by whom?)
The emotional support available to women throughout their whole journey and consideration of
the needs of family, partners and carers were discussed, with the key issues being:
 Issue of time – not willingness. Staff find it frustrating that this is the part of the care that
is compromised due to volume of work and undertaking tasks that can be delivered by
other care team colleagues (ie admin tasks)
 the service is 24/7 with lots of open access points for service users and this makes the
“added value” part such as emotional support difficult to deliver – particularly when
dealing with emergencies
 Managing expectations can be difficult, however their needs to be a dialogue on what
those expectations are to improve the care given
 Some clinics and workshops that facilitate broader family involvement more easily (ie
weekend visits to labour ward as part of the ante natal prep)
 Balancing care delivery, privacy and dignity and emergency situations is paramount and
this leads to restrictions on who and how many can visit and whether partners can stay
overnight
 Access/availability arrangements as part of ante natal offer should be reviewed to
ensure they match modern lifestyles of women and their families



Engagement with patients, partners and families needs to be built into how we work to
continuously improve the service we offer
Action the results of the review of midwifery activity and skill mix differently to allow
midwives to better support patients and extended support networks as part of every day
activities (midwifery assistants, ward clerks, healthcare assistants etc)
Strengthen use of peer mentoring. There is good practice in place in some areas (a
strong bereavement support service, good use of volunteers in community services i.e.
breastfeeding) but more can be done to use patients and mothers to provide mentoring
support. It was acknowledged that there is experience elsewhere in the FT to tap into
Pledges:
 Trial Pregnancy Assessment Unit and 24/7 reception
 Review access in light of modern day working and lifestyles of service users
 Strengthen use of volunteers and peer mentoring (to join up great care with great
service)
7.
Next Steps
The anticipated outcome for the workshop was improved outcomes for women through
collaboration across boundaries; as such any emerging programme must be owned by all
agencies interested in improving outcomes for women.
The pledges outlined above will be discussed widely with partners, including patients and their
families, to determine an agreed approach.
The pledges will require further work up to determine service, financial and workforce
implications. The final report will be discussed at the Care Closer to Home Assurance Group for
sign off and agreement of next steps required to oversee implementation. It is intended to
develop a governance framework to take this forward across partners, potentially linking into the
framework under consideration following the paediatric summit.
This workshop represents the start of a sea change in our approach to women’s health –
an approach that embraces engagement with all our partners who have an interest in
improving outcomes for women.
8.
Appendices
Appendix 1:
Appendix 2:
Appendix 3:
Appendix 4:
Appendix 5:
Attendance List
Patient Stories
Presentation: Challenging Our Thinking
Our Patient’s Voice
Challenging Our Thinking (detail)